Every finding on record at Graceland Rehabilitation and Nursing Care Center

Based on facility policy review, medical record review, facility investigation review, hospital record review, medical transport services record review, and interview, the facility failed to ensure residents remained free from accident hazards for 2 of 5 (Resident #415 and #515) sampled residents reviewed for accident hazards. The facility failed to ensure a vulnerable, non-verbal, cognitively impaired resident who required 2-person assistance with bed mobility and care, remained free from accident hazards as evidenced by failure to provide the required amount of assistance for safe repositioning and/or transfer, resulting in a significant injury and hospitalization for Resident #415. On 3/7/2025 at approximately 11:20 AM, Resident #415, a cognitively impaired Resident who was totally dependent on staff for mobility and required 2-person assistance with activities of daily living (ADLs) was receiving care from Certified Nursing Assistant (CNA) A and CNA B. CNA A and CNA B repositioned Resident #415 in the bed on to her side, CNA B then exited the Resident's room to get more supplies, and left CNA A in the room alone with Resident #415 who was still positioned on her side. According to staff, Resident #415's weight shifted, which caused the Resident to fall from the bed to the floor, and hitting her head which resulted in a large hematoma to the Resident's left side of the forehead. Resident #415 was transported to the emergency roiagnom on [DATE] and remained hospitalized until 3/19/2025, with the admitting diagnosis of Focal Hemorrhagic Contusion of Cerebrum (a bruise to the brain caused by a head injury with bleeding and swelling). The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for Resident #415. The facility also failed to provide an environment free from accident hazards when Resident #515, a moderately cognitively impaired resident, who required assistance with mobility, sustained an unwitnessed fall. Resident #515 was found by staff on the floor, reported to staff right leg pain and the inability to move her right leg and asked staff for an x-ray of her leg. Staff assisted the Resident to the bed then used a mechanical lift to move the Resident from the bed to a wheelchair. Staff waited a total of 6 hours and 28 minutes later to call Emergency Transport Services to transport the Resident to the hospital. At the hospital, Resident #515 was diagnosed with a Displaced Subcapital Right Femoral Neck Fracture (hip fracture that occurs when the bone in the neck of the thighbone breaks, and the bone fragments are no longer in proper alignment) which resulted in actual HARM to Resident #515. The Administrator was notified of the Immediate Jeopardy on 5/7/2025 at 4:55 PM, in the Conference Room. The facility was cited at F-689 at a scope and severity of J, which is substandard quality of care. An extended survey was conducted from 5/8/2025 to 5/13/2025. An acceptable Removal Plan which removed the immediacy of the Jeopardy for F-689 was received on 5/9/2025, and the Removal Plan was validated on-site by the surveyors on 5/13/2025 by medical record review, in-service record review, audit review, observation, and staff interviews. The Immediate Jeopardy for F689 began on 3/7/2025 through 5/8/2025, the IJ was removed on 5/9/2025. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility policy titled, Safety and Supervision of Residents, dated July 2017, revealed .Our facility strives to make the environment as free from accidents and hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Safety risks .are evaluated on an ongoing basis through a combination of employee training, employee monitoring and reporting processes .QAPI [Quality Assurance and Performance Improvement] review of safety and incident/accident data .when accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards .Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents .Monitoring the effectiveness of interventions shall include the following .Ensuring that interventions are implemented correctly and consistently . Review of the facility policy titled, Repositioning, dated May 2013, revealed .The purpose of this procedure is to provide guidelines for evaluation of resident repositioning needs, to aid in the development of an individual's care plan for repositioning .review the resident's care plan to evaluate for any special needs .assemble the equipment and supplies as needed .encourage the resident to participate if able .two people . Review of the undated facility policy titled, Pain Management, revealed, .most common painful conditions occurring in long-term care residents .Fractures .Effective symptomatic treatment should not be withheld while a definitive diagnosis or cause of pain is identified .The Pain Evaluation prompts the licensed nurse to elicit from the resident or family members' approaches that make the resident's pain better or worse .factors that may increase pain include .Anxiety .Position .Just as the experience of pain is subjective, assessing another in pain is subjective .We must rely on behaviors observations, as well as intuition and personal judgment . 2. Review of the medical record revealed Resident #415 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of the Care Plan revealed .[1/02/2025] .[Resident #415] at risk for falls r/t [related to] unsteady gait .has bladder incontinence r/t limited mobility .has an ADL self-care deficit r/t .cerebral infarct [infarction/stroke] .has bowel incontinence r/t limited mobility .has dx [diagnosis] of Cerebral Vascular Accident [stroke] .impaired cognitive function or impaired thought processes r/t cognitive communication deficit . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed staff did not perform a Brief Interview for Mental Status (BIMS) score due to Resident #415's severe cognitive impairment. Resident #415 had short and long-term memory problems and cognitive skills for daily decision making indicated the resident had severe cognitive impairment. Resident #415 was dependent on staff for bathing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Review of the Progress Notes dated 3/7/2025 at 12:17 PM, revealed LPN (Licensed Practical Nurse) G documented .CNA x2 [times 2] was assisting res [Resident #415] with ADLs .res was assisted onto her right side and [had] BM [bowel movement] CNA cleaned BM off of res. res had additional BM after clean linen was applied to bed. one cna [CNA B] stepped out of [the] room to get extra linen/towels. cna [CNA A] that remained in room continued to hold res onto her side. res tilted forwarded and fell on to floor. writer [LPN G] assessed res and noted raised area on left side of res' head. Writer [LPN G] called res' daughter/RP [responsible party] .at 1120 [11:20 AM] to report fall and that res would be transported to hospital foreval [for evaluation]. writer contacted [Medical Transport 1] for res to be transferred to [Named hospital 1] per hospital choice on profile. 1123 [11:23 AM] writer called [responsible party] back to answer additional questions after transportation was called . Review of the Situation Background Assessment and Recommendation (SBAR) Physician/Nurse Practitioner (NP)/Physician Assistant (PA) Communication Tool dated 3/7/2025 at 3:24 PM, revealed Resident #415 fell and was transported to the hospital because of a recent fall. Resident #415 had some confusion, a blood pressure of 172/91, and non-verbal indicators of pain were present. Review of the facility's investigation dated 3/7/2025, confirmed there were 2 staff in the room, 1 staff left the room to retrieve some linen, and Resident #415 fell from the bed, while the second staff member was out of the room. Review of the Hospital Medical Records Radiology results dated 3/11/2025, confirmed Resident #415 had a Traumatic Brain Injury (TBI) with left frontal (lobe of the brain), right temporal (lobe of the brain), parenchymal (the tissue that performs the organ's primary function; indicates damage or problem in the brain tissue) and subarachnoid hemorrhage (bleeding in the space between the brain and covering the tissue in the brain). Review of Hospital #1's HOSPITALIST DISCHARGE SUMMARY dated 3/19/2024, revealed Named Resident #415 was discharged to the facility on [DATE]. During a telephone interview on 5/7/2025 at 1:05 PM, CNA B stated, [Named Resident #415] required a 2 person assist on the day of the fall. CNA B confirmed she went to assist CNA A, Resident #415 had a large bowel movement, they did not have enough supplies in the room at that time, and CNA B was asked to go out of the room to get some rags [linens]. CNA B stated, I was in the hallway and CNA A called out 'She fell , she fell '. CNA B stated LPN G was called and nurse LPN G and CNA B went to the room after Resident #415 had fallen from the bed. CNA B stated, Resident #415 was too close to the edge of the bed, I guess. During a telephone interview on 5/7/2025 at 1:45 PM, CNA A stated CNA B exited the room to get supplies because Resident #415 had a bowel movement. CNA A stated she was standing behind Resident #415 when CNA B exited the room. CNA A stated Resident #415 shifted her weight away from her and she couldn't catch Resident #415, and the Resident fell to the floor. CNA A stated the Resident's bed height was waist high. During an interview on 5/13/2025 at 3:58 PM, the Director of Nursing (DON) was asked what occurred when Resident #415 fell out of the bed on 3/7/2025. The DON stated 2 CNAs were providing care to the Resident, they ran out of supplies, and one CNA stepped out of the room to get more supplies. The DON stated that the Resident's weight shifted, and the Resident fell out of bed onto the floor. During an interview on 5/13/2025 at 4:48 PM, the Administrator was asked what they determined the root cause was that resulted in Resident #415 falling out of the bed. The Administrator stated there were 2 CNAs in the Resident's room giving care to Resident #415 and one CNA exited the room to get additional supplies leaving one CNA with the Resident. The Administrator stated Resident #415's weight shifted, and the Resident fell from the bed onto the floor. The facility failed to maintain 2-person assistance while providing care to Resident #415 resulting in a fall with injury which placed the Resident in Immediate Jeopardy. 3. Review of the medical record revealed Resident #515 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Lack of Coordination, Muscle Weakness, and Repeated Falls. Review of the Care Plan dated 12/5/2023, revealed .Focus .[Resident #515] is at risk for falls r/t new and unfamiliar environment, poor safety awareness, unsteady gait, weakness . Review of the admission MDS assessment dated [DATE], revealed Resident #515 had a BIMS score of 11, which indicated moderate cognitive impairment, and she required maximal assistance with ADLs. Review of the Progress Notes dated 1/7/2024 at 4:00 PM, for Resident #515 revealed .Resident in room screaming 'help'. Upon entering room resident observed on floor leaning on left side a few feet from restroom door .Resident c/o [complained of] pain to right hip and leg, requesting X-ray stating 'I can't move this side.' .Resident assisted to w/c [wheelchair] from bed via [by way of] total lift [mechanical device used to lift resident], staff x [times] 2. RP made aware. Unable to reach MD [Medical Director]. PRN [As needed] Tylenol admin [administered] for pain . The Progress Notes revealed the nurse moved Resident #515 using a mechanical lift after she voiced inability to move the right side and complained of pain. Review of the SBAR dated 1/7/2024, revealed .Situation .fall .1/7/2024 .Identify whether the problem/symptom has gotten worse/better/stayed the same since it started .Worse .Recent fall .Resident Reports Pain .Yes .Non-verbal indicators of pain evident .Yes .Describe appearance .in pain post fall . Review of the Progress Notes dated 1/7/2024 at 6:40 PM, revealed .New order per NP to transfer resident to ER [emergency room ] for eval. Medical transport contacted with 1.5hour ETA [Estimated Time of Arrival]. RP made aware . Review of the Progress Notes dated 1/7/2024 at 10:28 PM, revealed .Resident transferred to [Named Hospital #1] ER for eval. s/p [status post] fall . The Progress Notes revealed the nurse did not make any further calls to other ambulance service transports or call 911 to address Resident #515's immediate needs. Review of the Progress Notes revealed Resident #515 stayed at the facility for 6 hours and 28 minutes before she was transferred to the hospital. Review of the Prehospital Care Report Summary from Medical Transport #2 revealed, .1/07/2024 Call# [number]: 0645 [6:45 PM] .Transport by This EMS [Emergency Management Services] Unit .Initial Patient [Resident #515] Acuity: Critical (Red) .Dispatched: 21:18 [9:18 PM] .Left Scene .22:03 [10:03 PM] .Falls/Back Injuries (Traumatic) .Patient Physical Limitations: Right Leg Paresis [a partial or incomplete loss of muscle function] .distal femur [thighbone] swelling pain 8/10 [pain scale of 1 being lowest and 10 being highest pain level] .unwitnessed fall with injuries Duration: 6 Hours .Extremity Trauma .AOSTF [Arrived on scene to find] [age in years of female] seated in wheelchair by door .stated pain 15 [when asked pain level on scale of 1 to 10] when moving, alert daughter and son-in-law present in pt [patient] room .pt fpund [found] seated in wheelchair, should not be seated until fracture/injury determined . Review of the typed facility investigation for Resident #515 revealed, .On 1/7/24 [2024], [Named Resident #515] was noted yelling for help in her room. Upon the nurse's arrival resident was noted lying on the floor on her left side in front of the bathroom door .MD notified and resident was sent to ER for evaluation per MD orders. 1/8/24 [2024] DON were [was] notified that [Named Resident #515] had sustained a displaced subcapital right femoral neck fracture from the admitting hospital . During an interview on 5/7/2025 at 9:40 PM, the Nurse Practitioner (NP) #1 stated, .I raised up concerns in a recent meeting .I expressed concerns about patient safety .fall education on proper body mechanics .I know of issues with falls with injury . During an interview on 5/12/2025 at 3:23 PM, the MD was asked about Resident #415's fall. The MD stated, .she was supposed to be a 2 person assist someone left to go get supplies and then the resident fell .fall protocol that I expect them [referring to nursing staff] to follow, it hasn't changed, my fall protocol specifically follows what happens after the fall, the resident should not have been left, it would take the 3rd person getting the supplies . MD was asked if the fall was preventable for Resident #415. The MD stated, Yes, never, ever leave the person in the room alone . The MD was asked about Resident #515's fall and what the nurse should have done when she was unable to reach the NP. The MD stated, .we have the call process and text process if they follow those steps, shouldn't be a long period of time to get in contact with me .the nurse should have called me . The MD was asked when Resident #515 had an unwitnessed fall, expressed she was unable to move her leg, and she requested x-rays what would he expect the nurse to do. The MD stated, .expect to send the resident out for x-ray . During a telephone interview on 5/13/2025 at 8:55 AM, Family Member (FM) AA was asked about Resident #515's fall on 1/7/2025. FM AA stated, .Mom kept calling saying she was hurting after she fell .she was calling me on the phone .I got at [to] the facility .I told the nurse she is screaming in pain, I think we need an Xray and sent out to the hospital .the ambulance didn't come quick .I started to call 911 but the nurse told me it wasn't an emergency then we find out at the hospital her leg was broken . FM AA stated, .I stayed at the facility until she was transported out .she was in terrible pain and couldn't move her right leg .she was yelling . During a telephone interview on 5/13/2025 at 12:27 PM, Licensed Practical Nurse (LPN) KK was asked if she recalled a fall which involved Resident #515 on 1/7/2025 when she was on duty and assessed the resident. LPN KK stated, .I don't remember that incident . This surveyor read LPN KK's Progress Notes dated 1/7/2025. LPN KK stated, .now I remember .she was in pain .she kept hollering, eventually got transport to send her out .most times they [referring to the facility] don't want us to use 911 . LPN KK was asked when she would activate 911. LPN KK stated, .if patient was unresponsive . LPN KK was asked why she moved the resident from the floor with the lift. LPN KK stated, .She [Resident #515] wasn't assisting . During an interview on 5/13/2025 at 2:35 PM, the DON was asked if a resident had an unwitnessed fall, voiced the inability to move her leg, and complained of pain after being found on the floor would she expect the nurse to get the resident up. The DON stated, .I would expect the nurse to leave them in place . The DON was asked why she would not want the resident to be moved. The DON stated, .it could cause more injury and possibly cause the resident more pain . During an interview on 5/13/2025 at 5:16 PM, the Administrator was asked if an ambulance transport was unable to arrive for 1.5 hours for a resident who experienced an unwitnessed fall, was unable to move her leg, and experienced pain what would she expect the nurse to do. The Administrator stated, .call 911 . An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 5/9/2025 at 3:52 PM. The surveyors validated the Removal Plan by record review, review of facility audits, in-service sign-in sheets, observations, and interviews. An Assessment of Compliance (AOC) was conducted on 05/07/2025 to evaluate the appropriate implementation and documentation of 2-person assist with bed mobility at Graceland Rehabilitation and Nursing Center. This assessment included a fall incident audit and a review of care plans and Kardex's for accuracy and alignment with residents' current bed mobility needs. The facility immediately educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care, reviewed all falls, policies, Kardex's and care plans to align with each resident's current bed mobility needs. Immediately began in-servicing on Fall Management Program, Safety and Supervision of the Resident and Positioning and Repositioning of the resident for all licensed Nurses, CNAs and Respiratory Therapist. The root cause was CNA B left the room to get more supplies leaving CNA A alone in the room with Resident #415. CNA A and B were aware that resident #415 was a 2-person assist with bed mobility. The facility has implemented Fall audits, Care plan audits, Kardex audits, Policy audits, and on-going education with Licensed Nurses, CNAs and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies, skills competency with positioning and repositioning residents with return demonstration to prevent recurrence. The facility is monitoring all falls daily, ensuring all care plans and Kardex's are up to date and on-going competencies and education to ensure training is effective. The facility is measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency. Fall Audit: A facility wide fall audit was conducted on 05/07/2025 from 03/07/2025 to current with no major injuries. No fall concerns with 2-person assist with bed mobility. Care Plan Audit: A facility wide care plan audit was conducted on 05/07/2025 to ensure any resident that is a 2- person assist reflects accurately and was found to be up to date. Kardex Audit: A facility wide Kardex audit was conducted on 05/07/2025 to ensure all residents had an up-to-date Kardex and aligning with current care plan with 2-person assist with bed mobility. All Kardex's were found to be accurate. Policy Audit: Policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning were all reviewed by the Administrator and Director of Nursing on 05/07/2025 with no revisions needed. Education: All licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) will be in-serviced on Fall Prevention, Safety and Supervision of Residents, and Repositioning starting on 05/07/2025. Quality Assurance Improvement Plan (QAPI): The facility is continuing its on-going Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately. Conclusion: (Named facility) remains committed to ensuring resident safety through proper documentation and adherence to mobility assistance requirements. Continued monitoring and education will be conducted to maintain compliance and prevent future incidents. 47127

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 2 staff members (Licensed Practical Nurse (LPN) DD and Housekeeping CC) failed to wear Personal Protective Equipment (PPE) for Transmission-Based (Isolation) Precautions and failed to properly perform hand hygiene after exiting Transmission-Based Precautions resident rooms. The facility failed to limit interactions with other residents when 1 of 4 (Resident #74) sampled residents reviewed for contact precautions was allowed to interact outside of his room with other residents. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, dated April 2010, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Employees must wash their hands for at least (15) fifteen seconds using antimicrobial or non-antimicrobial soap and water .Before and after direct resident contact .Before and after entering isolation precaution settings .After removing gloves .In most situations, the preferred method of hand hygiene is with an alcohol- based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub .Before and after direct contact with residents .After contact with objects (medical equipment) in the immediate vicinity of the resident; and after removing gloves . Review of the undated facility policy titled, Transmission-Based (Isolation) Precautions, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogens .'Contact precautions' refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the residents or resident's environment .Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .Residents on transmission-based precautions should remain in their rooms except for medically necessary care .Contact Precautions .Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment . 2. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, Diabetes, and Seizures. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 was severely cognitively impaired, and was dependent on staff for all activities of daily living (ADLs). Review of the Physician's Order dated 2/11/2025, revealed Resident #60 had an order for Contact Isolation Precautions related to Candida Auris (an emerging fungus that can cause severe, often multidrug-resistant, infections. It spreads easily among patients in healthcare facilities). Observation in the resident's room on 5/5/2025 at 10:11 AM, revealed LPN F entered into Resident #60's room without donning PPE gown or gloves, touched the enteral pump, moved the residents over the bed table, exited the resident's room, turned and went back into the same room without donning PPE gown or gloves, touched Resident #81's (Resident #60's roommate) enteral pump. LPN F exited the room and walked to her medication cart in the hallway without performing hand hygiene. During an interview on 5/5/2025 at 10:20 AM, LPN F was asked should PPE be worn in the isolation room and hand hygiene performed after exiting room. LPN F stated, Yes, I should have .they both are in contact isolation for Candida Auris .I should use gloves then perform hand hygiene . 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Candidiasis, and Dependence on Renal Dialysis. Review of the quarterly MDS assessment dated [DATE], revealed Resident #74 had a BIMS score of 14 which indicated no cognitive impairment. Review of the Physician's Order dated 4/1/2025, revealed an order for .Contact Isolation for Candida Auris . Observation on 5/5/2025 at 12:25 PM, revealed Resident #74 was dressed, up in wheelchair, propelling self-exiting the main dining area with no PPE. Observation on 5/7/2025 at 8:15 AM, revealed Housekeeper CC entered Resident #74's room to clean the room and did not wear PPE. During an interview on 5/12/2025 at 4:10 PM, LPN DD was asked how contact isolation has been maintained with Resident #74. LPN DD stated, .he has been allowed to come out of his room if he wears the isolation gown. When asked why he would be out of his room without the isolation gown, LPN DD stated, .that at times he has been non-complaint with wearing the isolation gowns . 4. Review of the medical record revealed Resident #81 was admitted on [DATE], with diagnoses including Chronic Respiratory Failure, Hemiplegia and Hemiparesis, and Diabetes. Review of the annual MDS assessment dated [DATE], revealed Resident #81 was severely cognitively impaired, and was dependent on staff for all ADLs. Review of the Physician's Order dated 3/20/2025, revealed Resident #81 had an order for Contact Isolation Precautions related to Candida Auris. During an observation in Resident #81's room on 5/6/2025 at 2:35 PM, revealed Housekeeping CC entered the contact isolation room without donning PPE, moved the over the bed table, then cleaned the floor. Housekeeping CC then exited the room without performing hand hygiene. During an interview on 5/6/2025 at 2:40 PM, Housekeeping CC was asked should a PPE gown be donned prior to entering a contact isolation room and should staff perform hand hygiene after removing gloves. The Housekeeping CC stated, No, I don't think so . 5. Review of the medical record revealed Resident #119 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Anoxic Brain Injury, Gastrostomy, and Tracheostomy. Review of the quarterly MDS assessment dated [DATE], revealed staff did not perform a BIMS because Resident #119 was severely cognitively impaired. Resident was dependent on staff to perform ADLs. Review of Physician's Order dated 8/19/2024, revealed .Contact isolation precautions for Candida Auris: Use proper PPE when performing patient care every shift . Observation in the resident's room on 5/6/2025 at 8:32 AM, revealed Housekeeping CC entered Resident #119's room without applying PPE to sweep and clean the resident's floor. Housekeeping CC exited Resident #119's room and entered another resident's room without performing hand hygiene. During an interview on 5/13/2025 at 4:01 PM, the Director of Nursing confirmed all staff should wear PPE when entering a contact isolation room and perform hand hygiene before and after entering a resident room. During an interview on 5/13/2025 at 5:09 PM, the Administrator confirmed the facility should follow Transmission-Based Protocol related to Candida Auris. 47127

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when stainless steel tables and metal storage racks were found with rust on the legs and black buildup around the base, the ice machine contained a dark brown, rust colored substance on the metal inside flap, food stored in the reach in cooler was unlabeled and undated, food items left on top of stainless steel tables was unattended and uncovered, dust was observed on top of a reach in cooler and around the edges of the ceiling vents, and when a substance with the appearance of rust was found around the edges of the ceiling vent and metal grates, when 9 stainless steel trays with food were found in the reach in cooler unlabeled and undated, the can opener contained thick black gummy buildup around the blade, when food items were found on top of a stainless steel table opened and undated, when dry ingredient storage bins that contained sugar and flour were unlabeled and undated with the lids soiled with thick yellow sticky debris, when the ice cream freezer and milk cooler were without thermometers and the facility failed to maintain temperature logs, when staff used the same alcohol wipe to clean the thermometer numerous times in between taking tray line temperatures of different food items, and when the high temperature dish machine was being utilized to wash dishes and was not reaching appropriate temperatures and the facility failed to use paper products. The facility had a census of 158 with 133 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility undated policy titled, Sanitation, revealed The food service area is maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects .All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals hinges and fasteners are kept in good repair. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions .Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are .High Temperature Dishwasher (Heat Sanitization) .Wash temperature (150-165 F [Fahrenheit]) .Rinse temperature (180 F)-(160 degrees F .) .Ice Machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions . Review of the facility undated policy titled, Refrigerators and Freezers, revealed This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures .Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening .All food is appropriately dated to ensure proper rotation by expiration dates .Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy .Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary .All foods stored in the refrigerator or freezer are covered, labeled and dated .Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen or discarded . Review of the facility undated policy titled, Food Receiving and Storage, revealed Foods shall be received and stored in a manner that complies with safe food handling practices . Observation in the kitchen on 5/5/2025 at 9:21 AM, revealed the following: a. dark brown rust and black buildup on the legs and at the base of the legs of a stainless-steel metal table that the coffee machine and juice machine were sitting on. b. dark brown rust color particle and black dried particles on the legs at the base of the one compartment sink by the ice machine. c. dark brown rust color substance on the upper lid and metal tray inside the ice machine. d. 1 box of banana moon pies opened and undated, 1 box of 4 oz (ounce) apple sauce cups opened and undated, 1 box of [NAME] Krispies Treats opened and undated, and 1 box of Cheez Its crackers opened and undated on top of a stainless-steel metal rack located near the ice machine. e. 1 box of 8 oz foam cups with 25 cups laying in the bottom of a box uncontained with the box on the floor by the one compartment sink. Observation in the kitchen on 5/5/2025 at 9:25 AM, revealed the following: a. dried white streaks on the exposed left side of Reach in Cooler #1, dark gray dust particles visible on top of Reach in Cooler #1, and dark black dried particle build up around the base of Reach in Cooler #1. b. dark gray dust particles and dark brown rust around the edges of the air vent located over the Reach in Cooler #1. c. dark gray dust particles and dark brown rust around the edges of an air vent leading to the cooking stove area. d. a large serving spoon in a plastic container with a dried unidentified white substance on the spoon. e. 1 large metal pan containing dried cooked spaghetti on top of a metal table uncovered and undated. f. a stainless steel can opener with black gummy build up around the blade. g. 1 jar of grape jelly sitting on top of a metal stainless steel table opened and undated. h. a 5-pound (lb) plastic container of peanut butter opened and undated sitting on top of a metal table. Observation in the kitchen in the Reach in Cooler #2 on 5/5/2025 at 9:27 AM, revealed the following: a. Tray #1 with 34 bowls of cold slaw, unlabeled and undated. b. Tray #2 with 12 bowls of banana pudding, 2 bowls of crushed pineapple, 7 bowls of sliced chocolate cake, 3 bowls of apple sauce, and 4 bowls of butterscotch pudding, unlabeled and undated. c. Tray #3 with 35 bowls of chocolate pudding with whipped cream topping, unlabeled and undated. d. Tray #4 with 4 bowls of chocolate pudding with whipped cream topping, unlabeled and undated. e. Tray #5 with 33 bowls of chocolate pudding with whipped cream topping, unlabeled and undated. f. Tray #6 with 34 bowls of chocolate pudding without whipped cream topping, unlabeled and undated. Observation and interview at Reach in Cooler #2 on 5/5/2025 at 9:36 AM, revealed Dietary [NAME] EE confirmed the trays of food should have been dated and labeled prior to placing them inside of the cooler. Observation in the kitchen on the tray line on 5/6/2025 at 11:37 AM, revealed Dietary [NAME] FF calibrated the thermometer, cleaned the thermometer with an alcohol pad, and cook the temperature for the smothered chicken, the mashed potatoes, the lima beans, and the meat balls. Dietary [NAME] FF failed to use a clean alcohol pad between each food item prior to taking the temperature for the mashed potatoes, lima beans, and the meat balls. Dietary [NAME] FF obtained a clean alcohol pad, and took the temperature for the steamed rice, the green beans, the fried chicken, mechanical soft lima beans, mechanical soft meat, mechanical soft potatoes, pureed lima beans, and puree ham. Dietary [NAME] FF failed to obtain a clean alcohol pad in between each food item prior to taking the temperature for the green beans, fried chicken, mechanical soft lima beans, mechanical soft meat, mechanical soft potatoes, pureed lima beans, and pureed ham. During an interview on 5/6/2025 at 11:45 AM, Dietary [NAME] FF confirmed that she should have used a clean alcohol pad in between each food item prior to taking the temperatures. Observation and interview in the dish room on 5/7/2025 at 8:03 AM, revealed Dining Service Aide GG was in the dish room running dishes through the dish machine, this Surveyor asked Dining Service Aide GG if the dish machine was a high or low temperature dish machine. Dining Service Aide GG confirmed she was unaware if it was a high or low temperature dish machine. Dining Service Aide GG was asked to run a cycle through the machine. This Surveyor asked Dining Service Aide GG what should the wash cycle temperature rise to during the wash cycle to ensure adequate sanitation because the dial on the machine remained at zero. Dining Service Aide GG was unsure and asked staff to go get Dietary [NAME] FF. Dietary [NAME] FF returned and confirmed the dish machine was a high temperature machine and that it had not been in working order since 5/6/2025, the day prior, between 1:30 PM and 2:00 PM when she left at the end of her shift. Dietary [NAME] FF confirmed that maintenance was informed on that same day and that staff was instructed to use the 3-compartment sink until the dish machine was repaired. During an interview in the dish room on 5/7/2025 at 8:15 AM, the Maintenance Director confirmed that he was told on 5/6/2025 between 1:30 PM and 2:00 PM that the dish machine was not working properly and that he called to have it serviced. The Maintenance Director confirmed that staff was told on 5/6/2025 not to use the dish machine until it was repaired and that paper products would have to be used to serve the residents their meal. During an interview on 5/7/2025 at 8:24 AM, Dietary [NAME] FF, confirmed that she failed to inform staff to not use the dish machine on 5/6/2025 and to use paper products until the dish machine was repaired. Observation in the dish room on 5/7/2025 at 8:30 AM, confirmed resident meals were not served on paper product or plastic. Observation and interview in the kitchen on 5/7/2025 at 8:30 AM, revealed Dietary [NAME] FF was asked where was the thermometer in the ice cream freezer. Dietary [NAME] FF stated, I don't see it . Dietary [NAME] FF was asked how the temperatures are being recorded to ensure proper temperature levels if there is no thermometer. Dietary [NAME] FF did not answer. Dietary [NAME] FF was asked where the thermometer was for the milk cooler. Dietary [NAME] FF stated, I do not see one . Observation in the milk cooler revealed no thermometer present and observation of the temperature log for the milk cooler revealed the temperature was obtained at 5:30 AM at 30 degrees. Dietary [NAME] FF was asked how a temperature was recorded for 5:30 AM if there is no thermometer present. Dietary [NAME] FF stated, I pulled the milk out this morning, placed it on ice for breakfast and then checked the temperature . Dietary [NAME] FF was asked should there not be a thermometer in each cooler and freezer to ensure the appropriate temperature for the food items. Dietary [NAME] FF confirmed that there should be thermometers in the ice cream freezer and the milk cooler and that the temperature should be recorded. Observation and interview in the dry food storage area on 5/7/2025 at 8:35 AM, revealed 2 white plastic containers with lids containing thick yellow dried debris and a yellow sticky substance on top, both containers were unlabeled and undated. Dietary [NAME] FF confirmed that container #1 contained sugar and container #2 contained flour and both should be labeled and dated. Dietary [NAME] FF confirmed that the lids should be clean and free of debris to avoid any particles falling into the containers. During an interview on 5/7/2025 at 9:30 AM, the Administrator confirmed she was not informed the dish machine was not in working order on 5/6/2025 and that she should have been informed at that time. During an interview on 5/7/25 at 9:40 AM, the Registered Dietician (RD) confirmed that she was in charge since the Certified Dietary Manager (CDM) II was out of the facility for the week. The RD confirmed the CDM was in charge of the day-to-day operations of the kitchen including the cleanliness and that food should be served in a sanitary manner. The RD confirmed that the CDM and the dietary staff are to ensure that the kitchen is clean, and equipment is in working order. The RD confirmed that no kitchen equipment, including metal racks, stainless steel tables, and vents, should have rust or particle build up on them if they are cleaned as they should be. The RD confirmed that if food is opened, stored on racks, in cabinets, and in coolers and freezers, it should have an open date on it. The RD was asked who was responsible to ensure the ice machine is clean. The RD confirmed that she was unsure, but the CDM was ultimately responsible to ensure all equipment is in working order and free from dust and rust. The RD confirmed that no food should be left unattended and uncovered. The RD confirmed that the can opener should be cleaned after each use, each cooler and freezer should have a thermometer, and the temperature should be recorded at least twice a day. The RD confirmed that no carbon buildup should be on any cooking equipment such as baking sheets, pots, pans, skillets, or saucepans. The RD confirmed that all cooking utensils should be inspected for any dried food particles and should be rewashed if found. The RD confirmed that all dry ingredients such as sugar, flour, and meal should be stored in clean containers with lids and should be labeled and dated. The RD was asked if staff are working in the dish room should they know if the dish machine is high or low temperature and what process is used to determine the compliance with temperature readings to ensure dishes are cleaned and sanitized. The RD confirmed that staff should know if the dish machine is high or low, and what (temperature) the cycle should get up to, to ensure the dishes and utensils are sanitized. The RD confirmed that she was working in the kitchen on 5/6/2025 all day and was not informed that the dish machine was not in working order until 5/7/2025, and that she should have been informed. The RD was asked when staff should change the alcohol pad when taking tray line temperatures. The RD confirmed the alcohol pad should be changed in between taking each food item temperature. Observation and interview in the Conference Room on 5/7/2025 at 10:38 AM, revealed the Administrator was asked to review the temperature log for the ice cream freezer and the milk cooler and was asked how can staff record a temperature if there was no thermometer present in the ice cream freezer or the milk cooler. The Administrator confirmed that each cooler and freezer should have a thermometer inside so the temperature can be recorded and a record kept of the temperatures. During an interview on 5/7/25 at 11:31 AM, the Administrator and the Dishwasher Repairman was asked is the dish machine a high or low temperature machine. The Dishwasher Repairman confirmed the dish machine is a high temperature machine, and it should get up to 160-175 F degrees for the wash cycle and up to 140-160 F degrees for the rinse. The Dishwasher Repairman confirmed that he ran a cycle, the machine did not get above 60 F degrees, the Relay switch for the booster and the Transfer switch were not working, and after a hard reset it still wasn't working and a new part had been ordered.

Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of psychotropic medications for 2 of 5 sampled residents (Resident #13 and #52) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated ,d+[DATE], revealed .Residents will not receive medication that are not clinically indicated to treat a specific condition .A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-psychotics .Anti-depressants .Anti-anxiety medications .Residents, families and/or the representative are involved in the medication management process .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Acute Cerebrovascular Insufficiency, Psychosis and Unspecified Dementia with Behavioral Disturbance. Review of the [Named Psychiatric Services] Follow Up dated [DATE], revealed .Psychosis, Anxiety, Adjustment Disorder, Dementia .Resident is being seen for follow up. He states I'm okay; just waiting for lunch. He denies depression or anxiety. He reports that his sleep and appetite are stable .No behavioral issues or concerns reported by staff .Continue current treatment regimen . Review of the [Named Psychiatric Services] Follow Up dated [DATE], revealed .Medication Management .Seroquel [Antipsychotic medication primarily used to treat mental health conditions] 25 mg PO [by mouth] BID [twice per day] .Resident with a history of depression, anxiety, psychosis being seen for follow up .He denies depression or anxiety. He reports that his sleep and appetite are stable .No behavioral issues or concerns reported by staff .Continue current treatment regimen . Review of the [Named Psychiatric Services] Follow Up dated [DATE], revealed .Medication Management .Seroquel 25 mg PO BID .Resident with a history of depression, anxiety, psychosis being seen for follow up, staff request related to depression, recent death of daughter. He stated, My daughter died . He is tearful during today's evaluation related to recent death of his daughter. He reports that his sleep and appetite are stable .GDR [Gradual Dose Reduction] is not appropriate at this time .Start Sertraline [ Zoloft, an Antidepressant medication used to treat depression] 25 mg PO QDay [every day]; Will follow up in 2 weeks or sooner if needed . The follow up note revealed a new antidepressant was started for Resident #13. Review of Medication Administration Record (MAR) from [DATE]-[DATE] revealed Resident #13 received Zoloft 25 mg daily and Seroquel 25 mg two times daily. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed no mood or behaviors noted during the assessment reference dates. Further review revealed Resident #13 received an antipsychotic and antidepressant medication over the last 7 days. Review of Resident #13's Order Summary Report dated [DATE] revealed .Seroquel Oral Tablet 25 MG [milligram] Give 1 tablet by mouth two times a day for Mood swings related to UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE .Order Date [DATE] . Zoloft Oral Tablet 25 MG Give 1 tablet by mouth one time a day for Depression .Order Date XXX[DATE] . Review of the MAR from [DATE]-[DATE] revealed Resident #13 received Zoloft 25 mg daily and Seroquel 25 mg two times daily. Review of the MAR from [DATE]-[DATE] revealed Resident #13 received Zoloft 25 mg daily and Seroquel 25 mg two times daily. During a telephone interview on [DATE] at 3:43 PM, Family Member (FM) MM stated, .I don't know anything about his medications he takes . 3. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Diabetes Mellitus, Bipolar Disorder, Depression, and Anxiety. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. Continued review revealed no mood or behaviors noted during the assessment reference dates. Further review revealed Resident #52 received an Antipsychotic, Antianxiety, and Antidepressant over the last 7 days. Review of the MAR dated [DATE]-[DATE] revealed Resident #52 received Ativan (an Antianxiety medication given for Anxiety) 0.5 mg PRN (as needed) 58 times during the month of ,d+[DATE]. Continued review revealed Resident #52 did not receive PRN Diazepam (an Antianxiety medication) during the month of ,d+[DATE]. Further review revealed Resident #52 received Risperidone (an Antipsychotic medication) 2 mg daily and Trazodone (an Antidepressant medication) 100 mg at bedtime daily. Review of Resident #52's Order Summary Report dated [DATE], revealed .Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Anxiety .Order Date XXX[DATE] .diazepam Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety .Order Date XXX[DATE] .risperidone [used to treat mental illness] Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth one time a day for bipolar [A disorder associated with episodes of mood swings ranging from depressive lows to manic highs] .Order Date [DATE] . trazodone HCL (Hydrochloride) 100 MG (Trazodone HCL) Give 1 tablet by mouth at bedtime for insomnia [difficulty sleeping] .Order Date XXX[DATE]. Review of the MAR dated [DATE]-[DATE], revealed Resident #52 received Ativan 0.5 mg PRN 52 times during the month of ,d+[DATE]. Continued review revealed Resident #52 did not receive PRN Diazepam during the month of ,d+[DATE]. Further review revealed Resident #52 received Risperidone 2 mg daily and Trazadone 100 mg at bedtime daily. Review of the MAR dated [DATE]-[DATE], revealed Resident #52 received Ativan 0.5 mg PRN 10 times during the review period. Continued review revealed Resident #52 did not receive PRN Diazepam. Further review revealed Resident #52 received Risperidone 2 mg daily and Trazadone 100 mg at bedtime daily. During an interview on [DATE] at 1:27 PM, The Regional Director of Clinical Services was asked where consents would be for psychotropic medications. The Regional Director stated, .I will ask the Director of Nursing (DON) where the consents are at . During an interview on [DATE] at 10:30 AM, the Social Service Director (SSD) was asked if she was involved in reviewing the medications, treatment options, and obtaining consents from resident or resident representative for psychotropic drugs. The SSD stated, .I have never done consents signed by the family . During an interview on [DATE] at 10:45 AM, the DON was asked if she had consents for the use of psychotropic medications for Resident #13 and Resident #52. The DON stated, .we do not have any consents right now .we started doing them last Friday [[DATE]] after the Consultant looked into the situation .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 1 of 78 (Resident #83) resident occupied rooms. The findings include: 1. Review of the facility policy titled, Storage of Medications, dated 4/2007, revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 2. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE], with diagnoses including Diabetes, Alzheimer's Disease, Depression, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #83 was severely cognitively impaired. During a random observation in the Resident's room on 5/5/2025 at 10:36 AM and at 11:22 AM, an unsecure and unattended medication cup with 8 pills was observed on the Resident's dresser. Observation and interview in the Resident's room on 5/5/2025 at 11:27 AM, revealed Licensed Practical Nurse (LPN) BB confirmed that she was not assigned to the resident and was unaware of the medications in the medication cup and confirmed meds should not be left at bedside. During an interview on 5/13/2025 at 3:58 PM, the Director of Nursing (DON) confirmed that medications should not be left at the bedside.

Based on policy review, medical record review, and interview, the facility failed to follow physician's orders and obtain lab work for 2 of 5 (Resident #4 and #100) sampled residents reviewed for unnecessary medication use. The findings include: 1. Review of the facility policy titled, Laboratory Services and Reporting, dated 11/24/2024, revealed .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state la .The facility is responsible for the timeliness of the service . 2. Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE], with diagnoses including Diabetes, Urinary Tract Infection, and Colostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated Resident #4 was severely cognitively impaired and received hypoglycemic medications. Review of the Care Plan dated 2/21/2025, revealed .diagnosis of Diabetes Mellitu .Labs as ordered per MD [Medical Doctor] . Review of the Physician Orders dated 1/26/2025, revealed .every 3 months-HgbA1c [Hemoglobin A1C is a blood test that measures average blood sugar levels over 2 to 3 months] .December .March . Review of the medical record revealed the facility failed to obtain a HgbA1C level for March 2025 for Resident #4. During an interview on 5/7/2025 at 10:45 AM, the Administrator confirmed that labs should be obtained per physician orders. 3. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Colon (Cancerous tumor in the colon), Diabetes, Vitamin D Deficiency, Anemia, Convulsions, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #100 was moderately cognitively impaired. Review of the quarterly Care Plan for Resident #100 dated 2/26/2025, revealed .Obtain and monitor lab/diagnostic work as ordered . Review of the Physician Orders dated 5/5/2025, revealed .drawn every year .PSA [Prostate-Specific Antigen] .Labs to be drawn every 6 months .CK [Creatine Kinase is a lab to measure the amount of metabolism of muscle] .November .May .Labs to be drawn every 3 months .HgbA1C .February . Review of the medical record revealed the facility failed to obtain a CK level and a PSA level for Resident #100 for October 2024 and failed to obtain a HgbA1C level for February 2025. During an interview on 5/12/2025 at 4:45 PM, the Director of Nursing (DON) confirmed that labs should be obtained as ordered by the physician. 51740

Based on policy review, record review, and interview, the facility failed to notify the resident's representative or family member of the intent to discharge for 1 of 3 (Resident #316) sampled residents reviewed for discharge. The findings include: 1. Review of the facility policy titled, Transfer or Discharge ., dated 8/2018, revealed .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .Notify the representative (sponsor) or family member . 2. Review of the medical record revealed Resident #316 was admitted to the facility on [DATE], with diagnoses including Pulmonary Embolism, Myocardial Infarction, and Acute Kidney Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #316 was severely cognitively impaired. Review of the Nurse's Note dated 8/2/2023, revealed Resident discharged to [Named] Psychiatric Care, left via (by way of) stretcher in stable condition, denies pain and discomfort. Resident left with all his belonging. Community Service transport resident to [Named] Psychiatric Care . Review of the Social Services Note dated 8/2/2023, revealed Phone call made to [Named facility] .we will not be able to accept him back because of his elopement risk and that he's needing a lock down unit for his safeness [safety] . During a telephone interview on 5/8/2025 at 12:56 PM, the Resident's representative (RP) confirmed she was unaware of the facility's decision to discharge the resident, and the facility would not be accepting the resident back. During an interview on 5/12/2025 at 10:59 AM, the Social Services Director (SSD) confirmed that Resident #316's representative was not informed of the facility's intent to discharge the resident from the facility. The SSD confirmed that Social Services was responsible for informing the resident's representative of intent to discharge from the facility and the refusal to accept the resident back. During an interview on 5/13/2025 at 3:58 PM, the Director of Nursing (DON) confirmed that Social Services was responsible for informing residents and/or representative of intent to discharge. The DON confirmed that the communication with the representative regarding the facility's decision to discharge should be documented in the resident's medical record.

Based on the facility policy review, medical record review, Incident Reporting System (IRS), and interview the facility failed to report sufficient information to describe the results of all investigations to the State Survey Agency within 5 working days of the incident for 1 of 2 (Resident #515) sampled residents reviewed for an injury of unknown origin. The findings include: 1. Review of the facility policy titled, Abuse Investigations, dated 4/2010, revealed .Policy Statement .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .Should an incident .of unknown source be reported, the Administrator .will appoint a member of management to investigate the alleged incident .The Administrator will provide a written report of the results of all .investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident . Review of the facility policy titled, ACCIDENT & [and] INCIDENT DOCUMENTATION & INVESTIGATION RESIDENT INCIDENT, dated 7/2018, revealed .Accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC [Long Term Care] system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents .The Executive Director/Director of Nursing will notify the State Department of Health in accordance with reporting guidelines in the event the accident/incident is reportable . 2. Review of the medical record revealed Resident #515 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease, Lack of Coordination, Muscle Weakness, and Repeated Falls. Review of Resident #515's care plan dated 12/5/2023, revealed .Focus .is at risk for falls r/t [related to] new and unfamiliar environment, poor safety awareness, unsteady gait, weakness .Interventions .Be sure the call light is within reach and educate the resident on use. Reinforce and encourage resident to call for assistance. Respond promptly to all requests for assistance as needed . Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #515 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Continued review revealed Resident #515 required substantial/maximal assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer was not attempted due to medical condition or safety concerns and dependent for walking 10 feet. Further review revealed Resident #515 had a fall in the last month. Review of the Progress Notes dated 1/7/2024 at 4:00 PM, revealed .Resident [#515] in room screaming 'help'. Upon entering room resident observed on floor leaning on left side a few feet from restroom door. Resident's w/c [wheelchair] observed on left side of resident's bed. Call light clipped onto resident's bed. No call light in use. Prior to fall this nurse witnessed resident sitting up on left side of bed. Resident c/o [complained of] pain to right hip and leg, requesting X-ray stating 'I can't move this side.' No redness/swelling nor abnormalities noted to right hip and leg at this time. No abnormalities noted to resident's head. ROM [Range of Motion] WNL [Within Normal Limit] to left leg and BUE [Bilateral Upper Extremity]. Resident assisted to w/c from bed via [by way of] total lift, staff x [times] 2. RP [Responsible Party] made aware. Unable to reach MD [Medical Doctor]. PRN [As needed] Tylenol admin [administered] for pain . Review of the Progress Notes dated 1/7/2024 at 6:40 PM, revealed, .New order per NP [Nurse Practitioner] to transfer resident [#515] to ER [emergency room ] for eval. Medical transport contacted with 1.5hour ETA [Estimated Time of Arrival]. RP made aware . Review of the Progress Notes dated 1/7/2024 at 10:28 PM, revealed .Resident [#515] transferred to [Named Hospital #1] ER for eval. s/p [status post] fall . Review of the IRS revealed .Allegation Type .Other Not Listed .Facility became aware of the incident .1/8/2024 11:00 AM .Name [Named Administrator] .Alleged Victim .[Named Resident #515] .Allegation Details .unwitnessed Fall .Date and time when the alleged incident occurred .1/07/2024 4:00 PM .residents [resident's] room .Provide details of any physical harm .resident complaints of right shoulder and hip pain .Provide all steps taken immediately to ensure resident(s) are protected .On 1/7/24 [2024] [Named Resident #515] was noted yelling for help in her room. Upon the nurse's arrival resident was noted lying on the floor on her left side in front of the bathroom door. The wheelchair was noted on the left side of the bed where the resident was last reported sitting on her bed. Resident was assisted to bed where full body audit was performed. Resident did report c/o [complaint of] right shoulder and hip pain. MD [Medical Doctor] notified and resident was sent to ER [emergency room ] for evaluation per MD orders .ATTENTION: PLEASE INCLUDE ENOUGH INFORMATION IN THIS BOX TO EXPLAIN BRIEFLY WHAT OCCURRED AND WHAT YOUR IMMEDIATE INTERVENTION/S WAS .ADD also: Investigation initiated . The IRS box for the information was blank with no investigation submitted. Review of the complaint intake dated 1/8/2024 revealed, Follow up submitted the same day Right femoral fracture. Mrs. [Responsible Party] made aware @ 1600 [4:00 PM]. The intake revealed no interventions or investigation was noted in the follow up submission. The facility reported 1 sentence as their follow-up investigation and failed to provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken. During a telephone interview on 5/12/2025 at 6:51 AM, State Agency Intake Staff stated, .the facility did not submit a final investigation . During an interview on 5/13/2025 at 5:16 PM, the Administrator was asked if the facility had reported incident to the state agency, when would the facility submit the final investigation. The Administrator stated, .In 5 days .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure as needed (PRN) psychotropic medications for 1 of 5 (Resident #52) sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or document rationale for continued use of the medication. The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated 7/2022, revealed .Residents will not receive medication that are not clinically indicated to treat a specific condition .A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-psychotics .Anti-depressants .Anti-anxiety medications .Psychotropic medication management includes .indications for use .dose .duration .adequate monitoring for efficacy and adverse consequences .preventing, identifying and responding to adverse consequences .Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record .Prn orders for psychotropic medications are limited to 14 days .if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus, Bipolar Disorder, Depression, and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #52 was cognitively intact. Continued review revealed no mood, or behaviors were noted during the assessment reference dates. Further review revealed Resident #52 received an Antianxiety over the last 7 days. Review of the Medication Administration Record (MAR) dated 3/1/2025-3/31/2025, revealed Resident #52 received Ativan (Antianxiety medication given for Anxiety) 0.5 milligram (mg) PRN 58 times during the month of 3/2025. Continued review revealed Resident #52 did not receive Diazepam (Antianxiety) during the month of 3/2025. Review of Resident #52's Order Summary Report dated 4/1/2025, revealed .Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Anxiety .Order Date .3/10/2025 .diazepam Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety .Order Date .8/22/2024 . Review of the MAR dated 4/1/2025-4/30/2025, revealed Resident #52 received Ativan 0.5 mg PRN 52 times during the month of 4/2025. Continued review revealed Resident #52 did not receive PRN Diazepam during the month of 4/2025. Review of the MAR dated 5/1/2025-5/6/2025, revealed Resident #52 received Ativan 0.5 mg PRN 10 times in the last 6 days. Continued review revealed Resident #52 did not receive PRN Diazepam in the last 6 days. Review of the Pharmacist Consultant Note dated 5/7/2025, revealed Resident #52 received monthly pharmacy reviews from 10/2024 to 3/2025 with no new recommendations. During an interview on 5/12/2025 at 10:30 AM, the Social Service Director (SSD) stated, .we have GDR [Gradual Dose Reduction] meeting monthly . SSD was asked what the rationale for Resident #52 having two prn orders for an antianxiety and why were they ordered over (for longer than) 14 days. SSD stated, .I didn't really know anything about them being ordered over 14 days. Review of the Patient Information Report from Hospice #1 Agency with print date 5/12/2025, revealed no documentation for the rationale for prn Ativan and prn Diazepam. During an interview on 5/12/2025 at 3:50 PM, the Medical Director (MD) was asked the reason or rationale for Resident #52 having orders for Ativan and Diazepam over 14 days. The MD stated, .she is under hospice care that doctor would be reviewing her medications . During a telephone interview on 5/12/2025 at 4:04 PM, the Pharmacist was asked why Resident #52 would have an order for prn Ativan and prn Diazepam, two different Antianxiety medications. The Pharmacist stated, .I honestly don't have the answer for you .one of those should be discontinued . The Pharmacist was asked if a PRN psychotropic medication should have a stop date. The Pharmacist stated, .they don't have to have a stop date is my understanding .

Based on policy review, medical record review, and interview, the facility failed to provide education and written information to resident and/or family representative to formulate an Advance Directive for 27 of 35 sampled residents (Resident #4, #22, #28, #29, #30, #37, #39, #42, #48, #66, #69, #75, #87, #91, #100, #102, #112, #119, #125, #129, #137, #139, #143, #146, #151, #265, and #465) reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled, Advance Directives, dated 2001, revealed .The resident has the right to formulate an advance directive .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family and/or his or her legal representative, about the existence of any written advance directives .The resident or representative is provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so . 2. Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE], with diagnoses including Diabetes, Hemiplegia/Hemiparesis, Dementia, Anxiety, Cerebrovascular Disease, and Colostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated Resident #4 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Anoxic Brain Damage, Sudden Cardiac Arrest, Heart Failure, and Quadriplegia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 was in a persistent vegetative state/no discernible consciousness. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 4. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Diabetes and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #28 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or the resident representative was educated regarding advance directives and/or to formulate an advance directive. 5. Review of the medical record revealed Resident #29 was admitted on [DATE], with diagnoses including Chronic Kidney Disease, Cerebral Infarction, Dependent on Renal Dialysis. Review of the admission MDS assessment dated [DATE], revealed staff did not perform a BIMS due to Resident #29 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 6. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes and Anoxic Brain Injury. Review of the quarterly MDS assessment dated [DATE], revealed Resident #30 was in a persistent vegetative state/no discernible consciousness. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 7. Review of the medical record revealed Resident #37 was readmitted to the facility on [DATE], with diagnoses including Hypertensive Chronic Kidney Disease, Malnutrition, and Dysphagia. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 0, which indicated Resident #37 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 8. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Trisomy 21 and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 3, which indicated Resident #39 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 9. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Diabetes, Hemiplegia, and Aphasia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 8, which indicated Resident #42 was moderately cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 10. Review of the medical record revealed Resident #48 was readmitted to the facility on [DATE], with diagnoses including Diabetes, End Stage Renal Disease, Heart Failure, and Traumatic Amputation of Left Knee and Ankle. Review of the annual MDS assessment dated [DATE], revealed a BIMS of 15, which indicated Resident #48 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 11. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Diabetes, Atherosclerotic Heart Disease and Adjustment Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #66 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 12. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Chronic Obstructive Pulmonary Disease, and Atherosclerotic Heart Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #69 was moderately cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 13. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Diabetes, Malnutrition, Schizoaffective Disorder, Hypertension, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #75 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 14. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE], with diagnoses including Diabetes, Malnutrition, Schizoaffective Disorder, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #87 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 15. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Malnutrition, Tracheostomy, and Pressure Ulcer of Sacral Region. Review of the quarterly MDS assessment dated [DATE], revealed staff did not perform a BIMS due to Resident #91 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 16. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Colon (Cancerous tumor in the colon), Diabetes, Dementia, Psychotic Disturbance, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #100 was moderately cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 17. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Depression and Diabetes. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #102 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 18. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE], with diagnoses including Anoxic Brain Damage and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed the staff did not perform a BIMS due to Resident #112 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 19. Review of the medical record revealed Resident #119 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Anoxic Brain Injury, Gastrostomy, and Tracheostomy. Review of the quarterly MDS assessment dated [DATE], revealed staff did not perform a BIMS due to Resident #119 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 20. Review of the medical record revealed Resident #125 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Dysphagia, Cerebral Infarction, Dementia, and Viral Hepatitis. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #125 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 21. Review of the medical record revealed Resident #129 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Dysphagia, and Schizoaffective Disorder. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #129 was moderately cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 22. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 7, which indicated Resident #137 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 23. Review of the medical record revealed Resident #139 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Chronic Respiratory Failure, Diabetes, and Anxiety. Review of quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #139 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 24. Review of the medical record revealed Resident #143 was admitted to the facility on [DATE], with diagnoses including Anoxic Brain Injury, Chronic Respiratory Failure, Diabetes, and Malnutrition. Review of the significant change MDS assessment dated [DATE], revealed a BIMS was not performed due to Resident #143 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 25. Review of the medical record revealed Resident #146 was admitted to the facility on [DATE], with diagnoses including Myopathy, Chronic Respiratory Failure, Diabetes, Gastrostomy, and Adult Failure to Thrive. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #146 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 26. Review of the medical record revealed Resident #151 was admitted on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, Schizophrenia, and Traumatic Brain Injury. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #151 was cognitively intact. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 27. Review of the medical record revealed Resident #265 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Diabetes, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #265 was severely cognitively impaired. The facility was unable to provide completed documentation in the medical record that the resident and/or resident representative was educated regarding advance directives and/or to formulate an advance directive. 28. Review of the medical record revealed Resident #465 was admitted to the facility on [DATE], with diagnoses including Diabetes, Adjustment Disorder, Malnutrition, and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #465 was cognitively intact. The facility was unable to provide completed documentation in the medical record the resident and/or resident representative was educated regarding advance directives and/or to formulate and advance directive. During an interview on 5/12/2025 at 11:18 AM, the Marketing Director was asked the process for advance directives. The Marketing Director confirmed that there was not a process in place prior to last week for educating residents and/or representatives on how to formulate an advance directive. 38909 46252 47127 47835 49269 51740 51992

Based on policy review, medical record review, facility investigation review and interview, the facility failed to follow the resident ' s comprehensive person-centered care plan for 1 of 3 residents (Resident #4) reviewed for fall prevention and care plans. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 7/10/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .The comprehensive care plan will include measurable objectives and timeframes to meet the resident ' s needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident ' s progress .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the facility policy titled, Fall Prevention Program, dated 7/10/2024, revealed .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Interventions will be monitored for effectiveness . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Personal History of Sudden Cardiac Arrest, Unspecified Sequelae of Cerebral Infarction, Chronic Respiratory Failure with Hypoxia, and Osteopenia. Review of the comprehensive care plan dated 8/14/2024, with a revision date of 9/12/2024, revealed Resident #4 was assessed for high fall risk and required 2-person assist for bed mobility. Review of the facility Incident Audit Report, dated 10/5/2024, revealed Licensed Practical Nurse (LPN) F was .called to resident's [Resident #4] room per CNA [Certified Nursing Assistant] [G] .CNA [G] stated that she slid the resident to the floor .resident assessed for injuries none noted . assisted up and back into to bed via [by] [brand name of a mechanical lift] & 3 staff members . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #4 had severely impaired cognition. Review of the Nurses Note dated 10/5/2024, revealed .called to resident's room per CNA [G], found resident lying on her back on the floor beside her bed on the (R) [right] side of bed, CNA [G] stated that she slid the resident to the floor . During a phone interview on 1/29/2025 at 8:25 AM, LPN F confirmed that at the time of the occurrence on 10/5/2024, CNA G had Resident #4 turned on her side to change her and provide care. When LPN F was asked if anyone assisted CNA G with turning of Resident #4, LPN F stated, No, but I was outside in the hallway. During an interview on 1/29/2025 at 9:38 AM, the Director of Nursing (DON) confirmed that staff were not following Resident #4's plan of care at the time of the fall on 10/5/2024.

Based on facility policy review, Resident Assessment Instrument (RAI) manual review, medical record review, weekly skin evaluations review, facility document review, and interview, the facility failed to accurately document skin assessments for 1 of 3 (Resident #1) residents with wounds reviewed. The findings include: 1. Review of the facility policy titled, Prevention of Pressure Injuries, with revision date of 4/2020, revealed .The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Risk Assessment .Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .Use a standardized pressure injury screening tool to determine and document risk factors .Supplement the use of a risk assessment tool with assessment of additional risk factors .Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident ' s risk factors, and prior to discharge . Review of the Resident Assessment Instrument (RAI) manual version 3.0 dated 10/2024 revealed, .Section M Skin Conditions .The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries .It is important to recognize and evaluate each resident ' s risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Left Hemiplegia and Hemiparesis, Diabetes, Morbid Obesity, Hypertension (HTN), and Anxiety. Review of Resident #1's Order Summary Report dated 8/15/2023 revealed, .Weekly Skin Evaluation: Nurse to initial and code appropriately. 0 = [equals] No Skin Impairment 1 = Pre-existing Skin Condition 2 = New Area (proceed to appropriate Pressure/Nonpressure Wound .every night shift every Wed [Wednesday] . Review of the Medication Administration Record (MAR) dated 10/2024, revealed the Nurse completing the Weekly Skin Evaluation should initial 0 for skin impairment, 1 for pre-existing skin condition, and 2 for new area. Continued review revealed a check mark with the initials of the nurse who completed the weekly skin evaluation on 10/2/2024, 10/9/2024, 10/16/2024, 10/23/2024 and 10/30/2024. The review revealed the Weekly Skin Evaluation was not accurately assessed as noted in the order. Review of the MAR dated 11/2024, revealed the Nurse completing the Weekly Skin Evaluation should initial 0 for skin impairment, 1 for pre-existing skin condition, and 2 for new area. Continued review revealed a check mark with the initials of the nurse who completed weekly skin evaluation on 11/6/2024, 11/13/2024, 11/20/2024, and 11/27/2024. The review revealed the Weekly Skin Evaluation not accurately assessed as noted in the order. Review of Resident #1's Non-Pressure Ulcer Skin Condition dated 11/27/2024, revealed a diabetic wound found to the right 2nd toe which measured 1.5 centimeters (cm) in length, 1.0 cm in width, depth not measured (nm) and description of wound bed 100 % necrosis (the death of tissues in the body). Review of Resident #1's Non-Pressure Ulcer Skin Conditions dated 11/27/2024 revealed a diabetic wound found to the left 1st toe which measured 1.0 cm in length, 1.5 cm in width, depth nm and description of wound bed 100 % necrosis. Review of the MAR dated 12/2024, revealed the Nurse who completed the Weekly Skin Evaluation should initial 0 for skin impairment, 1 for pre-existing skin condition, and 2 for new area. Continued review revealed a check mark with the initials of the nurse who completed the weekly skin evaluations on 12/4/2024, 12/11/2024, 12/18/2024, and 12/25/2024. The review revealed the Weekly Skin Evaluation was not accurately assessed as noted in the order. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition, required set up with eating, dependent for toileting, shower, dressing, personal hygiene, substantial/maximal assist with bed mobility, and always incontinent of bowel and bladder, and had 2 diabetic foot ulcers present during the assessment period. Review of the MAR dated 1/2025, revealed the Nurse completing the Weekly Skin Evaluation should initial 0 for skin impairment, 1 for pre-existing skin condition, and 2 for new area. Continued review revealed a check mark with the initials of the nurse who completed weekly skin evaluation on 1/1/2025, 1/8/2025, 1/15/2025, and 1/22/2025. The review revealed the Weekly Skin Evaluation was not accurately assessed as noted in the order. During an observation on 1/28/2025 at 8:53 AM, Resident #1 was in bed lying in supine position with posey boots (multipurpose foot boot to help prevent heel and toe ulcers) noted to both lower extremities. Resident #1 was unable to answer questions during the interview. During a telephone interview on 1/28/2025 at 9:13 AM, Family Member (FM) A stated, .I was not made aware of the wounds. I found out one day when I came to visit. I usually visit her about once per week. She has been at this facility for almost a year .Someone called me the other day and said she had a new wound .she has been a Diabetic for years and that's another concern because I know when wounds happen sometimes, they have to amputate toes, and I don't want that to happen . During an interview on 1/28/2025 at 4:37 PM, the Director of Nursing (DON) was asked to review the Prevention of Pressure Injuries policy and asked if a check mark described the risk factors or was a comprehensive skin assessment for Resident #1. The DON stated, .it is a just a check mark showing the skin assessment was done . The DON was unable to provide weekly skin assessment documentation for Resident #1 for 10/2024 until the two diabetic ulcers were found on 11/27/2024 when the wounds were noted as necrotic tissue. The DON confirmed the weekly skin evaluations should be marked as 0 for no skin impairment, 1 for an existing condition, and 2 for new area on the MARS for Resident #1. During an interview on 1/28/2025 at 4:50 PM, Licensed Practical Nurse (LPN) H was asked to review Resident #1's weekly skin assessment documentation on the 1/2025 MAR. LPN H stated, .the order is not put in correctly .the only thing charted is a check mark .

Based on policy review, observation, and interview, the facility failed to provide reasonable accommodations of needs for bathing when the water was not at the minimum temperature for hot water for 5 of 10 sampled residents (Resident #2, #7, #8, #9 and #10) reviewed for resident rights. The findings include: Review of the facility's undated policy titled Resident Rights revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .self-determination . Review of the Rules of the Tennessee Health Facilities Commission dated July 2022, revealed .Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105 [degrees] F [Fahrenheit] and 115 F . Review of the Resident Council Minutes dated October 8, 2024, revealed . MAINTENACE [MAINTENANCE] .WATER STILL NOT GETTING HOT . Review of .QAPI [Quality Assurance Process Improvement] MINUTES 12/19/2024, revealed .12/19/24 .MEASURE PERFORMANCE .Hot Water Tanks .1/23/25 Received Traditional quote .Estimate accepted .on 1/22/25 . Review of the Resident Council Minutes dated January 14, 2025, revealed . MAINTENACE [MAINTENANCE] .WATER NOT GETTING HOT . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of the left Buttock, Anemia and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15 which indicated that Resident #2 was cognitively intact. Review of the medical revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia, Chronic Obstructive pulmonary Disease, and Diabetes. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated Resident #7 was moderately cognitively impaired. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, End Stage Renal Disease and Congestive Heart Failure. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident #8 was cognitively intact. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hemiplegia and Hemiparesis following a Cerebral Infarction. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #9 was cognitively intact. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Kidney Disease and Anemia. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #10 was cognitively intact. Observation and interview on 1/27/2025 at 12:00 PM with the Maintenance Director revealed water temperatures in the Resident Rooms were between 80 F and 104 F. When asked what the water temperature should be the Maintenance Director stated .between 97 F and 105 F . During an interview on 1/27/2025 at 2:40 PM, Resident #10 stated, .water is too cold take a shower and it has been cold for a long time . During an interview on 1/28/2025 at 8:40 AM, Resident #2 stated . haven't had a bath in a few days .the water is too cold . During and interview on 1/28/2025 at 8:45 AM, Resident #7 was asked about her shower procedure. She stated .water is too cold . During an interview on 1/28/2025 at 8:55 AM, Resident #8 stated .no hot water for a while .not had a good bath . During an interview on 1/28/2025 at 9:13 AM, Resident #9 .haven't had a shower in a long time. The water is cold . During an interview on 1/28/2025 at 10:54 AM, the Administrator was asked if she was aware the water was an issue in October 2024. She stated, I was not aware, maintenance could have known and did not tell me. During an interview on 1/28/2025 at 2:12 PM the Administrator was asked if the Maintenance Director was aware of the issue in October should this have been addressed then. She stated .if he was made aware of it in October, he should have made me aware .

Based on policy review, user instruction manual review, job description review, medical record review, observation, and interview, the facility failed to ensure staff practices to prevent the potential spread of infection were maintained when multi-use blood glucometers were not cleaned and disinfected after/between resident testing to prevent cross-contamination of bloodborne pathogens for 5 of 9 sampled residents (Resident #9, #10, #11, #12, and #13) reviewed for blood glucose monitoring, when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) when providing care to Residents #9, #10, #11, #12, #17, and #18, and when staff failed to ensure reusable equipment was cleaned and disinfected when 2 of 2 staff members (Certified Nursing Assistant (CNA) N and CNA M) were observed during transferring Resident #4 with a mechanical lift. The facility's failure to ensure nursing staff properly disinfected the multi-use blood glucose meter that was used for multiple residents without disinfecting after/between resident testing placed residents at risk for contamination with bloodborne pathogens and had the likelihood to cause serious injury, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operation Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-880 on 6/18/2024 at 1:13 PM, in the Conference Room. The facility was cited Immediate Jeopardy for F-880 at a scope and severity of K. The Immediate Jeopardy began on 6/18/2024 through 6/21/2024, the IJ was removed on 6/22/2024. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/18/2024 at 4:19 PM. The corrective actions were validated onsite by the surveyors on 6/21/2024 through review of in-service documentation, audits, and staff interviews. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, (Named Facility) Glucometer Disinfection, dated 2020, revealed .The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents .The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The glucometers will be disinfected with a wipe pre-saturated with an EPA [Environmental Protective Agency] registered healthcare disinfectant that is effective against HIV [human immunodeficiency virus], Hepatitis C, and Hepatitis B virus [infection of the liver] Glucometer will be cleaned and disinfected after each use and accordance to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use .Obtain needed equipment and supplies .Retrieve (2) disinfectant wipes from container .Use first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer .After cleaning use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry . Review of the undated [Named Company] User Instruction Manual, for Glucometers revealed .Cleaning & [and] Disinfecting Guidelines .We suggest cleaning and disinfecting the meter between patient use .Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe .Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used .use one wipe to clean and the second wipe to disinfect .With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level . Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment [Named Facility], dated 2022, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . Review of the facility's policy titled, Enhanced Barrier Precautions [Named Facility], dated 6/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .An order for enhanced barrier precaution will be obtained for residents with any of the following .Wounds .( .chronic wounds .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .indwelling medical devices .(urinary catheters, feeding tubes, tracheostomy/ventilator tubes .) .PPE for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident room .High-contact resident care activities .Dressing .Bathing .Transferring .Providing hygiene .Changing linens .Changing briefs or assisting with toileting .Device care or use .central lines, urinary catheters, feeding tubes, tracheostomy/ventilators tubes, hemodialysis catheters, PICC [peripherally inserted central catheter line] lines, midline catheters .Wound care .any skin opening requiring a dressing . Review of the Director of Nursing Services, Job Description signed 5/1/2024, revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities .Make daily rounds of your unit/shift to ensure that assigned CNAs and other nursing personnel are performing their work assignment in accordance with acceptable nursing standards . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with a readmission on 4/24/2024, with diagnoses including Chronic Respiratory Failure, Diabetes, Gastrostomy, Tracheostomy, and Hypertension. Review of the Physician's Orders dated 4/25/2024, revealed .Insulin Lispro [used to control blood sugar] .Injection Solution 100 UNIT/ML [millimeters] .Inject subcutaneously every 6 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and Peg (Percutaneous endoscopic gastrostomy is a medical device used to provide nutrition and hydration directly into the stomach), tube. Observation at the medication cart on 6/18/2024 at 5:32 AM, revealed Agency LPN A removed the blood glucometer from the top left drawer of the medication cart and placed the blood glucometer on top of the medication cart without a barrier. Agency LPN A gathered her supplies, the blood glucometer, entered Resident #9's room, and placed the blood glucometer and supplies on the resident's bed without a barrier. Agency LPN A pricked Resident #9's finger with the lancet, picked up the blood glucometer, inserted the test strip into the glucometer, placed the blood sample onto the test strip, then placed the blood glucometer back on Resident #9's bed to read the results. Agency LPN A exited Resident #9's room and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A failed to don her gown before providing direct care to a resident in enhanced barrier precaution. Agency LPN A failed to clean and disinfect the blood glucometer after/between resident testing. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with a readmission on 6/1/2024, with diagnoses including Anoxic Brain, Diabetes, Tracheostomy, Gastrostomy, Hypertension, and Vegetative State. Review of the Physician's Orders dated 4/11/2024, revealed .Check [PEG tube] placement by auscultation and aspiration prior to all medication administration, flush and feeding .every shift .Check Residual Q [every] Shift .every shift . Review of the Physician's Orders dated 5/22/2024, revealed .Insulin Aspart Injection Solution 100 UNIT/ML . Inject 12 unit subcutaneously three times a day related to .DIABETES .Hold for Blood sugar < [less than] 150 . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:37 AM, revealed Agency LPN A gathered her supplies, entered Resident #10's room, and placed the supplies and blood glucometer on the resident bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer and inserted the test strip into the glucometer, and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back on the resident's bed to read the results. Agency LPN A gathered the supplies and the blood glucometer, removed gloves, exited the resident's room, and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A gathered medication for administration via (by) PEG tube, and reentered Resident #10's room placing the medication cup on the nightstand. Agency LPN A administered the medication and when attaching the tip of the enteral tube into the PEG tube, the tip of the tubing dislodged and the tip of the tubbing fell on the floor. Agency LPN A picked up the enteral tubing off the floor, reinserted the tip of the enteral tube into the Peg tube and the tubing dislodged again and hit the floor a second time. LPN A picked up the enteral tube off the floor and reinserted the enteral tube to the PEG tube site. Agency LPN A failed to don her PPE (gown) before providing care to a resident in enhanced barrier precaution and failed to clean and disinfect the blood glucometer after/between resident testing. Agency LPN A failed to change out the contaminated enteral feeding tube that tip fell on the floor. 4. Review the of medical record revealed Resident #11 was admitted to the facility on [DATE], with a readmission on 1/13/2024, with diagnoses including Anoxic Brain, Gastrostomy, Persistent Vegetative State, and Diabetes. Review of the Physician's Orders dated 1/13/2024, revealed .NovoLOG [used to control blood sugar] PenFill Subcutaneous Solution Cartridge 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:57 AM, revealed Agency LPN A entered Resident #11's room, donned her gloves, hung the enteral feeding, exited the resident's room, and gathered the supplies and blood glucometer from on top of medication cart. Agency LPN A reentered Resident #11's room and placed the supplies and blood glucometer on the resident's bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer, inserted a test strip into the glucometer and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back down on the resident's bed to read the results. Agency LPN A removed her gloves, picked up the blood glucometer and supplies off of Resident #11's bed and walked to the opposite side of the resident's bed and picked up a towel off the floor and placed the towel on the resident's chest. Agency LPN A exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. LPN A picked up a dirty towel off the floor and placed it on the resident's chest. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with a readmission on 5/30/2024, with diagnoses including Chronic Respiratory Failure, Hyperglycemia, Methicillin Resistant Staphylococcus Aureus, and Diabetes. Review of the Physician's Orders dated 6/3/2024, revealed .HumaLOG [used to lower the blood sugar] Injection Solution 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation at the medication cart on 6/18/2024 at 6:37 AM, revealed Agency LPN A donned her gloves, gathered supplies and the blood glucometer, and then entered Resident #12's room. Agency LPN A placed the supplies and blood glucometer on the resident's bed with no barrier present, administered the eye drops and removed her gloves. Agency LPN A donned her gloved, pricked the resident's finger, picked up blood glucometer and inserted the test strip, obtained a blood sample and placed it on the strip, and placed blood glucometer back down on the resident's bed for the reading. Agency LPN A gathered the supplies and the blood glucometer and exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. Random observation in the resident's room on 6/24/2024 at 4:13 PM, revealed CNA O failed to don PPE when she bathed Resident #12, who was in enhanced barrier precautions. 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with a readmission on 3/1/2024, with diagnoses including Chronic Respiratory Failure, Diabetes, Hypertension and Anxiety. Review of the Physician's Orders dated 3/8/2024, revealed .Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours for .DM [Diabetes Mellitus] .per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy. Observation in the resident's room on 6/18/2024 at 6:30 PM, revealed Agency LPN B donned his gloves removed the blood glucometer from the medication cart, entered Resident #13's room pricked the resident's finger, inserted the strip and obtained a blood sample to check the blood sugar. Agency LPN B failed to clean and disinfect the blood glucometer before use when he removed the blood glucometer from the medication cart. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again . 7. Review the of medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, Tracheostomy, Gastrostomy, and Acute Respiratory Failure. Review of the Physician's Orders dated 5/8/2024, revealed .Check [PEG tube] Residual Q [every] Shift . Check placement by auscultation and aspiration prior to all medication administration, flush and feeding . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:21 AM, revealed Agency LPN A entered Resident #17's room with the resident's enteral feeding formula, donned her gloves, hung the enteral feeding on the intravenous pole, disconnected the old enteral feeding formula tube from the PEG tube and connected a new enteral feeding tube to the PEG tube. LPN A failed to don her PPE gown before providing care to a resident with a PEG tube in enhanced barrier precautions. 8. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with a readmission on 8/21/2023, with diagnoses including Gastrostomy, Tracheostomy, Respiratory Failure, Acute Kidney Failure, and Adult Failure to Thrive. Review of the Physician's Orders dated 8/22/2023, revealed .Check placement [of PEG tube] by auscultation and aspiration prior to all medication administration, flush and feeding .every shift . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 6:44 AM, Agency LPN A entered Resident #18's room for medication administration via PEG tube. Agency LPN A donned her gloves, raised bed with the remote, administered medication via PEG tube, flushed with 60 cc (centimeters) of water, administered medication and flushed with 30 cc water. Agency LPN A failed to don her PPE gown before providing care to a Resident #18 who had a PEG tube and was in enhanced barrier precaution. Agency LPN failed to remove her gloves and perform hand hygiene after raising the head of the bed with the remote with her gloved hands. Observation and interview on 6/18/2024 at 7:03 AM, after the medication pass, Agency LPN A placed the blood glucometer in the top left drawer of the medication cart after checking Residents #9, #10, #11 and #12's blood glucose. Agency LPN A fail to clean and disinfect the blood glucometer after use on each resident and rolled the mediation cart to the nursing station. Agency LPN A was asked if she was finished with the medication administration. Agency LPN A stated, Yes. 9. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .gather supplies .take the clean barrier with clean meter to the room .get another clean barrier and place it on bedside table .and place the clean meter on the clean barrier .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again .place the meter in the medication cart . The Interim DON was asked if the staff members should place the meter and supplies on the resident bed without a barrier. The Interim DON stated, No. The Interim DON was asked if the staff member should go from room to room without cleaning and disinfecting the blood glucometer. The Interim DON stated, No. The Interim DON was asked when the last time was that she educated the staff on the cleaning and disinfection of the blood glucometer. The Interim DON stated, .I have not done it [training] this last past year .I can't tell you when it was done last . The Interim DON was asked when you have an agency staff member coming in to work are they trained on the facility policies. The Interim DON stated, .We do not train the agency staff .they are in-serviced by the agency . The Interim DON was asked should the staff member pick up a dirty towel off the floor and place the towel back on the resident chest. The Interim DON stated, No. The Interim DON was asked if the feeding tube tip is dropped on the floor should the staff member hook it to the Peg tube. The Interim DON stated, No. 10. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Hypertension and Rhabdomyolysis. Observation and interview in Resident #4's room on 6/26/2024 at 11:26 AM, CNA M was asked where she got the lift. CNA M stated, .I got the lift from a room on 200 hall and brought the lift to resident's [Resident #4] room . CNA M and CNA N entered Resident #4's room, donned their gloves and placed the lift pad under the resident. CNA M and CNA N transferred Resident #4 to his wheelchair and removed the lift. CNA N exited the resident's room and placed the lift in the hallway. CNA N failed to clean and disinfect the lift after use. During an interview on 6/26/2024 at 1:11 PM, CNA M was asked who cleans the lifts when used for transfer. CNA M stated, .I don't know who cleans the lift when they are used to transfer residents . CNA M was asked when the lifts should be clean when used to transfer residents. CNA M stated, After use. During an interview on 6/26/2024 at 11:46 AM, the Interim DON was asked when the staff members should clean the lift when used for transfer. The Interim DON stated, Before and after use. During an interview on 6/27/2024 at 8:01 AM, Family Nurse Practitioner (FNP) #1 was asked when the staff members should clean and disinfect the blood glucometers. FNP #1 stated, .Between every patient .before and after, and let the meter dry for 2 minutes and proceed to the next patient, and then they should wash their hands . The FNP was asked when the staff members should clean the reusable equipment (lifts). The FNP stated, In between every patient and prior to use .because you don't know if the other [last] person had cleaned it . The surveyors verified the Removal Plan: The surveyors reviewed the in-services and made observations of return demonstration of the cleaning, disinfection of the blood glucometer during blood sugar checks, and interviewed nursing staff on all shifts. 1. LPN A and LPN B who failed to clean the glucometer before and after checking blood sugar between residents #9, #10, #11, #12 and #13 were reported to the staffing agency and not allowed to return to work. 2. The facility Administrator conducted a root cause analysis pertaining to this situation which resulted in an Immediate Jeopardy. The root cause analysis indicated that the agency nurses did not follow the facility's policy on glucometer cleaning.? 3. The facility policy on glucometer cleaning was reviewed, and no changes required. 4. Immediate in-services on glucometer cleaning and disinfecting before and after each resident use was initiated by staff educator for licensed nurses on 6/18/2024 and will be completed by 6/19/2024. 5. All licensed staff on leave or agency staff will be required to attend the in-service prior to starting their shift. DON/ADON (Assistant Director of Nursing)/Staff educator/Unit manager/charge nurse will educate licensed nurses on leave or agency nurses prior to beginning of their shift. This in-service will be ongoing for agency employees at the beginning of all shifts. The facility will conduct competency evaluation on glucometer cleaning by return demonstration prior to beginning of the shift. 6. Education includes: Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. 7. The DON/ADON/Staff educator/unit managers will be responsible to monitor the glucometer cleaning before and after each use and as needed. The DON/ADON/Staff educator/unit managers/charge nurses will?conduct random physical observation of glucometer cleaning on all three shifts. The DON/ADON/Staff educator/unit managers will conduct competency evaluation on licensed nurses for glucometer cleaning by return demonstration. Infection Preventionist to verify the competency of the DON/ADON/Staff educator/unit managers to conduct this competency evaluation related to glucometer cleaning on licensed nursing staff on 06/18/2024. 8. The facility will conduct daily QAPI (Quality Assurance and Performance Improvement) meetings as part of the morning meeting with the members of the interdisciplinary team to monitor glucometer cleaning and effectiveness of the removal plan. 9. All corrective actions will continue until a Plan of Correction is developed.

Based on job description review, facility document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI /QA) committee failed to ensure a QAPI program that identified, implemented actions, and monitored serious issues affecting facility staffing, quality of care, prescribed care and services, and residents' rights for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23 and #24 ) sampled residents reviewed for prescribed medications, treatments, care and services during [DATE], February 2024, [DATE] and [DATE]. (Resident #4) failed to receive appropriate monitoring after a fall on [DATE] and underwent an emergency craniotomy (a type of brain surgery where a surgeon removes part of your skull to access your brain) on [DATE]. Residents #5 and #6) reviewed for the implementation of basic life support were not immediately provided Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) CPR. The facility failed to provide hair care in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) sampled residents reviewed who were observed with unkempt, and matted hair. The facility's failure to provide and monitor hair care resulted in HARM for the 11 residents (Harm is a situation in which the provider's noncompliance resulted in a negative outcome that compromised the residents' ability to maintain and/or reach his/her highest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). The failure of the facility's QAPI program resulted in Immediate Jeopardy when the QAPI committee failed to ensure the facility's Administration were accountable to provide oversight, and to monitor and provide a safe environment, and ensure systems and processes were in place which attained and maintained the highest practicable level of functioning for all residents. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-689 on [DATE] at 3:44 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-725, F-726, F-760, F-835, and F-867 on [DATE] at 11:34 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on [DATE] at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 on [DATE] at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-725, F-760 on [DATE] at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-835, F-867 on [DATE] at a scope and severity of K. The facility was cited Immediate Jeopardy at F-678 on [DATE] at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-689, F-725, F-760, F-835 and F-867 was received on [DATE] and an acceptable Removal Plan. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on [DATE] and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on [DATE] through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on [DATE] through [DATE], the IJ was removed on [DATE]. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the Administrator job description dated ,d+[DATE] revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . 2. Review of the Director of Nursing (DON) job description dated ,d+[DATE] revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council, and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 3. Review of the QAPI documentation dated [DATE] through February 2024 revealed no documentation or evidence of data collection and analysis, documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities. 4. During an interview on [DATE] at 3:58 PM, the Administrator was asked who is over the QA process. The Administrator stated, .The DON . During an interview on [DATE] at 4:02 PM, the Director of Nursing (DON) was asked how often the QA meetings were held. The DON stated, .Once a month . The DON was asked who responsible for QA. The DON stated, .I am over the QA meetings . The DON was asked who attended the QA meeting. The DON stated, all department heads, and [Named Pulmonologist] over [the] Crown Unit [a unit with residents on mechanical ventilators and high acuity level of resident care and services] .[Named Medical Director] . The DON was asked what some of the focus areas has been covered in the meeting. The DON stated, .every department bring their own problem that need to be fixed in their area .the Social Worker brings the grievance log .Activity go over the complaints of the residents .dietary the same .hot food .cold food .address the problem and get it resolved .nursing talk about infections during the month .the falls we had .what unit and the time and day the fall occurred .pharmacy come and talk about the medication audits .they [pharmacy] come monthly .watch one nurse medication pass .go over any problems identified .check medication rooms .check the carts . The DON was asked if she had any audits in place at this current time. The DON stated, No. The DON was asked if she had any Performance Improvement Plans (PIPS) in place at this time regarding staffing and missed medications. The DON stated, .No .we talked about staffing .I don't have it on paper .we have a staffing meeting me the Administrator, and [Named Chief Operational Officer] . 5. In summary the Quality Assurance Performance Improvement (QAPI) meeting minutes reviewed for [DATE] through February 2024 did not contain any documentation of data collection and analysis at regular intervals and of reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events of missed medications and sufficient staffing. 6. The QAPI committee failed to ensure all residents' right to be free from neglect when the facility failed to provide hair care in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) sampled residents reviewed that had unkempt, greasy, matted hair, and matted hair that had to be cut off. The facility's failure at F-600 resulted in Harm for the 11 residents, which is Substandard Quality of Care. Refer to F-600. 7. The QAPI committee failed to ensure the facility provided Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) in accordance with the professional standards of care related to basic life support for healthcare providers and facility policy for 2 of 3 (Resident #5 and #6) sampled residents reviewed. The facility's failure at F-678 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-678. 8. The QAPI committee failed to ensure the facility completed assessments, provided necessary care, services, and treatments for residents as prescribed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements. The facility's failure at F-726 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-725, F-726. 9. The QAPI committee failed to ensure the facility provided a safe environment with adequate supervision for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls. On [DATE] Resident #4, with a history for falls, had unwitnessed fall and was sent to the hospital on [DATE] with Acute on Chronic Subdural hematomas (subdural hematoma is a blood clot collection of blood between the brain and the brain's outer covering, usually with an injury that jolts or shakes the brain) with a right to left midline shift (indicates a significant increase in pressure in the brain pushing the brain to the right or left) and required an emergency craniotomy (Surgery to cut a bony flap from the skull to access the brain). The facility's failure at F-689 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-689. 10. The QAPI committee failed to failed to ensure sufficient qualified nursing staff at all times to meet the residents' needs safely and promote each resident's well-being when there was no licensed nurse on the Crown Unit on 13 of 90 days ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] on the 11:00 to 7:00 AM shift, [DATE] on the 3:00 PM to 11:00 PM shift, [DATE], [DATE], [DATE], [DATE] on the 11:00 PM to 7:00 AM shift, and [DATE] from the 8:00 PM to 7:00 AM) reviewed for staffing and to established, monitored, and implemented policies and procedures to ensure adequate staffing on the Crown Unit. Refer to F-725, F-726, F-760. 11. The QAPI committee failed to ensure the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration and that the residents were free from significant medication errors when significant medications including antidiabetic, antiarrhythmics, antihypertensive, anticonvulsant, antiplatelets and cardiac medications were not administered as ordered by the physician. The facility ' s failure at F-760 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-725, F-726, F-760. 12. The QAPI committee failed to ensure the facility Administration was administered in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care and when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician. The Administration's failure at F-835 resulted in Immediate Jeopardy. Refer to F-835. The surveyors verified the Removal Plan by: 1. The facility conducted an Ad-hoc QAPI (when necessary or needed) meeting on [DATE] and conducted a root cause analysis. Root causes identified included inability to replace last minute call ins, nurses not following facility policies on medication administration, emergency management and accident supervision. The surveyors confirmed this by record review and interviews. 2. QAPI (Quality Assurance Performance Improvement) team members were in-serviced on [DATE] by the Corporate Consultant who is a licensed nursing home administrator and RN with Doctoral level education on how to use a systemic approach to determine underlying causes of problems impacting larger systems. The surveyors confirmed this by record review and interviews. 3. Training also focused on developing and implementing corrective actions to change processes at the systems level to attain and maintain the quality of care, and quality of life. The surveyors confirmed this by record review and interviews. 4. Following systems were put in place to immediately correct: Staffing coordinator to provide daily staffing to the Administrator/DON/ADON to review for the next day. If additional staff are needed, take appropriate actions such as agency usage, use of overtime, offer bonus/other incentives to meet the staffing needs. Nursing management to assist in last minute call ins. Vent unit has the highest staffing priority based on acuity. Nursing administration to check for medication errors daily and as needed. The surveyors confirmed this by record review and interviews. 5. Nursing administration to ensure CPR Certified nurses are available all three shifts for resident emergencies. The surveyors confirmed this by record review and interviews. 6. Non-licensed staff are not required to be CPR (Cardiopulmonary Resuscitation) Certified. The facility will also encourage non-licensed staff to get certified and additional CPR classes will be offered. The surveyors confirmed this by record review and interviews. 7. The facility will staff two licensed nurses for the day shift, two for the evening shift and one for the night shift in the Crown Unit. The surveyors confirmed this by record review and interviews. 8. Administrator/DON (Director of Nursing)/ADON will audit staffing daily for the following day to ensure adequate staff to perform admission assessments, manage emergency procedures, and no medication errors occurred. The surveyors confirmed this by record review and interviews. 9. Any negative findings will be corrected or completed immediately and brought to the next morning QAPI meeting to ensure completion and accuracy of assessments. The surveyors confirmed this by record review and interviews. 10. The facility will conduct daily QAPI meetings as part of the morning meeting with the members of the interdisciplinary team to monitor missing medications and effectiveness of the removal plan. The surveyors confirmed this by record review and interviews. 11. All corrective actions will continue until a Plan of Correction is developed. The facility is required to submit a plan of correction.

Based on job description review, record review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that provided oversight of the care being provided to residents, and ensure staff were sufficient in numbers and competent in their duties to provide care and services per physician orders and to meet the individualized needs of all residents. The facility Administration failed to have a system in place to ensure sufficient licensed nursing staff were available and with the knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40 and #41) reviewed who required medications and treatments. The medications not administered as ordered by the physician included anti-diabetics, anticoagulants, anticonvulsants, antibiotics, antiarrhythmics, hypertensive, and cardiac medications. The facility's failure to administer medications as ordered and provide care and services for residents resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-689 on [DATE] at 3:44 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-684, F-725, F-760, F-835, and F-867 on [DATE] at 11:34 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on [DATE] at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 on [DATE] at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-684, F-725, F-760 on [DATE] at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-835, F-867 on [DATE] at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-678 on [DATE] at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-684, F-689, F-725, F-760, F-835 and F-867 was received on [DATE] and an acceptable Removal Plan. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on [DATE] and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on [DATE] through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F-684, F-725, F-760, F-835, and F-867 began on [DATE] through [DATE], the IJ was removed on [DATE]. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's Administrator signed Job Description, revealed dated [DATE], revealed .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our resident at all times .As Administrator you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .to assure that the residents' need are continually met . Review of the facility's Director of Nursing (DON) Services Job Description dated [DATE], revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medial Director to ensure that the highest degree of quality care is maintained at all times .you are delegated the administrative authority, responsibility, an accountability necessary for carrying out your assigned duties .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator or his/her designee to ensure the accurate staffing information is posted .Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work .Report absentee call ins to the Nursing Supervisor and/or Unit Manager .Make daily rounds of your unit/shift to ensure that assigned CNAs [certified nursing assistant] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents .Supervise and assist scheduling of employees within established state guidelines .Assign a sufficient number of LPNs [licensed practical nurse] and RNs [registered nurse] for each tour of duty to ensure that quality care maintained . 2. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed Residents #4 experienced an unwitnessed fall on [DATE]. The nursing staff failed to perform neurological checks and vital signs per the facility policy post fall. Thirty-six hours later the Resident experienced a decline in mental status, was sent to the hospital and an emergency craniotomy was performed for a subdural hematoma (bleeding in the brain). Refer to F689. 3. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed nursing failed to administer residents their anticonvulsant medications, insulin, antibiotic, antiarrhythmic medications, antihypertensive medications, antibiotics, anti-platelet medications, antidiuretic medications, and antipsychotic medications, accu-checks, percutaneous endoscopic gastrostomy tube (PEG) care, breathing treatments and nutritional support in accordance with physician orders for 25 of 26 (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40 and #41) reviewed for medication administration and care and services per physician orders. Refer to F725, 726 and F760. 4. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed nursing was not readily available to perform cardiopulmonary resuscitation (CPR) measures for Residents #5 and #6. During an interview with the Licensed Practical Nurse (LPN) staff revealed on the evening shift when both Resident #5 and Resident #6 required CPR, there was not a nurse assigned to work on the Crown Unit/Ventilation Unit. Refer to F678. 5. During an interview on [DATE] at 11:17 AM, the Administrator, Director of Nursing (DON) and the Chief Operational Officer (COO) were asked if there were any nursing staffing issues at the facility. The COO stated, .[Named Administrator] calls and texts me with reportable events .major accidents .staffing .family complaints on daily basis . The COO was asked if he was aware of the missed medications and lack of nursing staffing issue on the Crown Unit. The COO asked, they missed medications and stated I did not know about that .I know now . The Administrator was asked if the Medial Director should be informed of missed medications and treatments. The Administrator stated, Yes. The Administrator was asked who performed and monitored the implementation of CPR when required. The Administrator stated, .we had a code team [a group assigned to perform CPR] in the past everyone had an assignment to take care of the patient [resident] .Respiratory Therapy .nurse .at night it could be ,d+[DATE] nurses. The Administrator was asked should the staff respond immediately for CPR. The Administrator stated, Yes. The Administrator was asked how often should the crash carts be checked for medications and items needed to perform CPR and who was responsible for checking the crash carts. The Administrator state, .Daily .the managers make sure it is done . The Administrator was asked if the Automated External Defibrillator (AED) should be in use during CPR. The Administrator stated. Yes. The COO was asked who was responsible for the operations in the facility. The COO stated, .the Administrator and the governing body . The Administrator was asked if the facility had a process in place to determine if the residents were receiving the care and services as ordered and needed. The Administrator stated, .Yes .we have 2 morning meeting .we discuss what is going on in the facility .each department heads are in the meeting .I ask, if there are any issue or concerns .the meeting is in 2 part meeting .have a QA [quality assurance] meeting with the unit managers .the ADON [assisted director of nursing] and DON .look at the falls .behaviors .exit seeking .anything identified . The Administrator was asked about staffing issues on the CROWN/ventilation unit. The Administrator stated, .We [Administrator, COO and DON] should have been notified or the DON should have come in .I could have come in to monitor the unit . The Administrator was asked how the facility is staffed when nurses call in and don't report for their shift. The Administrator stated, .we should split the facility equally among the nurses . The Administrator was asked if 2 CNAs should be responsible to take care of all the residents in the entire building. The Administrator stated, No .we would call in help and the nurse was responsible for helping them [CNAs] . During an interview on [DATE] at 11:29 AM Registered Nurse (RN) FF was asked how long they been working as the Unit Manager on the Crown Unit/Ventilation. RN FF stated, .3 month .I started here in August .I became the unit manager in September . RN FF was asked if she was aware there was not a nurse who worked on Crown Unit on several shifts. RN FF stated, Yes .and I let the DON know . RN FF was asked what as done about the lack of nursing staff on the CROWN unit. RN FF stated, .I would get up and come in . sometimes we would not know until the next morning . RN FF was asked if she was aware of the residents on the CVOWN unit had been not receiving all their missed medications. RN FF stated, .That was the days we did not have a nurse on crown [CROWN unit] .I told the DON and said she would take care of it .I told her the medications were still in pill packs on the cart .then I would hear there was no nurse . RN FF was asked if she notified the Medical Director. RN FF stated, .I went to the DON and don't know if she did anything . Refer to F678, F725, 726 and F760. The surveyors verified the Removal Plan by: 1. Corporate Consultant who is a licensed nursing home administrator and RN (Registered Nurse) with Doctoral level education in-serviced the Administrator/DON) Director of Nursing) on [DATE] on the importance of administering the facility in a manner that enabled its resources efficiently and effectively to attain and maintain highest practical well-being of the residents. The surveyors confirmed this by record review and interviews. 2. Administration has ensured oversight of nursing department including staffing, licensed nurses available at all times to administer medications and treatment. The surveyors confirmed this by record review and interviews. 3.The administration has ensured CPR (Cardiopulmonary resuscitation) trained licensed nurses are available for resident emergencies. The surveyors confirmed this by record review and interviews. 4. Administration has ensured licensed nurses are available to perform assessments of all new admits including vent (known as life-support machines) residents. The surveyors confirmed this by record review and interviews. 5. Immediate in-services on medication error, accident supervision and staffing were initiated by staff educator for licensed nurses on [DATE] and will be completed by [DATE]. The surveyors confirmed this by record review and interviews. 6. All licensed staff on leave or agency staff will require to attend the in-service prior to starting their shift. The surveyors confirmed this by record review and interviews. 7. Following systems were put in place to immediately on [DATE] to correct: The surveyors confirmed this by record review and interviews. Staffing coordinator to provide daily staffing to the Administrator/DON/ADON to review for the next day. If additional staff are needed, take appropriate actions such as agency usage, use of overtime, offer bonus/other incentives to meet the staffing needs. Nursing management to assist in last minute call ins. Vent unit has the highest staffing priority based on acuity. Nursing administration to check for medication errors daily and as needed. Nursing administration to ensure CPR Certified nurses are available all three shifts for resident emergencies. 8. The facility Administration will monitor the removal plan daily including weekends in specific areas such as assessments of all new admits by a licensed nurse, emergency management including availability of CPR certified licensed nurses, daily staffing, and review of medication errors. The surveyors confirmed this by record review and interviews. 9. The facility will conduct daily QAPI meetings as part of the morning meeting with the members of the interdisciplinary team to monitor missing medications and effectiveness of the removal plan. The surveyors confirmed this by record review and interviews. 10. All corrective actions will continue until a Plan of Correction is developed. The surveyors confirmed this by record review and interview. The facility is required to submit a plan of correction.

Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration. The facility's failure resulted in Immediate Jeopardy (IJ) when the residents' medications were not administered as prescribed for December 2023, January 2024, February 2024, March 2024, and April 2024, and had the likelihood to cause serious adverse outcomes. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F760 on 4/23/2024 at 11:34 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F760 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F760 was received on 4/25/2024 and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on 4/30/2024 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F760 began on 1/1/2024 through 4/30/2023, the IJ was removed on 5/1/2024. Non-compliance of F760 continues at a scope and severity of F, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Medication Administration dated 2021, and revised April 2024, 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 .Sign MAR [Medication Administration Record] after administered .If medication is a controlled substance, sign narcotic book .Correct any discrepancies and report to nurse manager .Medication timing .BID [abbreviation for twice daily] 9 am, 9 pm .HS [abbreviation for at bedtime] 9 pm QD [abbreviation for every day] .Q 4H [abbreviation for every 4 hours] 6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am .Q8H [abbreviation for every 8 hours] 6 am, 2 pm, 10 pm . Review of the facility's policy titled Medication Errors dated 2019, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services in an environment free of significant medication errors .Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety . Review of the facility policy titled, Obtaining a Fingerstick Glucose Level, dated 2011, revealed .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .record the following information in the resident's medial record .The blood sugar results .The signature and title of the person recording the data . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with a readmission on 4/4/2024, with diagnoses including Chronic Kidney Disease, Dependence on Ventilator, Diabetes, Dysphagia, Hypertension, and Gastrostomy tube (a tube inserted into the stomach) for nutrition and medication administration. Review of Physician's Orders dated 12/1/2023, revealed .Apixaban Oral Tablet 5 MG [milligrams] .Give 1 [one]tablet .two times a day related to .THROMBOSIS [a blood clot that forms and and enters the bloodstream] give in morning and HS [hour sleep] .amLODIPine .Oral Tablet 10 MG .Give 1 tablet .one times a day related to .HYPERTENSION .levETIRAcetam Oral Tablet 750 MG .Give 2 tablet .two times a day related to .SEIZURES .give in morning & [and] at HS . Review of Physician's Orders dated 12/6/2023 revealed .HumaLOG [to treat blood glucose levels] Injection Solution 100 UNIT/ML [milliliters] .Inject subcutaneously every 8 hours . Review of Physician's Orders dated 12/21/2023, revealed .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG [milligram]/3ML .3 ml [milliliters] .every 4 hours as needed for wheezing AND 3 ml .every 6 hours for Shortness of Breath . Review of the January 2024 Medication Administration Record (MAR) revealed the following medications, were not administered as prescribed in the physician orders: a. Apixaban on 1/6/2024 at 9:00 PM. b. Keppra on 1/6/2024 at 9:00 PM. c. Lacosamide on 1/6/2024 at 9:00 PM. d. Blood sugar (glucose) checks were not performed, and insulin administered per sliding scale On 1/2/2024 at 6:00 AM. On 1/3/2024 at 2:00 PM. On 1/3/2024, 1/6/2024, 1/16/2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/24/2024, 1/26/2024, 1/28/2024, 1/29/2024 and 1/30/2024 at 6:00 AM. On 1/6/2024 at 9:00 PM. e. Valproate on 1/6/2024 at 5:00 PM. f. ipratropium-Albuterol inhalation treatment on 1/2/2024, 1/6/2024, 1/14/2024, 1/21/2024, 1/28/2024, 1/29/2024, 1/30/2024 at 6:00 AM; on 1/8/2024, 1/17/2024, 1/22/2024 at 12:00 PM, 1/17/2024 at 6:00 PM; and on 1/28/2024 at 12:00 AM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician's orders: a. Amlodipine on 2/6/2024 at 9:00 AM. b. Apixaban on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. c. Keppra on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. d. Lacosamide 10 mg on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. e. Lacosamide 150 mg on 2/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and insulin administered by sliding scale: On 2/1/2024. 2/3/2024, 2/8/2024, 2/11/2024, 2/12/2024, 2/19/2024 and 2/21/2024 at 8:00 AM. On 2/6/2024, and 2/14/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/8/2024, and on 2/17/2024 at 10:00 PM. g. Valproate on 2/6/2024 at 9:00 AM, 1:00 PM and on 5:00 PM. h. Ipratropium-Albuterol inhaler on 2/8/2024 and 2/16/2024 at 12:00 AM; on 2/3/2024, 2/4/2024, 2/8/2024, 2/11/2024, 2/15/2024, and 2/19/2024 at 6:00 AM; on 2/2/2024, 2/15/2024, 2/17/2024 and 2/19/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, and 2/14/2024 at 6:00 PM. Review of Physician's Orders dated 3/14/2024, revealed .cloBAZam Oral Tablet 20 MG .Give 1 tablet .two times a day related to .SEIZURES .Apixaban Oral Tablet 5 MG .Give 1 tablet .two times a day related to .CEREBRAL INFARCTION [A stroke is a medical emergency that occurs when the blood supply to part of the brain is blocked or reduced ] .Valproic Acid Oral Solution 250 MG/5ML .Give 15 ml .three times a day related to .SEIZURES .levETIRAcetam [Keppra] Oral Tablet 1000 MG .Give 1 tablet .two times a day related to .SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 30 ml .every 12 hours related to .SEIZURES .Insulin Lispro [used to lower glucose] Injection Solution .Inject subcutaneously every 8 hours related to helps keep blood sugar under control .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day related to .HYPERTENSION . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed the Brief Interview for Metal Status (BIMS) score for Resident #1 was left blank, which indicated the Resident was severely impaired and never/rarely made decisions. Review of Physician's Orders dated 3/21/2024, revealed .Linezolid Intravenous Solution 600 MG/300ML .600 mg [milligram] intravenously two times a day related to BACTERIAL PNEUMONIA . Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician's orders: a. Apixaban on 3/23/2024 at 9:00 PM. b. Clobazam 3/23/2024 at 9:00 PM. c. Lacosamide on 3/23/2023 at 9:00 PM. d. Levetiracetam on 3/23/2024 at 9:00 PM. e. Linezolid on 3/23/2024 at 9:00 PM. f. Blood sugar checks were not performed, and insulin administered per sliding scale: On 3/18/2024, and 3/19/2024 at 6:00 AM. On /23/2024 and 3/25/2024 at 10:00 PM. Review of the April 2024 MAR revealed the Blood sugar checks were not performed, and insulin not administered per sliding scale on 4/5/2024 at 6:00 AM. 3. Review of medical record revealed Resident #2 was admitted on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Tracheostomy Status, Dysphagia, Heart Failure, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 4/2/2024, revealed .Apixaban [used to prevent serious blood clots from forming] Oral Tablet 2.5 MG .Give 1 tablet via PEG-Tube two times a day .Metoprolol Tartrate Oral Tablet 100 MG .Give 1 tablet via PEG-Tube two times a day related to TACHYCARDIA .Midodrine HCl Oral Tablet 5 MG .Give 1 tablet .every 8 hours related to HYPOTENSION .Losartan Potassium Oral Tablet 100 MG .Give 1 tablet .one time a day related to .HYPERTENSION .Budesonide Inhalation Suspension 0.5 MG/2ML .0.5 mg via [by] vent two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Losartan Potassium on 4/5/2024 at 9:00 AM. b. Mitazapine on 4/4/2024 at 9:00 PM. c. Apixaban on 4/4/2024 at 9:00 PM. d. Metoprolol on 4/3/2024 and 4/5/2024 at 9:00 AM, and 4/4/2024 at 9:00 PM, e. Midodrine on 4/4/2024 at 10:00 PM, and 4/5/2024 at 6:00 AM and 2:00 PM. f. Budesonide inhalation on 4/7/2024 at 9:00 PM and 4/8/2024 at 9:00 AM. Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 3, which indicated the Resident was severely cognitively impaired. 4. Review of medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dysphagia, Tracheostomy, Anxiety Disorder, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 4/2/2024, revealed .Apixaban Oral Tablet 5 MG .Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE .Arformoterol Tartrate [is used as a long-term (maintenance) treatment to prevent and decrease wheezing and shortness of breath caused by breathing problems] Inhalation Nebulization Solution 15 MCG/2ML .Budesonide Inhalation Suspension 0.5 MG/2ML .2 ml inhale orally two times a day related to ACUTE AND CHRONIC RESPIRATORY FAILURE Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours related to .DIABETES Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG/3ML .3 ml inhale orally every 8 hours related to ACUTE AND CHRONIC RESPIRATORY FAILURE . Review of Physician's Orders dated 4/6/2024, revealed .Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG [micrograms] .2 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 13, which indicated the Resident was cognitively intact. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM. b. Arfomoterol inhalation on 4/4/2024 at 9:00 PM. c. Budesonide inhalation on 4/4/2024 and 4/9/2024 at 9:00 PM. d. Ipratropium - Albuterol inhalation on 4/4/2024 at 10:00 PM and 4/5/2024 at 6:00 AM. e. Blood sugar checks were not performed, and insulin administered per sliding scale: On 4/4/2024 and 4/9/2024 at 10:00 PM. On 4/5/2024, 4/8/2024, and 4/10/2024 at 6:00 AM. f. Spiriva inhalation on 4/8/2024 at 9:00 AM. 5. Review of medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 3/1/2024, revealed .Metoprolol Tartrate Oral Tablet 50 MG .Give 2 tablet via PEG-Tube two times a day for HTN [hypertension] .LevETIRAcetam Oral Solution 100 MG/ML .Give 10 ml via PEG-Tube two times a day for Seizures . Review of the admission MDS dated [DATE], revealed Resident #5's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Levetiracetam on 3/16/2024 at 900 PM. b. Metoprolol on 3/16/2024 at 900 PM. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Levetiracetam on 4/4/2024 at 9:00 PM. b. Metoprolol on 4/4/2024 at 9:00 PM. 6. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, Tracheostomy Status, Gastrostomy Status, Type 2 Diabetes, Chronic Pain, Seizure Disorder, Contracture of Right Hand and Left Hand. Review of a Physician's Orders with a start date of 11/29/2023, and discontinued on 12/11/2023, revealed Gabapentin (a controlled substance used to treat seizures - high doses are associated with a 60 percent increased risk of death) 100 milligrams (mg) 1 capsule to be given at bedtime. Review of the Controlled Substances count sheet revealed a Pharmacy label with prescription #4095079 for Gabapentin 100 mg capsule (1) to be given twice daily. Review of the Controlled Substances count sheet revealed Gabapentin 100mg was signed out to Resident #7 twice a day as follows instead of once at bedtime as ordered: a. 11/30/2023 - 1 capsule at 9:00 AM and 9:00 PM. b. 12/1/2023 - 1 capsule at 9:00 AM and 9:00 PM. c. 12/2/2023 - 1 capsule at 9:00 AM and 9:00 PM. d. 12/3/2023 - 1 capsule at 9:00 AM and 9:00 PM. e. 12/5/2023 - 1 capsule at 9:00 AM AND 9:00 PM. f. 12/6/2023 - 1 capsule at 9:00 AM AND 9:00 PM. g. 12/8/2023 - 1 capsule at 9:00 AM AND 9:00 PM. h. 12/9/2023 - 1 capsule at 9:00 AM AND 9:00 PM. i. 12/10/2023 - 1 capsule at 9:00 AM AND 9:00 PM. j. 12/11/2023 - 1 capsule at 9:00 AM AND 9:00 PM. Review of Resident #7's MAR for November 2023 and December 2023 revealed the nursing staff documented the Resident was administered Gabapentin 100 mg (1) capsule at 9:00 PM on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023, 12/5/2023, 12/6/2023, 12/8/2023, 12/9/2023, 12/10/2023 and 12/11/2023. There was no documentation on the MAR the Resident received the Gabapentin at 9:00 AM. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was severely cognitively impaired. During an interview with the Interim Director of Nursing (DON) on 4/30/2024 at 2:57 PM, when asked if Resident #7 was given Gabapentin as ordered during the months of November and December 2023, the Interim DON reviewed the Controlled Substance count sheet and stated, It's hard to tell. I can't say. Looks like it was given twice . 8. Review of medical record revealed Resident #8 was admitted on [DATE], with a readmission on 2/27/2024, with diagnoses including Chronic Respiratory Failure, Tracheostomy, Colostomy, Diabetes, Hypertension, Colostomy, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 1/3/2024, revealed .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day related to ACUTE EMBOLISM .Moxifloxacin HCl Ophthalmic Solution 0.5 % .Instill 1 drop in both eyes every 4 hours for eye infection for 1 Week .Insulin Aspart Subcutaneous Solution Cartridge 100 UNIT/ML .Inject subcutaneously every 8 hours related to .DIABETES .Inject as per sliding scale .Ipratropium-Albuterol Inhalation Solution .3 ml via vent every 6 hours related to CHRONIC RESPIRATORY FAILURE . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Blood sugar checks were not performed, and insulin administered per sliding scale: On 1/15/2024, 1/16/2024, 1/21/12024, 1/22/2024, 1/23/2024, 1/24/2024, 1/28/2024, and 1/29/2024 at 6:00 AM. On 1/4/2024, 1/7/2024, 1/18/2024,1/21/024, and 1/25/2024 at 2:00 PM. b. Moxifloxacin on 1/4/2024 at 8:00 AM and 12:00 PM, and 1/18/2024 at 1:00 PM. c. Ipratropium-Albuterol inhalation on 1/14/2024, 1/21/2024, 1/22/2024, and 1/29/2024 at 6:00 AM; on 1/3/2024, 1/8/2024, and 1/11/2024 at 12:00 PM; and on 1/6/2024 and 1/17/2024 at 6:00 PM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Blood sugar checks were not performed and sliding scale insulin not administered: On 2/8/2024 and 2/26/2024 at 6:00 AM. On 2/14/2024 and 2/16/2024 at 2:00 PM; and on 2/6/2024 and 2/8/2024 at 10:00 PM. b. Moxifloxacin eye drops on 2/6/2024 at 5:00 PM and 9:00 PM; on 2/29/2024 at 12:00 AM; and on 2/8/2024 and 2/29/2024 at 4:00 AM. c. Ciprofloxacin eye drops on 2/14/2024 at 2:00 PM. d. Ipratropium-Albuterol inhalation on 2/8/2024 at 12:00 AM; on 2/8/2024 and 2/11/2024 at 6:00 AM; on 2/2/2024, 2/5/2024, 2/10/2024 at 12:00 PM; and on 2/7/2024 and 2/14/2024 at 6:00 PM. Review of Physician's Orders dated 2/29/2024, revealed .Ciprofloxacin HCl Ophthalmic Solution .Instill 1 unit in both eyes every 2 hours for infection . Review of the significant change MDS dated [DATE], revealed Resident #8's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 3/6/2024 and 3/15/2024 at 9:00 PM. b. Blood sugar checks were not performed, and sliding scale insulin was not administered: On 3/1/2024, 3/2/2024, and 3/4/2024 at 6:30 AM. On 3/3/2024 at 4:00 PM. On 3/7/2024, 3/10/2024, 3/14/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00 AM. On 3/6/2024, 3/9/2024, 3/10/2024, 3/13/2024 and 3/25/2024 at 10:00 PM. c. Moxifloxacin eye drop every 4 hours on 3/2/2024, and 3/7/2024 at 4:00 AM. Review of Physician's Orders dated 3/29/2024, revealed .Carboxymethylcellulose .Ophthalmic Gel 1 % .Instill 1 drop in both eyes every 4 hours for infection . Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM. b. Carboxymethylcellulose eye drops on 4/4/2024 at 4:00 PM and 8:00 PM; and on 4/5/2024 and 4/10/2024 at 12:00 AM and 4:00 AM. c. Moxifloxacin eye drops on 4/4/2024 at 5:00 PM. d. Blood sugar checks were not performed and sliding scale insulin not administered: On 4/5/2024 and 4/8/2024 at 6:00 AM. On 4/6/2024 at 2:00 PM. On 4/4/2024 at 10:00 PM. 9. Review of medical record revealed Resident # 9 was admitted on [DATE], with a readmission on 1/18/2024, with diagnoses including Chronic Respiratory Failure, Chronic Kidney Disease, Colostomy, Tracheostomy, Atrial Fibrillation, Peripheral Vascular Disease, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 12/20/2023, revealed .Apixaban Oral Tablet 5 MG .Give 5 mg .two times a day for anticoagulant . Review of Physician's Orders dated 1/18/2024, revealed .Apixaban Oral Tablet 5 MG .Give 5 mg .two times a day for anticoagulant .levETIRAcetam Oral Solution 100 MG/ML .Give 1000 mg .two times a day related to EPILEPSY .busPIRone HCl Oral Tablet 5 MG .Give 5 mg .two times a day related to .ANXIETY .Metoprolol Tartrate Oral Tablet 25 MG .Give 25 mg .two times a day related to .HYPERTENSION .Valproic Acid Oral Solution 250 MG/5ML .Give 10 ml .two times a day related to EPILEPSY .NovoLOG Injection Solution 100 UNIT/ML .Inject subcutaneously every 8 hours for .related to .DIABETES .Inject as per sliding scale . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 1/5/2024 at 9:00 PM. b. Buspirone on 1/6/2024 at 9:00 PM. c. Levetiracetam on 1/6/2024 at 9:00 PM. d. Metoprolol on 1/6/2024 at 9:00 PM. e. Valproic Acid on 1/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 1/2/2024, 1/3/2024, 1/6/2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/28/2024, and 1/29/2024 at 6:00 AM. On 1/2/2024, 1/6/2024, and 1/29/2024 at 2:00 PM. On 1/6/2024 at 10:00 PM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 2/4/2024 and 2/6/2024 at 9:00 PM. b. Buspirone on 2/4/2024, 2/6/2024, and 2/17/2024 at 9:00 PM. c. Levetiracetam on 2/4/2024, 2/6/2024, 2/17/2024, and 2/17/2024 at 9:00 PM. d. Metoprolol on 2/4/2024, 2/6/2024, 2/7/2024, and 2/17/2024 at 9:00 PM. e. Valproic Acid on 2/4/2024, 2/6/2024, and 2/17/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 2/8/2024, 2/12/2024, 2/19/2024, 2/21/2024, 2/23/2024, 2/25/2024, and 2/29/2024 at 6:00 AM. On 2/14/2024, and 2/29/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/17/2024, and 2/22/2024 at 10:00 PM. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Buspirone on 3/6/2024 at 9:00 PM. b. Levetiracetam on 3/6/2024 at 9:00 PM. c. Metoprolol on 3/6/2024 at 9:00 PM. d. Valproic Acid on 3/6/2024 at 9:00 PM. e. Blood sugar checks were not performed, and sliding scale insulin not administered: On 3/1/2024, 3/2/2024, 3/9/2024, 3/10/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00 AM. On 3/3/3034 at 2:00 PM, 3/3/2024, 3/4/2024, 3/6/2024, 3/9/2024, 3/10/2024, 3/18/2024, and 3/25/2024 at 10:00 PM. Review of the significant change MDS dated [DATE], revealed Resident #9's BIMS score was blank which indicated the Resident was severely impaired. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Buspirone on 4/4/2024 at 9:00 PM. b. Levetiracetam on 4/4/2024 at 9:00 PM. c. Metoprolol on 4/4/2024 at 9:00 PM. d. Valproic Acid 4/4/2024 at 9:00 PM. e. Blood sugar checks were not performed, and sliding scale insulin not administered: On 4/5/2024, 4/8/2024 and 4/10/2024 at 6:00 AM. On 4/2/2024, 4/4/2024 and 4/9/2024 at 10:00 PM. 10. Review of medical record revealed Resident #10 was admitted on [DATE], with a readmission on 11/8/2023, with diagnoses including Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, Hypertension, Tracheostomy, Diabetes, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 11/8/2023, revealed .Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML .2 ml via trach two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML .3 ml via trach every 6 hours related to CHRONIC RESPIRATORY FAILURE .Insulin Lispro Injection Solution 100 UNIT/ML .Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale .Apixaban Oral Tablet 5 MG .Give 2 tablet .two times a day related to .CARDIAC ARREST .Give 1 tablet .two times a day related to .CARDIAC ARREST .Phenytoin Oral Suspension 100 MG/4ML .Give 8 ml .three times a day related to SEIZURES .levETIRAcetam Oral Solution 100 MG/ML .Give 15 ml .two times a day related to SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 20 ml .two times a day related to SEIZURES .OXcarbazepine Oral Tablet 300 MG .Give 1 tablet .two times a day related to SEIZURES . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 1/5/2024 at 9:00 PM. b. Lacosamide on 1/6/2024 at 9:00 PM. c. Levetiracetam on 1/6/2024 at 9:00 PM. d. Oxcarbazepine o 1/6/2024 at 9:00 PM. e. Arformoterol nebulization on 1/3/2024, 1/8/2024, 1/15/2024, 1/17/2024, 1/18/2024, and 1/31/2024 at 9:00 AM; and on 1/11/2024 and 1/17/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered as follows: On 1/2/2024, 1/3/2024 at 6:00 AM. On 1/6/2024 at 6:00 AM and 6:00 PM. On 1/15/2024, 1/16,2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/24/2024, 1/26/2024, 1/28/2024 and 1/29/2024 at 6:00 AM. g. Phenytoin on 1/6/2024 at 5:00 PM. h. Ipratropium-Albuterol on 1/6/2024, 1/14/2024, 1/21/2024 and 1/29/2024 at 6:00 AM; on 1/3/2024, 1/8/2024, 1/13/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/22/2024, and 1/31/2024 at 12:00 PM; and on 1/17/2024 at 6:00 PM. Review of Physician's Orders dated 2/7/2024, revealed .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day for Anticoagulant . Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 2/9/2024 at 9:00 AM and 2/17/2024 and 2/22/2024 at 9:00 PM. b. Apixaban on 2/4/2024 and 2/6/2024 at 9:00 PM. c. Lacosamide on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. d. Levetiracetam on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. e. Oxcarbazepine on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 2/1/2024, 2/8/2024, 2/12/2024, 2/18/2024, 2/19/2024, 2/21/2024, 2/23/2024, 2/25/2024, and 2/29/2024 at 6:00 AM. On 2/14/2024, and 2/22/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/7/2024, 2/17/2024, and 2/22/2024 at 10:00 PM. g. Phenytoin on 2/22/2024 and 2/29/2024 at 1:00 PM and 2/6/2024 at 5:00 PM. h. Arformoterol inhalation on 2/15/2025 and 2/28/2024 at 9:00 AM; and on 2/6/2024, 2/7/2024, 2/8/2024, 2/14/2024, 2/21/2024, and 2/22/2024 at 9:00 PM. i. Ipratropium-Albuterol inhalation on 2/8/2024, 2/16/2024, 2/23/2024 and 2/29/2024 at 12:00 AM; on 2/8/2024, 2/16/2024, 2/19/2024, 2/23/2024 and 2/29/2024 at 6:00 AM; on 2/5/2024, 2/6/2024, 2/15/2024, 2/28/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, 2/14/2024, 2/22/2024, and 2/27/2024 at 6:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician's orders: a. Apixaban on 3/6/2024 at 9:00 PM. b. Arformoterol inhalation on 3/2/2024, 3/7/2024, 3/8/2024, 3/27/2024, and 3/26/2025 at 9:00 AM and 3/3/2024, 3/6/2024, 3/20/2024, and 3/22/2024 at 9:00 PM. c. lacosamide on 3/6/2024 at 9:00 PM. d. Levetiracetam on 3/6/2024 at 9:00 PM. e. Oxcarbazepine on 3/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 3/1/2024, 3/2/2024, 3/4/2024, 3/7/2024,3/9/2024, 3/10/2024, 3/13/2024, 3/14/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00AM. On 3/3/2024 at 2:00 PM. On 3/3/2024, 3/4/2024, 3/6/2024, 3/9/2024, 3/10. 2024, and 3/25/2024 at 10:00 PM. g. Arformoterol inhalation on 3/2/2024, 3/7/2024, 3/8/2024, 3/27/2024, and 3/26/2025 at 9:00 AM; and on 3/3/2024, 3/6/2024, 3/20/2024, and 3/22/2024 at 9:00 PM. h. Ipratropium-Albuterol inhalation on 3/1/2024, 3/2/2024, 3/4/2024, and 3/27/2024 at 12:00 AM; on 3/1/2024, 3/2/2024, 3/4/2024, 2/14/2024, 3/16/2024, 3/26/2024 and 3/27/2024 at 6:00 AM; and on 3/3/2024, 3/4/2024, 3/6/2024; and 3/10/2024 at 6:00 PM. Review of the significant change MDS dated [DATE], revealed Resident #10's BIMS score was blank which indicated the Resident was severely impaired. Review of the April 2024 MAR revealed the following medications were not administered as prescribed on the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. b. Lacosamide on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. c. Levetiracetam on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. d. Oxcarbazepine on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. e. Blood sugar checks were not performed and sliding scale insulin not administered: On 4/2/2024 and 4/4/2024 at 10:00 PM. On 4/4/5/2024, 4/8/2024, and 4/10/2024 at 6:00 AM. On 4/5/2024 at 2:00 PM. f. Phenytoin on 4/4/2024 at 5:00 PM, and 4/5/2024 at 9:00 AM and 1:00 PM. g. Ipratropium-Albuterol inhalation on 4/4/2024 and 4/10/2024 at 6:00 PM; on 4/8/2024 at 12:00 PM; and on 4/4/2024 at 6:00 PM. 11. Review of medical record revealed Resident #11 was admitted on [DATE] with a readmission on 2/27/2024, with diagnoses of Anoxic Brain Damage, Seizures, Diabetes, Gastroparesis, Dementia, Dependence on Respirator, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 2/3/2024, revealed .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally via nebulizer every 6 hours for Congestion .related to PNEUMONIA .Perampanel Oral Tablet 6 MG .Give 1 tablet .one time a day related to CONVERSION DISORDER WITH SEIZURES .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally via nebulizer every 6 hours for Congestion .related to PNEUMONIA .Acetaminophen Oral Tablet .Give 2 tablet .every 8 hours for pain .Meropenem Intravenous Solution Reconstituted 1 GM .Use 1 gram intravenously every 8 hours related to PNEUMONIA .HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML .Inject subcutaneously every 6 hours related to [lower blood sugar] .inject as per sliding scale .Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS .Apply 1 patch transdermally every 72 hours for Nausea and Vomiting .Lacosamide Oral Tablet 150 MG .Give 1 tablet .two times a day related to SEIZURES .levETIRAcetam Oral Solution 100 MG/ML .Give 7.5 ml .two times a day related to SEIZURES .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day for HTN [hypertension] . Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Amlodipine on 2/5/2024 at 9:00 AM. b. Perampanel on 2/5/2024 at 9:00 AM. c. Lacosamide on 2/4/2024 at 9:00 PM and 2/5/2024 at 9:00 AM. d. Levetiracetam 2/4/2024 at 9:00 PM and 2/5/2024 at 9:00 e. Acetaminophen on 2/4/2024 at 6:00 AM, 2:00 PM and 10:00 PM and on 2/5/2020 at 6:00 AM and 2:00 PM. f. Meropenem every 8 hours on 2/3/2024 at 2:00 PM and 10:00 PM; on 2/4/2024 at 10:00 PM, and on 2/5/2024 at 6:00 AM and at 2:00 PM. g. Blood sugar checks were not performed and sliding scale insulin not administered on 2/5/2024 at 600 AM and 12:00 PM. h. Ipratropium-Albuterol on 2/3/2024 at 6:00 PM. Review of the 5-day MDS dated [DATE], revealed Resident #11's BIMS score was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Lacosamide on 3/6/2024 at 9:00 PM. b. Levetiracetam on 3/6/2024 at 9:00 PM. c. Acetaminophen on 3/1/2024, 3/2/2024, 3/7/2024, 3/9/2024, 3/14/2024, 3/16/2024, 3/19/2024, 3/26/2024, and 3/26/2024 at 6:00 AM; on 3/3/2024 at 2:00 PM; on 3/4/2024, 3/6/2024, 3/9/2024, 3/10/2024; and on 3/25/2024 at 10:00 PM. d. Blood sugar checks were not performed, and sliding scale insulin not administered: On 3/1/2024, 3/2/2024, 3/4/2024, 3/7/2024, 3/10/2024, 3/14/2024, 3/19/2 [TRUNCATED]

Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide readmission assessments and services for 1 of 3 sampled residents (Resident #1) readmitted to the Crown Ventilation Unit on 4/4/2024 and failed to administer significant and other medications for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit. The facility failed to ensure sufficient qualified nursing staff at all times to meet the residents ' needs safely and promote each resident's well-being when there were not a licensed nurse on the Crown Unit on 13 of 90 days (1/1/2024, 1/2/2024, 1/3/2024, 1/6/2024, 1/22/2024, 1/27/2024, and 1/28/2024 on the 11:00 to 7:00 AM shift, 1/6/2023 on the 3:00 PM to 11:00 PM shift, 3/13/2024, 3/18/2024, 3/25/2024, 3/26/2024 on the 11:00 PM to 7:00 AM shift, and 4/4/2024 from the 8:00 PM to 7:00 AM) reviewed for staffing. Medications were not administered as ordered for all residents residing on the Crown Unit. This failure had the potential for serious harm and/or death. The facility's failure to ensure staffing was sufficient to provide oversight of the residents and ensure timely assessments and medications were administered resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-725 on 4/23/2024 at 11:34 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F725 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-725 was received on 4/25/2024 and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on 4/30/2024 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F684 began on 1/1/2024 through 4/30/2023, the IJ was removed on 5/1/2024. Non-compliance of F-725 continues at a scope and severity of E, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the Unit Manager, Job Description dated 5/15/2023, revealed .As Unit Manager you are delegated the administrative authority, and accountability necessary for carrying out your assigned duties .Assist in the development of Nursing Services in obtaining staffing information that must be posted on a daily basis .Provide the Director of Nursing Services with information relative to the nursing needs of the resident and to the Nursing Services Department's ability to meet those needs .Ensure that rooms are ready for new admission .Monitor mediation passes and treatment schedules to ensure that medications are being administered as ordered and that treatment are provided as scheduled .Report mediation errors to the Director of Nursing Services . Review of the Staffing Coordinator, signed Job Description, dated 10/11/22023, revealed .The primary purpose of you position is to ensure adequate and appropriate staffing of the Facility's nursing department to meet the needs of the residents .Report to Director of Nursing Services (DON) when scheduling with excess tardiness or absenteeism, in accordance with Facility policy .Complete monthly nursing schedule coordinating requests to ensure appropriate coverage of units . Review of the Charge Nurse [Licensed Practical Nurse (LPN], Job Description dated 5/26/2020, revealed .The primary purpose of your position is to provide direct nursing care to the resident, and to supervise the day-to-day nursing activities performed by CNAs . and other nursing personnel .ensure that the highest degree of quality care is maintained at all times .Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained .Admit .residents as required .Perform administrative duties such as completing medical forms .charting .as necessary .Report all discrepancies noted concerning physician's orders .charting error .to the Nursing Supervisor .Unit Manger [Manager] .Prepare and administer medication as ordered by the physician .Inform the Nurse Supervisor .Unit Manager of staffing needs when assigned personnel fail to report to work .Nursing Care Functions .Review the resident ' s chart for specific treatment, medication orders . Review of the facility policy titled, Medication Errors (Named Facility) Rehabilitation and Nursing Center, dated 2016, revealed .The facility shall ensure mediations will be administered as following .According to physician's orders .In accordance with accepted standards and principles which apply to professionals providing services . Review of the facility policy titled, Staffing, dated 2007, revealed .Our facility provides adequate staffing to met needed care and services for our resident population .Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services . Review of the Facility Assessment, dated 2/28/2024, revealed .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .residents on ventilators .the facility assessment [NAME] be reviewed and updated to address how the facility staff, resources, physical environment .meet the needs of those residents and any areas requiring attention .Awareness of any limitations of administrating medications Administration of medication that residents need . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE],with diagnoses including Chronic Kidney Disease, Dependence on Ventilator, Diabetes, Dysphagia, Hypertension, and Gastrostomy tube (a tube inserted into the stomach) for nutrition and medication administration. Review of Physician's Orders dated 12/1/2023, revealed .Apixaban Oral Tablet 5 MG [milligrams] .Give 1 tablet .two times a day related to .THROMBOSIS [a blood clot that forms and and enters the bloodstream] give in morning and HS [hour sleep] .amLODIPine .Oral Tablet 10 MG .Give 1 tablet .one times a day related to .HYPERTENSION .levETIRAcetam Oral Tablet 750 MG .Give 2 tablet .two times a day related to .SEIZURES .give in morning & [and] at HS .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milliliter] .3 ml .every 6 hours as needed for wheezing .Liquid Protein supplement two times a day for wounds . Review of Physician Orders dated 12/6/2023 revealed .HumaLOG [to treat blood glucose levels] Injection Solution 100 UNIT/ML [milliliters] .Inject subcutaneously every 8 hours . Review of Physician Orders dated 12/21/2023, revealed .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG [milligram]/3ML .3 ml [milliliters] .every 4 hours as needed for wheezing and 3 ml every 6 hours for Shortness of Breath . Review of Physician Orders dated 3/14/2024, revealed .Famotidine Oral Tablet 20 MG .Give 1 tablet .two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE .cloBAZam Oral Tablet 20 MG .Give 1 tablet .two times a day related to .SEIZURES .Apixaban Oral Tablet 5 MG .Give 1 tablet .two times a day related to .CEREBRAL INFARCTION [ A stroke is a medical emergency that occurs when the blood supply to part of the brain is blocked or reduced] .Valproic Acid Oral Solution 250 MG/5ML .Give 15 ml .three times a day related to .SEIZURES .levETIRAcetam [Keppra] Oral Tablet 1000 MG .Give 1 tablet .two times a day related to .SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 30 ml .every 12 hours related to .SEIZURES .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML .3 ml via trach every 6 hours as needed for SOB or wheezing .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day related to .HYPERTENSION .metFORMIN .Oral Tablet 500 MG .Give 1 tablet .two times a day related to DIABETES .Polyethylene Glycol 3350 Powder .Give 17 gram .two times a day related to CONSTIPATION . Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS .Apply 1 patch transdermal one time a day every 3 day(s) for secretions and remove per schedule .Arginaid Oral Packet (Nutritional Supplements) .Give 1 packet via PEG-Tube two times a day for supplement . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed the Brief Interview for Metal Status (BIMS) score for Resident #1 was left blank, which indicated the resident was severely impaired and never/rarely made decisions. Review of Physician Orders dated 3/21/2024, revealed . Linezolid Intravenous Solution 600 MG/300ML . 600 mg [milligram] intravenously two times a day related to BACTERIAL PNEUMONIA . Review of Physician Orders dated 3/22/2024, revealed .Ascorbic Acid .Give 500 mg .two times a day for [wound] Healing for 14 Days . Review of the January 2024 Medication Administration Record (MAR) revealed the following medications, treatments, and services were not administered as prescribed in the physician's orders: a. Apixaban on 1/6/2024 at 9:00 PM. b. Famotidine on 1/6/2024 at 9:00 PM. c. Keppra on 1/6/2024 at 9:00 PM. d. Lacosamide on 1/6/2024 at 9:00 PM. e. Liquid Protein on 1/6/2024 at 9:00 PM. f. Metformin on 1/6/2024 at 9:00 PM. g. Valproate on 1/6/2024 at 5:00 PM. h. Atorvastatin on 1/6/2024 at 9:00 PM. i. ipratropium-Albuterol inhalation treatment on 1/2/2024, 1/6/2024, 1/14/2024, 1/21/2024, 1/28/2024, 1/29/2024, 1/30/2024 at 6:00 AM; on 1/8/2024, 1/17/2024, 1/22/2024 at 12:00 PM, 1/17/2024 at 6:00 PM; and on 1/28/2024 at 12:00 AM. Review of the February 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Amlodipine on 2/6/2024 at 9:00 AM. b. Atorvastatin on 2/6/2024 and 2/8/2024 at 9:00 PM. c. Doxazosin on 2/6/2024 and 2/8/2024 at 9:00 PM. d. Apixaban on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. e. Famotidine on 2/6/2024 and 2/8/2024 at 9:00 PM. f. Keppra on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. g. Lacosamide 10 mg on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. h. Lacosamide 150 mg on 2/6/2024 at 9:00 PM. i. Liquid protein on 2/6/2024 and 2/8/2024 at 9:00 PM. j. Metformin on 2/6/2024 at 9:00 AM, 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. k. Valproate on 2/6/2024 at 9:00 AM, 1:00 PM and on 5:00 PM. l. Ipratropium-Albuterol inhaler on 2/8/2024 and 2/16/2024 at 12:00 AM; on 2/3/2024, 2/4/2024, 2/8/2024, 2/11/2024, 2/15/2024, and 2/19/2024 at 6:00 AM; on 2/2/2024, 2/15/2024, 2/17/2024 and 2/19/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, and 2/14/2024 at 6:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 3/23/2024 at 9:00 PM. b. Apixaban on 3/23/2024 at 9:00 PM. c. Clobazam on 3/23/2024 at 9:00 PM. d. Arginaid nutritional supplement on 3/23/2024 at 9:00 PM. e. Famotidine on 3/23/2024 at 9:00 PM. f. Lacosamide on 3/23/2023 at 9:00 PM. g. Levetiracetam on 3/23/2024 at 9:00 PM. h. Linezolid on 3/23/2024 at 9:00 PM. i. Metformin on 3/23/2024 at 9:00 PM. j. Polyethylene on 3/23/2024 at 9:00 PM. k. Vitamin C on 3/23/2024 at 9:00 PM. l. Valproic Acid on 3/23/2024 at 5:00 PM. m. Vital signs were not checked on the evening shift on 3/23/2024 and on 3/18/2024 on the night shift. n. Scopolamine patch every 72 hours on 3/5/2024, 3/8/2024, and 3/11/2024. Review of the facility Admission/Readmission form for Resident #1 revealed the Resident was readmitted to the facility on [DATE] to the Crown/Vent Unit. There was no documentation the Resident received a readmission assessment, or the condition, needs and status of Resident #1. Review of the facility's Named Rehabilitation and Nursing Center Midnight Census Report. dated 4/4/2024, On the Crown Unit revealed there was no nurse from 8:00 PM - 7:00 AM on the Crown Unit and the facility had a total of 3 Licensed Practical Nurses (LPNs) on the 11:00 PM to 7:00 AM shift. The Crown unit had a total census of 21 resident and a total facility census of 171 residents. On 4/5/2024 at 7:40 PM, LPN P completed the paperwork for Resident #1's 4/4/2024 readmission. During a telephone interview on 4/5/2024 at 2:18 PM, the Paramedic was asked to explain about the night Resident #1 returned to the facility for readmission. The Paramedic stated, . [Resident #1] was discharged from [Named Hospital] ICU [intensive care unit] at to 2136 [9:30 PM] to [Named Nursing home] in [named room number on the Crown/ Vent Unit] .I [Paramedic] could not find anyone on the halls .there was no staff .I went down the hallway .went into the room there was just a bed frame no mattress .I was not expecting that . The Paramedic was asked if the hospital had called a report to the facility. The Paramedic stated, .Yes, they called at 2:00 PM [on 4/4/2024] in the afternoon .they [facility] should have had the room ready .it was a return patient .finally found someone at the desk RT [Respiratory Therapist] and CNA [certified nursing assistant] .when the RT came in [the room for Resident #1] I said [the Resident] is a vent [Ventilator] patient . [the Paramedic asked] what can I do with a bed with no mattress .the RT went and found a mattress .then the RT left and came back . she [the RT] was trying to figure out how to set up the vent .I told her [the RT] you may want to go next door to see what the other vent setups look like .while she [the RT] was gone we put patient [Resident #1] in the bed .he had a catheter .a PEG tube .padded booth .the CNA came back in [Resident #1'sroom] and said 'We cant receive the patient .the nurse left .walked out .so we have no nurse . ' I [the Paramedic] called the dispatch and told them we going to be here till we get things settle .I spent 30 additional minutes there until the RT got the vent working right . [the Paramedic] went to the nursing desk [Named LPN Q] I gave her the folder with all the paperwork .went out the door with my partner and told him had to report this .these people [facility staff] are not trained to take care of the patients [residents on the Crown/Vent unit] . During an interview on 4/5/2024 at 5:30 PM, LPN V was asked about the staffing on the night shift on 4/4/2024. LPN V stated, .I was in the middle get things ready for the shift .the other nurse there was [Named LPN W] . he [LPN W] came back to the nursing station and said I can't do this .I quit .I asked him what is wrong .he said .well one of the family member he had was asking him question about the resident's clothes and stuff in her room .and now she [resident's family member] in there crying and I'm yelling . [LPN W stated] ' I can't do it ' .he put the keys on the counter and he left .I [LPN V] got an admission at 6:20 PM shortly after that . LPN V was asked who did she give the keys to after LPV W left. LPN V stated, . [Named LPN U] on Delta [another unit of the nursing home] . During an interview on 4/5/2024 at 5:44 PM, the Lead RT was asked to explain about the training of the new RTs. The Lead RT stated, .We have training on hire .monthly meeting we go over positioning, suctioning .how to setup the vents .when they [new RT] come in and give them a week or 2 training . The Lead RT was asked if she was aware Resident #1 was coming back to the facility on the night of 4/4/2024. The Lead RT stated, .Yes, I got report on [Name Resident #1] that he was coming around 12:30 PM or 1:00 PM .most of his equipment .it should have been in the room . The Lead RT was asked if she checked the room to ensure the Resident's room was ready and the ventilator was setup. The Lead RT stated, No when the patient goes out .we throw the old items away and disinfect the equipment [vent] and bag the supplies needed . During an interview on 4/10/2024 at 10:21 AM, LPN P was asked when a resident who is readmission to the facility on the ventilator unit when should the assessment be completed. LPN P stated, . [Named Resident #1] assessment it was not done .I notice it was not done, and it had to be done within 24 hours . LPN P was asked what the process was receiving a readmission. LPN P stated, .Get the admission sheet .go by the sheet .do the note .put the medications in .when they first come in .do the vital signs .a head to toe assessment .look at the orders verify the orders .do a skin assessment .its normally done immediately when they first get here . During an interview on 4/10/2024 at 10:24 AM, the Pulmonologist was asked when you have a resident on the ventilator that is readmitted to facility what should be done on readmission. The Pulmonologist stated, .The nurse and RT go in and admit the resident .usually should be a routine admission .they get the vital sign, write a nurse note .do a full exam .they are assessed by the nurse and RT .if any abnormal finding they would notify me by phone .the Nurse Practitioner [NP] will see them as well .I will see them within a week of admission/readmission .the NP will see them with 24 hours . The Pulmonologist was asked if it was acceptable to not assess the resident on a ventilator on readmit. The Pulmonologist stated, .They should be assessed immediately within hours of the patient's arrival to the facility . During an interview on 4/10/2024 at 3:35 PM, CNA E was asked if she was working when Resident #1 was readmitted on [DATE]. CNA E stated, .Yes . I worked the 3:00 PM to 11:00 PM shift .he [Resident #1] came back some time after 9:00 PM .I went in there [the Resident's room] when the EMS [emergency medical services] came .I was coming back from my break .the nurse was [Named LPN W] that night .when he [Named Resident #1] came in the building there was not a nurse on the floor [Crown Unit] .the paramedic came and asked me who is the nurse .I told him I'm not sure who the nurse is .I don ' t see a nurse .I went to the 800 hall to get [Name LPN U] .I told him there was new patient who came, the paramedic came and asked for signature .he [the Paramedic] said he was going to call the DON [Director of Nursing] .I went to [Named Resident #1's] room to see how he [the Resident] was doing .I told the paramedic the nurse on the 800 hall was checking into it .the nurse [LPN Q] on [NAME] [another unit of the facility] signed for it [paperwork] . CNA E was asked where was the nurse on the Crown Unit. CNA E stated, .I'm not sure .the only nurse I saw after 7:00 PM was [Named LPN V] and from that point on we did not have a nurse on crown . CNA E was asked if any other nurses came to help out on Crown Unit. CNA E stated, .the only one with concerns about the new admit was the one on [NAME] [Named LPN Q] .the only thing I saw was [LPN W] walking towards the front with his things .I asked [Named LPN V] what happened, and she told me he left . During a telephone interview on 4/10/2024 at 4:16 PM, RT #1 was asked about the night Resident #1 was readmitted back to the facility on [DATE]. RT#1 stated, .on Thursday [4/4/2024] .[Name Resident #1] came back to the facility .I went to get a mattress for the bed .there was not a mattress on the bed and a vent [ventilator] setup in the room .with every case I have the vent is always setup and preset up .I did not realize the vent was not setup .I put the mattress on the bed .I went got everything for the vent except one piece I did to realize I needed .it was a filter .normally the filter it comes with everything .it was my first time setup a vent .I had to leave the room again to get a filter .there was no nurse on the hall [Crown Unit] to receive him [Named Resident #1] . RT #1 was asked if she knew what happened to the nurse on the Crown Unit. RT #1 stated, .I'm not aware .not sure all I know they did not have a nurse that night on crown .if nurses don ' t come to work .I continue to do my job .I asked the CNA what we do with no nurse .she said 'the people up front can sign for them [the residents] .we [RT] could not sign for them' .EMS took the paperwork up to the front .20 minutes later someone came and asked for paperwork . RT #1 was asked if there was a nurse the rest of the night on 4/4/2024. RT #1 stated, .I did not see a nurse on my shift the CNA said she [Name LPN V] left around 7:30 .she said [Name LPN W] was there . the CNA said he [Named LPN W] walked out . 3. Review of medical record revealed Resident #2 was admitted on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Tracheostomy Status, Dysphagia, Heart Failure, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 4/2/2024, revealed .Apixaban [used to prevent serious blood clots from forming] Oral Tablet 2.5 MG .Give 1 tablet via PEG-Tube two times a day .Metoprolol Tartrate Oral Tablet 100 MG . Give 1 tablet via PEG-Tube two times a day related to TACHYCARDIA .Sennosides-Docusate Sodium Oral Tablet 8.6-50 MG .Give 1 tablet via PEG-Tube at bedtime related to CONSTIPATION .Midodrine HCl Oral Tablet 5 MG . Give 1 tablet . every 8 hours related to HYPOTENSION .Mirtazapine Oral Tablet 15 MG .Give 1 tablet via PEG-Tube at bedtime for appitite [appetite] .Losartan Potassium Oral Tablet 100 MG .Give 1 tablet .one time a day related to .HYPERTENSION . Review of Physician Orders dated 4/2/2024, revealed .Budesonide Inhalation Suspension 0.5 MG/2ML .0.5 mg via [by] vent two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE .Pravastatin Sodium Oral Tablet 80 MG .Give 1 tablet .at bedtime related to HYPERLIPIDEMIA . Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Losartan Potassium on 4/5/2024 at 9:00 AM. b. Mitazapine on 4/4/2024 at 9:00 PM. c. Pravastatin on 4/5/2024 at 9:00 PM. d. Senosides on 4/4/2024 at 9:00 PM. e. Apixaban on 4/4/2024 at 9:00 PM. f. Budesonide inhalation on 4/7/2024 at 9:00 PM and 4/8/2024 at 9:00 AM. g. Metoprolol on 4/3/2024 and 4/5/2024 at 9:00 AM, and 4/4/2024 at 9:00 PM, h. Midodrine on 4/4/2024 at 10:00 PM, and 4/5/2024 at 6:00 AM and 2:00 PM. Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 3, which indicated she was severely cognitively impaired 4. Review of medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dysphagia, Tracheostomy, Anxiety Disorder, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 4/2/2024, revealed .Apixaban Oral Tablet 5 MG .Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE .Arformoterol Tartrate [is used as a long-term (maintenance) treatment to prevent and decrease wheezing and shortness of breath caused by breathing problems] Inhalation Nebulization Solution 15 MCG/2ML .Budesonide Inhalation Suspension 0.5 MG/2ML .2 ml inhale orally two times a day related to ACUTE AND CHRONIC RESPIRATORY FAILURE .Senna-Docusate Sodium Oral Tablet 8.6-50 MG .Give 1 tablet by mouth two times a day related to CONSTIPATION .Melatonin Oral Tablet 3 MG .Give 3 tablet by mouth at bedtime related to INSOMNIA .Lactulose Oral Solution 10 GM/15ML .Give 15 ml by mouth two times a day related to CONSTIPATION .Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours related to .DIABETES .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG/3ML .3 ml inhale orally every 8 hours related to ACUTE AND CHRONIC RESPIRATORY FAILURE .Vital assessment every shift . Review of Physician Orders dated 4/6/2024, revealed . Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG [micrograms] .2 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 13, which indicated he was cognitively intact. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Melatonin on 4/4/2024 at 9:00 PM. b. Spiriva inhalation on 4/8/2024 at 9:00 AM. c. Apixaban on 4/4/2024 at 9:00 PM. d. Arfomoterol inhalation on 4/4/2024 at 9:00 PM. e. Budesonide inhalation on 4/4/2024 and 4/9/2024 at 9:00 PM. f. Lactulose on 4/4/2024 at 9:00 AM. g. Senna-Docusate on 4/4/2024 at 9:00 PM. h. Ipratropium - Albuterol inhalation on 4/4/2024 at 10:00 PM and 4/5/2024 at 6:00 AM. 5. Review of medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 3/1/2024, revealed .Metoprolol Tartrate Oral Tablet 50 MG .Give 2 tablet via PEG-Tube two times a day for HTN [hypertension] .Juven [to support wound healing by enhancing collagen formation] Oral Packet .Give 1 packet via [by] PEG-Tube two times a day .LevETIRAcetam Oral Solution 100 MG/ML .Give 10 ml via PEG-Tube two times a day for Seizures . Review of Physician Orders dated 3/4/2024, revealed .Rosuvastatin Calcium [used to lower bad cholesterol] Oral Tablet 10 MG .Give 1 tablet via PEG-Tube at bedtime for .Senna Oral Tablet 8.6 MG .Give 2 tablet via PEG-Tube every night shift for Constipation .Proteinex [Protein Supplement] Oral Liquid .Give 30 ml via PEG-Tube two times a day . Review of the admission MDS dated [DATE], revealed Resident #5's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Rosuvastatin on 3/16/2024 at 9:00 PM. b. Senna on 3/16/2024 at 9:00 PM. c. Juven on 3/16/2024 at 9:00 PM. d. Levetiracetam on 3/16/2024 at 900 PM. e. Metoprolol on 3/16/2024 at 900 PM. f. Protinex on 3/16/2024 at 900 PM. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Rosuvastatin on 4/4/2024 at 9:00 PM. b. Senna on 4/4/2024 at 9:00 PM. c. Juven on 4/4/2024 at 9:00 PM. d. Levetiracetam on 4/4/2024 at 9:00 PM. e. Metoprolol on 4/4/2024 at 9:00 PM. f. Protinex on 4/4/2024 at 9:00 PM. 6. Review of closed medical record revealed Resident #7 was admitted on [DATE], with a readmission on 2/27/2023, with diagnoses including Chronic Respiratory Failure, Tracheostomy, Hypertension, Dysphagia, Acute Kidney Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 11/28/2023, revealed .Sodium Polystyrene .Give 60 ml .related to HYPERKALEMIA [high potassium levels in the blood which can lead to heart problems] . Review of Physician Orders dated 2/1/2024, revealed .Atorvastatin Calcium Oral Tablet 40 MG .Give 1 tablet .at bedtime related to HYPERLIPIDEMIA [high levels of fat in the blood] . Review of the admission MDS dated [DATE], revealed Resident #7's BIMS score was blank, which indicated the Resident was severely impaired. Review of Physician Orders dated 2/27/2024 revealed .Atorvastatin Calcium Tablet 80 MG Give 1 tablet .at bedtime related to HYPERLIPIDEMIA [high levels of fat in the blood] . Review of Physician Orders dated 2/28/2024 revealed .Atorvastatin Calcium Oral Tablet 40 MG .Give 40 mg .at bedtime related to HYPERLIPIDEMIA . Review of Physician Orders dated 3/6/2024, revealed .Colace [for constipation] Oral Capsule 100 MG .Give 1 tablet .two times a day for Bowels . Review of the February 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 2/6/2024 at 9:00 PM. b. Eliquis on 2/6/2024 at 9:00 PM. c. Polyethylene on 2/6/2024 at 9:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 3/15/2024 at 9:00 PM. b. Polyethylene on 3/15/2024 at 9:00 PM. c. Colace on 3/15/2024 at 9:00 PM. d. Eliquis on 3/15/2024 at 9:00 PM. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 4/4/2024 at 9:00 PM. b. Polyethylene on 4/4/2024 at 9:00 PM. c. Colace on 4/4/2024 at 9:00 PM. d. Eliquis on 4/4/2024 at 9:00 PM. at 9:00 PM. 7. Review of medical record revealed Resident #8 was admitted on [DATE], with a readmission on 2/27/2024, with diagnoses including Chronic Respiratory Failure, Tracheostomy, Colostomy, Diabetes, Hypertension, Colostomy, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 1/3/2024, revealed Arginaid Oral Packet .Give 1 packet .two times a day for [wound] Healing for 30 Days .Systane Ophthalmic Solution .Instill 1 drop in both eyes every 4 hours for eye lubricant .Ipratropium-Albuterol Inhalation Solution .3 ml via vent every 6 hours related to CHRONIC RESPIRATORY FAILURE .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day related to ACUTE EMBOLISM .Protein Oral Liquid .Give 30 ml .two times a day for Wound Healing for 30 Days .Moxifloxacin HCl Ophthalmic Solution 0.5 % .Instill 1 drop in both eyes every 4 hours for eye infection for 1 Week . Review of Physician Orders dated 2/29/2024, revealed .Ciprofloxacin HCl Ophthalmic Solution .Instill 1 unit in both eyes every 2 hours for infection . Review of Physician Orders dated 3/4/2024, revealed .Arginaid Oral Packet .Give 1 packet .two times a day for [wound] Healing for 30 Days . Review of the significant change MDS dated [DATE], revealed Resident #8's BIMS was blank, which indicated she was severely impaired. Review of Physician Orders dated 3/29/2024 revealed .Carboxymethylcellulose .Ophthalmic Gel 1 % .Instill 1 drop in both eyes every 4 hours for infection . Review of the January 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Ipratropium-Albuterol inhalation on 1/14/2024, 1/21/2024, [TRUNCATED]

Based on policy review, user instruction manual review, job description review, medical record review, observation, and interview, the facility failed to ensure staff practices to prevent the potential spread of infection were maintained when multi-use blood glucometers were not cleaned and disinfected after/between resident testing to prevent cross-contamination of bloodborne pathogens for 5 of 9 sampled residents (Resident #9, #10, #11, #12, and #13) reviewed for blood glucose monitoring, when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) when providing care to Residents #9, #10, #11, #12, #17, and #18, and when staff failed to ensure reusable equipment was cleaned and disinfected when 2 of 2 staff members (Certified Nursing Assistant (CNA) N and CNA M) were observed during transferring Resident #4 with a mechanical lift. The facility's failure to ensure nursing staff properly disinfected the multi-use blood glucose meter that was used for multiple residents without disinfecting after/between resident testing placed residents at risk for contamination with bloodborne pathogens and had the likelihood to cause serious injury, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operation Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-880 on 6/18/2024 at 1:13 PM, in the Conference Room. The facility was cited Immediate Jeopardy for F-880 at a scope and severity of K. The Immediate Jeopardy began on 6/18/2024 through 6/21/2024, the IJ was removed on 6/22/2024. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/18/2024 at 4:19 PM. The corrective actions were validated onsite by the surveyors on 6/21/2024 through review of in-service documentation, audits, and staff interviews. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, (Named Facility) Glucometer Disinfection, dated 2020, revealed .The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents .The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The glucometers will be disinfected with a wipe pre-saturated with an EPA [Environmental Protective Agency] registered healthcare disinfectant that is effective against HIV [human immunodeficiency virus], Hepatitis C, and Hepatitis B virus [infection of the liver] Glucometer will be cleaned and disinfected after each use and accordance to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use .Obtain needed equipment and supplies .Retrieve (2) disinfectant wipes from container .Use first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer .After cleaning use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry . Review of the undated [Named Company] User Instruction Manual, for Glucometers revealed .Cleaning & [and] Disinfecting Guidelines .We suggest cleaning and disinfecting the meter between patient use .Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe .Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used .use one wipe to clean and the second wipe to disinfect .With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level . Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment [Named Facility], dated 2022, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . Review of the facility's policy titled, Enhanced Barrier Precautions [Named Facility], dated 6/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .An order for enhanced barrier precaution will be obtained for residents with any of the following .Wounds .( .chronic wounds .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .indwelling medical devices .(urinary catheters, feeding tubes, tracheostomy/ventilator tubes .) .PPE for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident room .High-contact resident care activities .Dressing .Bathing .Transferring .Providing hygiene .Changing linens .Changing briefs or assisting with toileting .Device care or use .central lines, urinary catheters, feeding tubes, tracheostomy/ventilators tubes, hemodialysis catheters, PICC [peripherally inserted central catheter line] lines, midline catheters .Wound care .any skin opening requiring a dressing . Review of the Director of Nursing Services, Job Description signed 5/1/2024, revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities .Make daily rounds of your unit/shift to ensure that assigned CNAs and other nursing personnel are performing their work assignment in accordance with acceptable nursing standards . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Gastrostomy, Tracheostomy, and Hypertension. Review of the Physician's Orders dated 4/25/2024, revealed .Insulin Lispro [used to control blood sugar] .Injection Solution 100 UNIT/ML [millimeters] .Inject subcutaneously every 6 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and Peg (Percutaneous endoscopic gastrostomy is a medical device used to provide nutrition and hydration directly into the stomach), tube. Observation at the medication cart on 6/18/2024 at 5:32 AM, revealed Agency LPN A removed the blood glucometer from the top left drawer of the medication cart and placed the blood glucometer on top of the medication cart without a barrier. Agency LPN A gathered her supplies, the blood glucometer, entered Resident #9's room, and placed the blood glucometer and supplies on the resident's bed without a barrier. Agency LPN A pricked Resident #9's finger with the lancet, picked up the blood glucometer, inserted the test strip into the glucometer, placed the blood sample onto the test strip, then placed the blood glucometer back on Resident #9's bed to read the results. Agency LPN A exited Resident #9's room and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A failed to don her gown before providing direct care to a resident in enhanced barrier precaution. Agency LPN A failed to clean and disinfect the blood glucometer after/between resident testing. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Anoxic Brain, Diabetes, Tracheostomy, Gastrostomy, Hypertension, and Vegetative State. Review of the Physician's Orders dated 4/11/2024, revealed .Check [PEG tube] placement by auscultation and aspiration prior to all medication administration, flush and feeding .every shift .Check Residual Q [every] Shift .every shift . Review of the Physician's Orders dated 5/22/2024, revealed .Insulin Aspart Injection Solution 100 UNIT/ML . Inject 12 unit subcutaneously three times a day related to .DIABETES .Hold for Blood sugar < [less than] 150 . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:37 AM, revealed Agency LPN A gathered her supplies, entered Resident #10's room, and placed the supplies and blood glucometer on the resident bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer and inserted the test strip into the glucometer, and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back on the resident's bed to read the results. Agency LPN A gathered the supplies and the blood glucometer, removed gloves, exited the resident's room, and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A gathered medication for administration via (by) PEG tube, and reentered Resident #10's room placing the medication cup on the nightstand. Agency LPN A administered the medication and when attaching the tip of the enteral tube into the PEG tube, the tip of the tubing dislodged and the tip of the tubbing fell on the floor. Agency LPN A picked up the enteral tubing off the floor, reinserted the tip of the enteral tube into the Peg tube and the tubing dislodged again and hit the floor a second time. LPN A picked up the enteral tube off the floor and reinserted the enteral tube to the PEG tube site. Agency LPN A failed to don her PPE (gown) before providing care to a resident in enhanced barrier precaution and failed to clean and disinfect the blood glucometer after/between resident testing. Agency LPN A failed to change out the contaminated enteral feeding tube that tip fell on the floor. 4. Review the of medical record revealed Resident #11 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Anoxic Brain, Gastrostomy, Persistent Vegetative State, and Diabetes. Review of the Physician's Orders dated 1/13/2024, revealed .NovoLOG [used to control blood sugar] PenFill Subcutaneous Solution Cartridge 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:57 AM, revealed Agency LPN A entered Resident #11's room, donned her gloves, hung the enteral feeding, exited the resident's room, and gathered the supplies and blood glucometer from on top of medication cart. Agency LPN A reentered Resident #11's room and placed the supplies and blood glucometer on the resident's bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer, inserted a test strip into the glucometer and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back down on the resident's bed to read the results. Agency LPN A removed her gloves, picked up the blood glucometer and supplies off of Resident #11's bed and walked to the opposite side of the resident's bed and picked up a towel off the floor and placed the towel on the resident's chest. Agency LPN A exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. LPN A picked up a dirty towel off the floor and placed it on the resident's chest. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Hyperglycemia, Methicillin Resistant Staphylococcus Aureus, and Diabetes. Review of the Physician's Orders dated 6/3/2024, revealed .HumaLOG [used to lower the blood sugar] Injection Solution 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation at the medication cart on 6/18/2024 at 6:37 AM, revealed Agency LPN A donned her gloves, gathered supplies and the blood glucometer, and then entered Resident #12's room. Agency LPN A placed the supplies and blood glucometer on the resident's bed with no barrier present, administered the eye drops and removed her gloves. Agency LPN A donned her gloved, pricked the resident's finger, picked up blood glucometer and inserted the test strip, obtained a blood sample and placed it on the strip, and placed blood glucometer back down on the resident's bed for the reading. Agency LPN A gathered the supplies and the blood glucometer and exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. Random observation in the resident's room on 6/24/2024 at 4:13 PM, revealed CNA O failed to don PPE when she bathed Resident #12, who was in enhanced barrier precautions. 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Hypertension and Anxiety. Review of the Physician's Orders dated 3/8/2024, revealed .Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours for .DM [Diabetes Mellitus] .per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy. Observation in the resident's room on 6/18/2024 at 6:30 PM, revealed Agency LPN B donned his gloves removed the blood glucometer from the medication cart, entered Resident #13's room pricked the resident's finger, inserted the strip and obtained a blood sample to check the blood sugar. Agency LPN B failed to clean and disinfect the blood glucometer before use when he removed the blood glucometer from the medication cart. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again . 7. Review the of medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, Tracheostomy, Gastrostomy, and Acute Respiratory Failure. Review of the Physician's Orders dated 5/8/2024, revealed .Check [PEG tube] Residual Q [every] Shift . Check placement by auscultation and aspiration prior to all medication administration, flush and feeding . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:21 AM, revealed Agency LPN A entered Resident #17's room with the resident's enteral feeding formula, donned her gloves, hung the enteral feeding on the intravenous pole, disconnected the old enteral feeding formula tube from the PEG tube and connected a new enteral feeding tube to the PEG tube. LPN A failed to don her PPE gown before providing care to a resident with a PEG tube in enhanced barrier precautions. 8. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Gastrostomy, Tracheostomy, Respiratory Failure, Acute Kidney Failure, and Adult Failure to Thrive. Review of the Physician's Orders dated 8/22/2023, revealed .Check placement [of PEG tube] by auscultation and aspiration prior to all medication administration, flush and feeding .every shift . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 6:44 AM, Agency LPN A entered Resident #18's room for medication administration via PEG tube. Agency LPN A donned her gloves, raised bed with the remote, administered medication via PEG tube, flushed with 60 cc (centimeters) of water, administered medication and flushed with 30 cc water. Agency LPN A failed to don her PPE gown before providing care to a Resident #18 who had a PEG tube and was in enhanced barrier precaution. Agency LPN failed to remove her gloves and perform hand hygiene after raising the head of the bed with the remote with her gloved hands. Observation and interview on 6/18/2024 at 7:03 AM, after the medication pass, Agency LPN A placed the blood glucometer in the top left drawer of the medication cart after checking Residents #9, #10, #11 and #12's blood glucose. Agency LPN A fail to clean and disinfect the blood glucometer after use on each resident and rolled the mediation cart to the nursing station. Agency LPN A was asked if she was finished with the medication administration. Agency LPN A stated, Yes. 9. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .gather supplies .take the clean barrier with clean meter to the room .get another clean barrier and place it on bedside table .and place the clean meter on the clean barrier .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again .place the meter in the medication cart . The Interim DON was asked if the staff members should place the meter and supplies on the resident bed without a barrier. The Interim DON stated, No. The Interim DON was asked if the staff member should go from room to room without cleaning and disinfecting the blood glucometer. The Interim DON stated, No. The Interim DON was asked when the last time was that she educated the staff on the cleaning and disinfection of the blood glucometer. The Interim DON stated, .I have not done it [training] this last past year .I can't tell you when it was done last . The Interim DON was asked when you have an agency staff member coming in to work are they trained on the facility policies. The Interim DON stated, .We do not train the agency staff .they are in-serviced by the agency . The Interim DON was asked should the staff member pick up a dirty towel off the floor and place the towel back on the resident chest. The Interim DON stated, No. The Interim DON was asked if the feeding tube tip is dropped on the floor should the staff member hook it to the Peg tube. The Interim DON stated, No. 10. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Hypertension and Rhabdomyolysis. Observation and interview in Resident #4's room on 6/26/2024 at 11:26 AM, CNA M was asked where she got the lift. CNA M stated, .I got the lift from a room on 200 hall and brought the lift to resident's [Resident #4] room . CNA M and CNA N entered Resident #4's room, donned their gloves and placed the lift pad under the resident. CNA M and CNA N transferred Resident #4 to his wheelchair and removed the lift. CNA N exited the resident's room and placed the lift in the hallway. CNA N failed to clean and disinfect the lift after use. During an interview on 6/26/2024 at 1:11 PM, CNA M was asked who cleans the lifts when used for transfer. CNA M stated, .I don't know who cleans the lift when they are used to transfer residents . CNA M was asked when the lifts should be clean when used to transfer residents. CNA M stated, After use. During an interview on 6/26/2024 at 11:46 AM, the Interim DON was asked when the staff members should clean the lift when used for transfer. The Interim DON stated, Before and after use. During an interview on 6/27/2024 at 8:01 AM, Family Nurse Practitioner (FNP) #1 was asked when the staff members should clean and disinfect the blood glucometers. FNP #1 stated, .Between every patient .before and after, and let the meter dry for 2 minutes and proceed to the next patient, and then they should wash their hands . The FNP was asked when the staff members should clean the reusable equipment (lifts). The FNP stated, In between every patient and prior to use .because you don't know if the other [last] person had cleaned it . The surveyors verified the Removal Plan: The surveyors reviewed the in-services and made observations of return demonstration of the cleaning, disinfection of the blood glucometer during blood sugar checks, and interviewed nursing staff on all shifts. 1. LPN A and LPN B who failed to clean the glucometer before and after checking blood sugar between residents #9, #10, #11, #12 and #13 were reported to the staffing agency and not allowed to return to work. 2. The facility Administrator conducted a root cause analysis pertaining to this situation which resulted in an Immediate Jeopardy. The root cause analysis indicated that the agency nurses did not follow the facility's policy on glucometer cleaning.? 3. The facility policy on glucometer cleaning was reviewed, and no changes required. 4. Immediate in-services on glucometer cleaning and disinfecting before and after each resident use was initiated by staff educator for licensed nurses on 6/18/2024 and will be completed by 6/19/2024. 5. All licensed staff on leave or agency staff will be required to attend the in-service prior to starting their shift. DON/ADON (Assistant Director of Nursing)/Staff educator/Unit manager/charge nurse will educate licensed nurses on leave or agency nurses prior to beginning of their shift. This in-service will be ongoing for agency employees at the beginning of all shifts. The facility will conduct competency evaluation on glucometer cleaning by return demonstration prior to beginning of the shift. 6. Education includes: Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. 7. The DON/ADON/Staff educator/unit managers will be responsible to monitor the glucometer cleaning before and after each use and as needed. The DON/ADON/Staff educator/unit managers/charge nurses will?conduct random physical observation of glucometer cleaning on all three shifts. The DON/ADON/Staff educator/unit managers will conduct competency evaluation on licensed nurses for glucometer cleaning by return demonstration. Infection Preventionist to verify the competency of the DON/ADON/Staff educator/unit managers to conduct this competency evaluation related to glucometer cleaning on licensed nursing staff on 06/18/2024. 8. The facility will conduct daily QAPI (Quality Assurance and Performance Improvement) meetings as part of the morning meeting with the members of the interdisciplinary team to monitor glucometer cleaning and effectiveness of the removal plan. 9. All corrective actions will continue until a Plan of Correction is developed.

Based on policy review, job descriptions, medical record review, observation, and interview, the facility failed to provide supervision and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls, failed to ensure the resident's right to be free from neglect when the facility failed to provide necessary goods and services and failed to treat residents in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 sampled residents (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) reviewed for daily hair care, and failed to ensure residents' vital signs were monitored [DATE], February 2024, [DATE] and [DATE], for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements. Resident #4 experienced unwitnessed falls on [DATE], [DATE], [DATE], and on [DATE]. The facility failed to monitor Resident #4's condition post unwitnessed fall per facility policy which resulted in Immediate Jeopardy (IJ) when Resident #4 did not receive neurological (neuro) checks (examination to determine whether the nervous system is impaired affecting the brain), frequent vital signs (measurement of the body's most basic functions) monitoring and supervision after an unwitnessed fall on [DATE] at 2:00 AM. Resident #4 had a decline in condition and was not transferred to the hospital until [DATE] at 2:22 PM, approximately 36 hours after the unwitnessed fall on [DATE]. Resident #4 was admitted to the hospital on [DATE] with Acute on Chronic Subdural hematomas (subdural hematoma is a blood clot collection of blood between the brain and the brain's outer covering, usually with an injury that jolts or shakes the brain) with a right to left midline shift (indicates a significant increase in pressure in the brain pushing the brain to the right or left) and required an emergency craniotomy (Surgery on the brain to treat the bleeding in the brain). The facility's failure to monitor resident's Activities of Daily Living (ADL) care including daily hair care resulted in HARM for 11 of 11 residents (a situation in which the provider's noncompliance resulted in neglect that compromised the residents' ability to maintain and/or reach his/her highest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services), cited at a scope/severity of H which is substandard quality of care. Non-compliance of F-600 continues at a scope and severity of H, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Neurological Assessment, dated 2002, revealed .The purpose of this procedure is to provide guidelines for a neurological assessment .upon physician order .when following an unwitnessed fall .subsequent to a fall with a suspected head injury .when indicated by resident conditions .Neurological assessment are indicated .Following an unwitnessed fall .When assessing neurological status, always, include frequent vital signs. Particular attention should be paid the widening pulse pressure (difference between systolic and diastolic pressure) .This may be indicative of increasing intracranial pressure (ICP) .Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately .perform neurological check [Neuro Checks] with the frequency as ordered or per fall protocol .Observe resident's pattern of speech and speech clarity .Take temperature, pulse, respirations, blood pressure .check pupil reaction .Determine motor ability .Determine sensation in extremities .The date and time the procedure was performed .The name and title of the individual(s) who performed the procedure . Review of the facility policy titled, Assessing Falls and Their Causes, dated 2018, revealed .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying cause of the fall .Resident must be assessed upon admission and regularly afterward for potential risk of falls .If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities .Obtain and record vital signs as soon as it is safe to do so .Notify the residents attending physician and family in an appropriate time frame . Review of the facility's undated policy titled, .Abuse Prevention, revealed, .Neglect: A failure of the facility, it's employees, or services provided .to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain . Review of the facility's undated policy titled, .Activities of Daily Living (ADLs), revealed, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy titled, Resident Right, dated 2016, revealed .Federal and state laws guarantee certain basic rights to all resident in this facility .equal access to quality of care . Review of the facility undated policy titled, NOTICE OF RESIDENT RIGHTS, revealed .This facility will protect and promote the rights of each resident .To reside and receive services in the facility with reasonable accommodation of individuals needs and preferences .To have appropriate assessment and management plan . Review of the facility policy titled, Provision Ordered Services, dated 2020, revealed .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting . Review of the Director of Nursing Services, Job Description dated [DATE], revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medial Director to ensure that the highest degree of quality care is maintained at all times .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Report absentee call-ins to the Nursing Supervisor and/or Unit Manager .Make daily rounds of your unit/shift to ensure that assigned CNAs [certified nursing assistants] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Assign a sufficient number of LPNs and RNs for each tour of duty to ensure that quality care maintained . Review of the Unit Manager, Job Description dated [DATE], revealed .Provide the Director of Nursing Services with information relative to the nursing needs of the resident and to the Nursing Services Department's ability to meet those needs .Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatment are provided as scheduled .Report medication errors to the Director of Nursing Services . Review of the Staffing Coordinator, signed Job Description, revealed .The primary purpose of you position is to ensure adequate and appropriate staffing of the Facility's nursing department to meet the needs of the residents .Complete monthly nursing schedule coordinating requests to ensure appropriate coverage of units .Make written or oral reports and recommendation to the DON concerning staffing and scheduling issues . Review of the Charge Nurse [licensed practical nurse (LPN)] Job Description dated [DATE], revealed .The primary purpose of your position is to provide direct nursing care to the resident, and to supervise the day-to-day nursing activities performed by CNAs [certified nursing assistants] .Report all discrepancies noted concerning physician's orders .charting error .to the Nursing Supervisor .Unit Manger [Manager] .Inform the Nurse Supervisor .Unit Manager of staffing needs when assigned personnel fail to report to work .Nursing Care Functions .Review the resident's chart for specific treatment, medication orders .Use an Automated External Defibrillator .Perform Cardiopulmonary resuscitation (CPR) .Ensure that resident who are unable to call for help ae checked frequently . 2. Review of medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Heart Failure, Hypertension, Gastrostomy, previous history of Traumatic Subdural Hemorrhage, Anxiety Disorder, and Diabetes. Review of the Fall Incident Report, dated [DATE], revealed .On [DATE] resident [Resident #4] was found sitting on floor by ADON [Assistant Director of Nursing] who summoned nurse to room to assess patient [Resident #4]. Patient was alert and had no visible injuries noted. Was able to move all extremities. Resident stated she was trying to get some water when she got out of bed . There was no documentation staff performed Neuro Checks and frequent Vital signs following the unwitnessed fall on [DATE]. Review of the Physician's Orders dated [DATE], revealed .Eliquis [a blood thinner, bleeding is the most common adverse event related to Eliquis] Oral [by mouth] Tablet 5 MG [milligrams] .give 1 tablet by mouth two times a day for Anticoagulant Therapy . Review of the Fall Incident Report, dated [DATE], revealed .Resident [Resident #4] slid off of low bed onto the floor .I got out of the bed [Residents description]. No injuries observed at time of incident . There was no documentation staff performed Neuro Checks and frequent Vital signs following the unwitnessed fall on [DATE]. Review of the Fall Incident Report, for Resident #4 dated [DATE] at 7:30 AM, revealed .Therapy called writer [Charge Nurse] to [Resident #4's room] .SPL [Speach Language Pathologist] stated to writer resident [Resident #4] on her knees as if she was praying, resident noted holding on the bed rail with both hands .Neuro checks started d/t [due to] unwitness [unwitnessed] . Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET dated [DATE], for the [DATE] fall revealed the neuro checks on [DATE] were only completed at 7:30 AM and at 9:00 AM. There was no documentation of additional neuro checks and vital signs in accordance with the facility policy. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #4 scored a 00 on the Brief Interview for Mental Status (BIMS), which indicated the Resident could not recall the correct answers. Further review of the [DATE] MDS revealed, .Acute Onset mental Status Change . [question] Is there evidence of an acute change in mental status from the resident ' s baseline . No . [question] Was the resident's thinking disorganized or incoherent [rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject] .Behavior not present . Altered Level of Consciousness .behavior not present . Review of the Social Service Progress Note dated [DATE], revealed .Visited with [Named Resident #4] to conduct a BIMS assessment, resident is severely impaired with BIMS score being a 01 [severely cognitively impaired] [Resident #4] is A&O [alert and oriented], but unable to say the three words correct sock blue and bed; resident said stop blue and bird and she did not know the month, year or day of the week. SW [Social Worker] will continue to assist as needed . Review the Weekly Assessment Note dated [DATE] revealed, . [Resident#4] is alert to self. Answers some questions appropriately with yes and no . Periodically talks about the past times as a child and known for reminiscing . Review of the Progress Note, dated [DATE], revealed . [Resident #4] noted with N/V [Nausea/Vomiting] new order KUB [kidney, ureter, bladder - an X-ray study that assesses the organs of your urinary and gastrointestinal systems] . Review of the facility Fall Incident Report, dated [DATE] at 2:00 AM, revealed LPN Z documented, .Resident [Resident #4] found in sitting position on the floor. [Door side of bed] .Resident Unable to give Description .Resident assessed from head to toe for any injury, none found . Further review revealed LPN Z documented Resident #4 was oriented to person, and had predisposing factors as confused, had a gait imbalance, and immobility. The section for Predisposing Physiological Factors was left blank. Review of the facility's Neurological Check list revealed the neurological checks should be completed every (q) 15 minutes time 4, every 30 minutes times 2, every hour times 2 hours and every 4 hours times 24 hours. Review of the Neurological Check List, for Resident #4's unwitnessed fall on [DATE], revealed the neuro checks were performed on [DATE] as follows: The q 15-minute neuro checks were initiated on [DATE] at 2:00 AM and conducted every 15 minutes until completed at 2:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q 30-minute neuro checks were initiated at 3:15 AM and completed at 3:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q one-hour neuro checks were initiated at 4:45 AM and completed at 5:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q 4-hour neuro checks for 24 hours were only completed at 6:45 AM, 10:45 AM and 2:45 PM. There was no documentation the q 4 hour neuro checks were conducted for 24 hours, and no documentation of vital signs with the neurological checks. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. Review of the Vitals Summary dated [DATE], revealed Resident #4's Vital signs were checked as follows: On [DATE] at 2:45 AM, and at 10:34 AM. On [DATE] at 11:27 AM and at 1:31 PM. Review of the Situation, Background, Assessment, Recommendation (SBAR) note, (an electronic notification to the physician/practitioner), for Resident #4 dated [DATE] at 2:40 AM, revealed . Mental Status or Neuro Changes .found on floor .She [Resident #4] deny [denies] pain .Instructed to call for asst [assistance] when she [Resident #4] need [needs] something . There was no documentation the physician/practitioner was notified of Resident #4's rambling speech that was documented in the neurological check list. The intervention to instruct Resident#4 to call for assistance was an inappropriate intervention due to BIMS of 01 and the lack of cognitive ability to remember to call for assistance. Review of Progress Note, dated [DATE] at 2:13 PM, revealed .Staff reported resident [Resident #4] not acting like her normal self post fall day 2. Reported changes to [Named Medical Director] at 133p [1:33 PM] and he gave an order to send to the hospital for head ct [Computerized Tomography scan - detailed image of the body] . Review of Nurses Note for Resident #4 dated [DATE], (for the events that occurred on [DATE]), revealed .Went in to assess patient [Resident #4], she was not speaking or answering any questions verbally or nonverbally AAOx0 [Awake Alert Oriented times zero] . This entry was not documented as a late entry. Review of the Emergency Medical Services (EMS) report dated [DATE] revealed EMS received an emergency call on [DATE] at 1:40 PM and arrived at the nursing home at 2:00 PM. The EMS report revealed, .en-route to [Named Facility] .for emergency complaint of altered mental status post-fall .on arrival, pt [Resident #4] was .minimally responsive .Nurse stated pt fell x [times] 2 days ago . ' neuro checks' were started this morning approx [at approximately] 0200 [2:00 AM] .at 2:30 [AM] and had degraded .Pt has hx [history] of trauama [trauma] subdural hematoma .Pt would open eyes to loud verbal stimulus at times pt would not respond unless painful stimulus was applied .pupils were unequal at 4mm [millimeters] on left and 5 mm on right .reactive to lights . EMS left the facility at 2:22 PM, transporting Resident #4 to the hospital Emergency Department (ED). Review of the Hospital Emergency Department (ED) records dated [DATE], revealed Resident #4 presented to the ED on [DATE] at 2:45 PM via EMS. Review of the hospital Triage assessment dated [DATE] at 2:47 PM, revealed . [Resident #4] to triage via [Name of EMS] with cc [chief complaint of] fall x [times] 2 days ago .LKW [Last Known Well] was 0200 [2:00 AM] this morning [[DATE]] .not following commands in triage . The ED Assessment for Resident #4 dated [DATE] at 4:18 PM, revealed .Speech Garbled . Review of the Hospital ED History & Physical for Resident #4 dated [DATE] at 4:41 PM, revealed .Last known well: Date/time [DATE] 02:30:00 [2:30 AM] . According to the EMS NH [Nursing Home] staff noticed that the patient [Resident #4] is experiencing altered mental status around 2:30 AM [approximately 12 hours prior to arriving to the ED] when they started neuro checks on her and noticed declining mental status . Review of the Hospital ED Physician Consultation for Resident #4 dated [DATE] at 4:58 PM revealed, .Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma XXX[AGE] year-old female with a past medical history of hypertension, diabetes, thyroid disease and previous subdural hematoma, status post craniotomy in 2019 .She presents today after a fall at her nursing home .The patient has had a progressive decline in her mental status which prompted a presentation to the emergency department for further evaluation. CT [Computerized Tomography] scan demonstrates a large right subdural hematoma with mass effect [increasing pressure within the skull and potentially causing midline shift or deadly brain herniation] and midline shift for which Neurosurgery has been consulted .We will take the patient emergently to the operating room for a right craniotomy for subdural hematoma evacuation . Review of the Hospital Records for Resident #4 dated [DATE], revealed .As per the patient's daughter patient was at her baseline alert oriented x [times] 3 walking with assistance on Monday of last week [[DATE]], her granddaughter went to see her on Tuesday and Wednesday [[DATE] and [DATE]] when she noticed that she [Resident #4] is becoming confused and the family were informed by the NH [Nursing Home] that the patient fell down on Tuesday [[DATE]] and again on Friday [[DATE]] . Initial CT head reports an acute moderate to large sized right subdural hematoma [Acute subdural hematomas commonly form because of a severe head injury] with 1.5 cm [centimeter] right to left midline shift. She [Resident #4] was taken to the OR [Operating Room] by NSY [Neurosurgery] and underwent R [Right] FT [Frontal] craniotomy for evacuation of SDH [Subdural Hematoma] . Patient was admitted to ICU [Intensive Care Unit] for closer monitoring and critical care management. She is now s/p [Status/Post] craniotomy on [DATE] [2024]. Patient on AED [anti-epileptic drugs .as a prophylactic factor for post-traumatic seizures] prophylaxis. Repeat CTH [CT of the head] is stable .CONSULTATION XXX[DATE] .REASON FOR CONSULTATION . Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma .The patient will need intensive care unit level of care, q.1 h. [every one hour] neurological checks . The Post surgery CT Scan results for Resident #4 on [DATE] revealed, . Mild improvement in leftward midline shift, now measuring 5 mm [millimeter] compared with 7 mm previously when measured at the foramen of [NAME] [an anatomical structure in the human brain that plays a significant role in cerebrospinal fluid circulation and brain imaging]. Ventricles are unchanged in size and configuration . Patient was admitted to ICU [Intensive Care Unit] for closer monitoring and critical care management. She is now s/p [Status/Post] craniotomy on [DATE] [2024]. Patient on AED [anti-epileptic drugs .as a prophylactic factor for post-traumatic seizures] prophylaxis. Repeat CTH [CT of the head] is stable .CONSULTATION XXX[DATE] .REASON FOR CONSULTATION . Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma .The patient will need intensive care unit level of care, q.1 h. [every one hour] neurological checks . During a telephone interview on [DATE] at 11:13 AM, Family Member #4 was asked about Resident #4's recent falls in the facility. Family Member #4 stated, .It started off ok .my mom keep on falling .she [Resident #4] here at the hospital with that fall [[DATE]] she [Resident #4] been here at [Named Hospital] for the past 2 weeks .on [DATE] she had surgery, on Wednesday [[DATE]] she [Resident #4] started throwing up .no one called and told us .my daughter was there and said grandmom is throwing up .so I called the unit manager [Name Unit Manager on [NAME]] .she [Unit Manager] said she don ' t know why she [Resident #4] is throwing up they [staff] are going to order an US [Ultra Sound] and they [staff] will me let know the results .on Thursday [[DATE]] when my daughter of [Family member #4's daughter] was up there [at the facility] mom [Resident #4] was confused .they [facility staff] did not call and let me know that either .she [Resident #4] had 2 Blood clots on her brain and had [a] stroke that [that's] how she [Resident #4] ended up in the nursing home .Friday [[DATE]] got a call from [Named LPN Z] at 6:59 AM said my mom [Resident #4] fell and he [LPN Z] did not know if she [the Resident] hit her head or what .he [LPN Z] said when he found [Resident #4] she was on her butt [on the floor] .I found out from the nurse on Saturday [[DATE]] [Named Registered Nurse (RN) FF] she [Resident #4] was not eating, she [RN FF] called the doctor and he said send to the ER [emergency room ] .look [looks] like she need [needs] a CT [computerized tomography - a detailed image of the brain] scan .we wanted her [Resident #4] sent [to Named Hospital #2] .her BP [blood pressure] was ,d+[DATE] [when the Resident arrived at hospital] rushed her [Resident #4] to do a CT scan and told me they had to do emergency surgery, a craniotomy [surgery to cut a bony flap from the skull to access the brain and treat the bleeding in the brain] .she [Resident #4] had a bleed that shifted her brain .[Named RN FF] said he [Staff Licensed Practical Nurse (LPN) Z] was doing neuro checks on your mom [Resident #4] like she [the Resident] was alert oriented . During a telephone interview on [DATE] at 2:07 PM, CNA L was asked if she was aware Resident #4 had a fall. CNA L stated, .No, not until Saturday [[DATE]] .the nurse relayed the message to me .[Named RN FF] .she told me that morning .I went and told her [the nurse] [Named Resident #4] was not saying anything .so for breakfast she was not eating and acting the same [Resident #4 was not acting as she usually/normally does] .so she [Named RN FF] said let me go and check the notes .said she [Resident #4] had a fall . I reported that she [Resident #4] did not eat her breakfast and is not talking .I told her [RN FF] again at lunch she [Resident #4] did not eat and did not say anything to me .she [RN FF] came in and checked on her [Resident #4] and a little later she [RN FF] told me she was going to send her [Resident #4] out [to the hospital] . I knew it was a change for her [Resident #4] .a significant change .she [Resident #4] talks all day, and she [Resident #4] always eats . During an interview on [DATE] at 8:49 AM, the Director of Nursing (DON) reviewed each Resident #4 fall incident and was asked how she identified who performed the Neuro checks on [DATE]. The DON stated, .There is no name on the forms .you can't tell . The DON was asked to review the fall incident for Resident #4 on [DATE] and on [DATE] and asked if the falls were witnessed or unwitnessed falls. The DON stated, Unwitnessed Fall . The DON was asked if the nursing staff should have documented and started Neuro checks and vital signs following the [DATE] and [DATE] falls. The DON stated, .Yes, ma'am . The DON was asked to review the fall incident for Resident #4 which occurred on [DATE] and asked if the Neuro Checks were complete. The DON stated, No it's [the neuro checks] not . The DON was asked to review the unwitnessed fall for Resident #4 which occurred on [DATE] and asked if the Neuro Checks and Vital Signs were completed according to the facility policy. The DON stated, .No, ma ' am . The DON was asked how the Neuro checks, and frequent vital signs should be taken. The DON stated, .Every 15 minutes times 4, every 30 minutes time 2, every hour times 2, and every 4 hours times 24 hours . During an interview on [DATE] at 1:10 PM, the Medical Director was asked if he would expect the staff to complete Neuro checks and vital signs to identify potential neurological problems and inform him when a resident who was on anticoagulants experienced an unwitnessed fall. The Medical Director stated, .Absolutely and let me know .if unwitnessed and don't know if they hit their head .I send them out for a CT right away . The Medical Director was asked what caused a subdural hematoma (bleeding in the brain). The Medical Director stated, .It comes from trauma . During an interview on [DATE] at 9:12 AM, LPN CC was asked about Resident #4's fall on [DATE]. LPN CC stated, .It was the therapy person who found her [Name Therapy Staff Member] .it was change of shift .I was still here .it was around 7:30 AM . I just assessed her [Resident #4] .she said she was not hurting .no pain or discomfort . LPN CC was asked what was completed when a resident experienced an unwitnessed fall. LPN CC stated, .We do the neuro sheet . LPN CC was asked to review the Neurological Assessment Flow Sheet and if it was complete. LPN CC stated, .No its not complete .I documented at 7:30 AM the first neuro check . LPN CC was asked when you have a resident with an unwitnessed fall that is on an anticoagulant, what do you do. LPN CC stated, .Notify the doctor and 9 times out of 10 they will send them [the resident] out to the hospital . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #4's fall. LPN Z stated, .the CNA told me .she [Resident #4] had a fall .I was on the other end of the hallway helping a man in [named room number] .she [Resident #4] was on the floor .she [Resident #4] had her back against the bed .I asked her how she got down there .she [Resident #4] just looked and did not say anything .I don't remember her telling me anything .I assessed her and asked her if she was hurting .she shook head no .she had no injuries .the bed was in the floor position .we put her back to bed . LPN Z was asked if the fall was a witnessed or unwitnessed fall. LPN Z stated, .As far as I know it was unwitnessed .the CNA did not tell me she saw her [Resident #4] fall . LPN Z was asked what the process was for an unwitnessed fall. LPN Z stated, .we fill out the incident report, the SBAR [Situation, Background, Assessment, Recommendation], and start neuro checks .I notify doctor and family . LPN Z was asked if Resident #4 had a fall on Tuesday [DATE]. LPN Z stated, No. LPN Z was asked what else was documented besides the neuro checks. LPN Z stated, .All we do is the regular neuro checks .document and monitor the rest of the night .the new neuro system .we have to do vital signs every time we do the neuro checks .sign and put our name on it [Neuro check form] . LPN Z was asked if he signed the neuro check sheet for Resident #4. LPN Z stated, .No .there was no place for a signature on the sheet anywhere . LPN Z was asked what rambling speech meant for Resident #4. LPN Z stated, .She [Resident #4] is aways confused .when ask a question .she talks about something else .that's the way her conversations went . LPN Z was asked what did Resident #4 look like at the end of the shift. LPN Z stated, .she was fine .she laid there the rest of the night just looking around .I was still doing the neuro checks .it's so busy for one nurse .I was trying to do the best I can . In summary, Resident #4 had a history of a Subdural Hematoma with craniotomy and was on a medication with a potential side effect of increased bleeding. The facility had a history of not completing the neurological checks for Resident #4's previous unwitnessed falls. Resident #4 had an unwitnessed fall on [DATE] at 2:00 AM, the facility initiated neurological checks at 2:00 AM through 2:45 PM on [DATE]. The facility failed to complete the neurological checks for the 24-hour period and did not document the resident's vital signs with each neurological check in accordance with the facility's policy. The neurological checks that were performed revealed Resident #4's speech was rambling. The neurological checklist was dated [DATE] at 2:00 AM, the nurse reported to EMS the neurological checks were initiated on [DATE] at 2:00 AM. The facility reported to EMS on [DATE] at 2:00 PM (when EMS arrived) Resident #4 had degraded (declined) since 2:30 AM and did not notify the Medical Director or seek emergency treatment until approximately 12 hours later. Resident #4 had a decline between [DATE] (after the last neurological check was performed) at 2:45 PM and when the Medical Director was notified on [DATE] at 2:13 PM, almost 36 hours after the unwitnessed fall on [DATE]. 3. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted after hospitalization on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, Tracheotomy Status, Gastrostomy Status, Type 2 Diabetes, Chronic Pain, Seizure Disorder, and Contracture of Right Hand and Left Hand. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was severely cognitively impaired. Review of the MDS assessment at Section GG dated [DATE], revealed Resident #7 required maximal assistance with mobility, transfers, bathing, dressing, and eating. Review of the Comprehensive Care Plan dated [DATE], revealed [Named Resident #7] has an ADL self-care deficit r/t [related to] Disease Process anoxic brain injury, Weakness and Deconditioning .Goal [Named Resident #7] Will have her personal ADL needs met with the assistance of staff, while pro [TRUNCATED]

Based on policy review, review of the American Heart Association Provider Manual, medical record review, observation, and interview, the facility failed to initiate and provide Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR - perform measures to assist the person with breathing and to stimulate a heart rate) for 2 of 3 sampled residents (Resident #5 and #6) reviewed in accordance with the professional standards of care related to basic life support for healthcare providers. Resident #5 who resided on the ventilation unit called the Crown Unit was found unresponsive and not breathing by Certified Nursing Assistant (CNA) B on [DATE] at 2:45 AM and was a full code (to receive CPR). Resident #6 who resided on the [NAME] Unit was found unresponsive on [DATE] at 3:50 AM by CNA H and was a full code. The facility failed to immediately initiate CPR according to the professional standard of practice for a healthcare provider and in accordance with the facility policy. The facility's failure to immediately provide basic life support placed Resident #5 and #6 in an environment detrimental to their health, safety, and wellbeing. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on [DATE] at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F678 at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on [DATE] and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on [DATE] through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F678 began on [DATE] through [DATE], the IJ was removed on [DATE]. Non-compliance of F678 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Medical Emergency Response (Named Facility) Rehabilitation and Nursing Center, dated 2019, revealed .It is the policy of this facility to respond to medical emergencies for residents .The employee who first witnesses or is first on the site of a medial emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance .A nurse will: a. Assess the situation and determine the severity of the emergency. b. Stay with the resident. c. Designate a staff member to announce a Code Blue [overhead call for staff to come to and assist with CPR], if necessary, notify the physician and call 911 as needed .A Code Blue will be announced over the intercom system .All available staff will respond to the emergency accordingly .The RN [Registered Nurse] supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed .This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS [Emergency Medical System] .Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider . Review of the American Heart Association Basic Life Support Provider Manual dated 2020, revealed .No breathing or gasping, pulse not felt .Start CPR .Use AED [Automated External Defibrillator] as soon as it is available .The first rescuer who arrives .check the victim for responsiveness .should send another rescuer to activate the emergency response system and get the AED .Make sure the victim is face up on a firm flat surface .Perform chest compressions .Provide Breaths .Give breaths, watching for chest rise and avoiding excessive ventilation [oxygenation during cardiac arrest] .Early defibrillation increases the chance of survival for cardiac arrest . 2. Review of medical record revealed Resident #5 was admitted to the Crown/vent unit on [DATE], with diagnoses of Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy. Review of the Post Form (a form used to notify staff if an individual would like CPR in the event it's needed) dated [DATE], for Resident #5 revealed .Resuscitate (CPR) .Full Treatment . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #5's Brief Interview for Mental Status (BIMS) was blank, which indicated the Resident was severely impaired. Review of the Respiratory Therapy Progress Note for Resident #5 dated [DATE] at 12:36 AM, revealed Respiratory Therapist (RT) #1 documented .Resident is alert and appears comfortable saturations [measure of oxygen in the blood stream] 96% [percent] and heart rate 89 bpm [beats per minute] on Airvo [a humidifier with integrated flow generator that delivers warmed and humidified respiratory gases to spontaneously breathing patients] . RR [respirations] 16. Resident received oral and trach care; BS [breath sounds] was coarse before suctioning. Resident's secretions were thick and pale in color. BS improved after suctioning . Review of the Respiratory Therapy Progress Note, dated [DATE] at 2:30 AM, revealed Respiratory (RT) #1 documented .CNA [CNA B] found the resident [Resident #5] unresponsive. [CNA B] told me immediately after finding the resident. I check [checked] the resident pulse and for breath sounds. After not finding either, I instructed the CNA to call 911, find the other RT [Respiratory Therapist] and tell her that we had a code blue, along with finding a nurse to help conduct CPR because there was not one on our floor [Crown Unit], while I grabbed a O2 [oxygen] tank and started CPR [Cardiopulmonary Resuscitation] . EMS [Emergency Medical Services/Paramedic and emergency medical technician (EMT)] took over at approximately 0257 [2:57 AM] and left with the resident around 0307 [3:07 AM] for [Named Hospital #1] . Review of the Nursing Progress Note for Resident #5 dated [DATE] at 3:19 AM, revealed LPN JJ documented .Resident [Resident #5] noted per cna [CNA B] at 0245 [2:45 AM] to be unresponsive and informed this nurse on Delta [another unit separate from the Crown Unit]. Nurse [Delta Nurse who was not CPR certified at the time of the code] assessed [Resident #5] and immediately respiratory [therapist] started cpr. This nurse immediately called 911 and firefighters [Paramedic and EMT] arrived [continued cpr]. Contacted and informed [Named Family Member #6] . of [Resident #5] current status and after firefighters left with resident enroute to [Named Hospital #1]. RR [Resident Representative] asked why they didn't go to [Named Hospital #2] .Nurse informed her in emergency cases/possible cardiac arrest the nearest hospital is first option. She stated she would call them. Nurse expressed wishes for the best outcome and call ended. Informed DON [Director of Nursing] and NP [Nurse Practitioner] . RT #1's progress note revealed Resident #5 was found unresponsive at 2:30 AM. LPN JJ's progress note revealed Resident #5 was found unresponsive at 2:45 AM. The Fire Department report revealed the 911 call to dispatch was at 2:36 AM; and the last known time the Resident was checked with no problems was reported by the facility as 2:35 AM. The facility to failed ensure accurate documentation of the CPR event, in accordance with facility policy. Review of the Fire Department Prehospital Patient Report dated [DATE], revealed they were dispatched to the nursing home on [DATE] at 2:36 AM, arrived at the nursing home at 2:47 AM, and arrived at Resident #5's bedside at 2:50 AM. The report revealed, .Last know well [Resident #5 had no problems] XXX[DATE] .02:35 [2:35 AM] . [Unit Number of named Fire Department] dispatched to cardiac arrest. [Unit number of Named Fire department] arrived on scene to find a 43 yo [year old] female lying on the bed. Pt [patient/Resident #5] was unresponsive, GCS [Glasglow Coma Scale used to measure the consciousness of patients] of 3 [Severe trauma to the brain], cc [Chief Complaint] of cardiac arrest . [facility staff] on scene stated that pt [patient/Resident #5] was last seen normal approximately 30 minutes before [Fire Department] arrived. [Facility Staff] . on [the] scene [and] initiated CPR prior to [Unit number Fire department] .arrival. [Unit number Fire Department] assisted . with CPR and interventions . ALS [Advanced Life Support] procedure, interventions, and medications. Pt [Resident #5] was placed onto stretcher, secured by straps and rales, and placed into unit. Paramedic .rode in with unit crew. Unit crew assisted paramedic .with pt care during transport to hospital .Pt [Resident #5] was transferred to hospital ED [Emergency Department] and offload into [ED Room number]. Pt care was transferred to ED staff . The Fire Department report revealed they left the facility with Resident #5 at 3:08 AM and arrived at the hospital emergency department (ED) at 3:12 AM. Resident #5 had a Rhythm of PEA (Pulseless electrical activity-is a condition where your heart stops because the electrical activity in your heart is too weak to make your heartbeat). Resident #5 was pronounced as deceased in the ED on [DATE]. 3. During a telephone interview on [DATE] at 2:42 PM, Respiratory Therapist #2 (RT) was asked how she found out about Resident #5's code on the Crown Unit. RT #2 stated, .the CNA came and found both [RTs], I went in there immediately and started CPR .did chest compression and [Named RT #1] was bagging [ambu bags are kept in each room on the ventilator unit used to administer breaths to Residents who are not breathing] . RT #2 was asked what type of equipment was in the room. RT #2 stated, .oxygen tank . crash cart .had suctioning in the room .I think [Resident #5] was on oxygen she was not my patient . RT #2 was asked if the AED [Automated External Defibrillator] was in use. RT #2 stated, .We never used it . EMS came in they put her on their monitor .to be honest I don't know . [if the AED was in the room] I'm prn [as needed] there . I work 3 days out of the month .I still don't know how to do things there [at the nursing home] .before anyone brought the crash cart in the room .we were there for 5 minutes . RT #2 was asked if she remembered if the facility had called the code overhead .RT #2 stated, .No . no one called a code overhead .I was in [Named Resident #1's] room and one of the CNAs came running and grabbed me . RT #2 was asked if she knew what time of night it was when Resident #5 needed CPR. RT #2 stated, .I don't remember the time .a nurse came in there [Resident #5's room] .a female [LPN JJ] .a guy [LPN Z] came in there [Resident #5's room] . another CNA [CNA H] did . During a telephone interview on [DATE] at 4:21 PM, RT #1 was asked how she found out about the Code for Resident #5 on the Crown Unit. RT #1 stated, .The CNA went in and found her [found Resident #5 unresponsive] .I had just been there [Resident #5's room] 30 minutes before it happen .[Named Resident #23] heart rate was 148 .we did not have a nurse on crown [the Crown/Vent unit] .I had to keep my eye on her [Resident #23] . RT #1 was asked who was the CNA who came and got her. RT #1 stated, she [CNA B] has natural hair .the same CNA [CNA B] when doing my rounds .she [CNA B] came in the office and said she [Resident #5] was not responding .I ran down there [to Resident #5's room] .I felt for a pulse .no pulse grabbed the oxygen mask and the oxygen tank .told her [CNA B] to get the other RT .call for any nurse available .call code blue .[RT #2] got there before the nurse .she [RT #2] started compression .I was bagging her [Resident #5] with ambu bag [a method for providing a person with immediate air ventilation using a self-inflating bag ] .the nurse said need to grab crash cart .I asked for a board [a board to place under a resident's back in order to perform CPR for accurately] first .we took turns on compression and bagging until EMS got there .I had to put her [Resident #5] trach back in . EMS [emergency medical services] tried to move her [Resident #5] and I had to put trach back in . EMS step [stepped] out the room . RT #1 was asked if they used the AED. RT #1 stated, .We did not use the AED .the EMS used theirs .by time crash cart came into play . EMS put there monitor on her [Resident #5] .first just the 2 of us [RT #1 and RT #2] doing CPR .I assumed when the nurse came into play .they [nurses would] get the AED it did not come into play . RT #1 was asked what time the Code happened. RT #1 stated, . I'm not sure . RT #1 was asked who recorded the times and the event of the code. RT #1 stated, .Nobody . RT #1 was asked how she would know who did what, when, and where during the code if not documented. RT #1 stated, .I don't .normally the nurse would run the code .but there was no nurse on the floor [Crown Unit] it was a lot going on with no nurses on the floor .getting new patient in .patient died .it was a lot going on .and still trying to take care of patients still there on Crown .we did not have a nurse all night .all we had was RT [Respiratory Therapy] and a CNA .every place I went [worked] they have a recorder, and it will be the nurse . RT #1 was asked what did LPN JJ do during the Code in Resident #5's room. RT #1 stated, .the dark skin short lady [LPN JJ- who did not have a current CPR certification] .she was on the computer trying to get everything ready [paperwork] after she left, she sat down to try to write a note about what happen . RT #1 was asked if the ,d+[DATE] AM nurse came in to work. RT #1 stated, .I don't think so .at 12:00 AM and 1:00 AM .I said there's still no nurse here on the floor .we were telling the nurse who came at 7:00 AM what happened .there was no nurse on the hall [Crown/Vent unit] all night . During a telephone interview on [DATE] at 5:17 AM, CNA H was asked about the code on the Crown Unit in Resident #5's room. CNA H stated, .All I know is they called Code over the speaker .I did go down there to the hall [Crown Unit] to assist .I got the dinamap [used to measure blood pressure] to get some vital signs .and the pulse oximeter [use to measure blood oxygen] .I put the pulse oximeter on her finger .I put the pulse oximeter on [Resident #5's] finger to see if I could get a reading [there was no documented reading] .I left the room .I was just in there briefly . During a telephone interview on [DATE] at 5:26 AM, LPN Q was asked if she attended the Code on the Crown Unit for Resident #5. LPN Q stated, .No .I did not .I have a bad wrist .I would not be no good . During a telephone interview on [DATE] at 5:40 AM, Staff LPN JJ was asked about the code on the Crown Unit for Resident #5. LPN JJ stated, .I was working on Delta unit and CNA [CNA D] came to get me .when she came and got me she told me there is a Code on the Crown Unit, when I got to room [Resident #5's room], RT [Respiratory Therapy] was there. I went and got the crash cart, they [nurse] took the crash cart .I got on the phone and called 911, they [EMS] got here quickly . LPN JJ was asked if she went back to Resident #5's room. LPN JJ stated, .I did not go in the room .EMT [Emergency Medical Technician] was in the room .I went to the desk .paged Code again .I was in charge of getting EMT and fire department there .when I finished getting paper work .EMT was there I did not get chance to do CPR .there was enough people in the room . LPN JJ was asked did she chart in the nursing notes that she had assessed the Resident #5 for vital signs. LPN JJ stated, .I checked for a pulse .no chest rise and falling .I tried to get her [Resident #5] to response .her eyes were fixated .told them I'm going to call 911 . LPN JJ was asked when was the last time that Resident #5 had been checked prior to requiring CPR. LPN JJ stated, .There was no nurse on the Crown unit .I went in her [Resident #5] room at 12:30 AM .I went to change her feeding bag out .put water in her bag .if a nurse has to leave .they will come to me and I would take the keys .nobody gave me the keys that night .the CNA came over said there is no nurse on Crown unit .when I got over there was no nurse .that is when I found out .I came back to my hall to complete my work . LPN JJ was asked if she called the manager on call to inform them there was no nurse on Crown Unit. LPN JJ stated, No. LPN JJ was asked if she called the DON. LPN JJ stated, .No .I got here around 11:00 PM .that nurse on Crown left early .[Named LPNV] left early .[Named LPN W] left .I did not get this information until later .I was on my hall doing my work .I was behind on my hall, I have 40 plus patients [residents] on my hall . LPN JJ was asked if anyone notified the DON. LPN JJ stated, .Yes .I texted her .it was around 3:16 AM .I don't recall talking to her the [DON] . Review of LPN Staff JJ's employee file revealed there was a CPR certification card with an issue date of [DATE]. The facility was unable to provide information that LPN JJ was CPR certified during Resident #5's Code on [DATE], LPN JJ failed to maintain CPR certification in accordance with the facility policy. During a telephone interview on [DATE] at 6:14 AM, CNA D was asked about the Code with Resident #5. CNA D stated, .The CNA [CNA B] called my name .I was in the patients [residents] room next door visiting when the CNA she called me in the hallway .she [CNA B] asked if she thought she [Resident #5] was breathing .I went to [Name Resident #5's] room .then I left the room to called Code in the building . CNA D was asked where she went when she left the room. CNA D stated, .Down the hall to let another nurse know .told them I'm going to direct the ambulance and to let them [ambulance] in . CNA D was asked if there was a nurse on the Crown Unit. CNA D stated, .There was not a nurse .there was no nurse on Crown . CNA D was asked if she knew when the next nurse would come in [NAME] work n the Crown Unit. CNA D stated, Around 6:30 to7:00 AM the next morning . CNA D was asked if she saw any nurse pass medication to residents on the Crown Unit. CNA D stated, .I was not working that hall that night .all I know is [Named CNA B] was the CNA . During a second interview on [DATE] at 3:07 PM, CNA D was asked how the staff was notified of the Code on the Crown unit for Resident #5. CNA D stated, .I went to call a Code .she [CNA B] left to get the RT . there was no nurse for that hall .so we had to go get the nurse for my hall [Delta unit] .I was running and tell people by mouth . CNA D was asked if she should have used the call light that night and requested help. CNA D stated, .I did not push the light .there was no nurse on the hall [the Crown unit] .she was the only one [CNA B] . CNA D was asked if she checked for a pulse for Resident #5. CNA D Stated, .No . I did not feel her pulse .but I did look to see if her chest was rising or falling . CNA D was asked if CNA B checked for a pulse. CNA D stated, .I don't know .she asked me if she was breathing .she was warm .I looked at her chest .no she don't look like she is breathing .after [afterwards] I called a Code .I did not go back into the room .I went to get the door, to guide the Fire Department in . RT #1 was in the office at the nursing station down the hall . CNA D was asked if she was certified in CPR. CNA D stated, .No, it had expired, to my knowledge . During a second telephone interview on [DATE] at 8:50 AM, CNA H was asked if he went to Resident #5's Code on the Crown Unit. CNA H stated, .Yes ma'am .I went in the room .RT was doing compressions .the second RT was bagging .I got the dinamap [machine to measure vital signs] .took in the room and put the cuff on arm and pulse oximeter [machine to measure oxygen in the blood] on the finger for vital signs .checked the oxygen .from that point I stepped out the room let them do their job . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #5's Code on [DATE]. LPN Z stated, .I went there .they [RT's] were doing CPR .we don ' t have a crash cart .I went to the desk and brought it back .continued with compression and bagging until fire department get there .they wanted the pulse oximeter she did not have one on .[Named LPN JJ] came .[Named LPN Q] she did not come .[Named JJ] she came in the room everybody was doing CPR .she went to the desk to do the paperwork . LPN Z was asked if he was aware there was no nurse working on the Crown Unit that night. LPN Z stated, .Yes. LPN Z was asked if management told them to wrap the building [divide the building equally]. LPN Z stated, .No . they [management] did not tell anyone to wrap that night .if they did .I'm not aware of it .I have 53 -56 resident on my hall . In summary, the facility failed to ensure a RN or unit Charge Nurse documented an accurate account of the CPR, failed to ensure a nurse stayed with the resident who required CPR, failed to ensure the certified CPR staff member (CNA B) initiated immediate action-including CPR, failed to ensure the nurse (LPN JJ) who came from another unit was CPR certified at the time of Resident #5's code on [DATE], in accordance with the facility policy. Staff was unable to determine how long it took to initiate CPR after Resident #5 was found unresponsive. Staff had to go to a separate unit and find someone to start CPR. The facility failed to immediately initiate CPR or use the AED as soon as it was available, first rescuer who arrived should send another rescuer to activate the emergency response system and get the AED in accordance with the American Heart Association Basic Life Support Provider Manual to increase the chance of survival for cardiac arrest. Resident #5 was in arrest and had a PEA rhythm when EMS left the facility and was pronounced dead in the Emergency Department. 3. Review of medical record revealed Resident #6 was admitted on [DATE], with a readmission on [DATE], with diagnoses of Heart Failure, Hypertension, Chronic Pain, Acute Hepatitis C, Dysphagia, and Diabetes. Review of the quarterly MDS dated [DATE], revealed Resident #6 with a BIMS score of 14 which indicated the Resident was cognitively intact. Review of the Nurses' Progress Notes dated [DATE] at 3:50 AM, revealed LPN Z documented .Resident found unresponsive by her CNA [CNA H]. CPR begun and 911 called .[ Named Fire Department] arrived at 4am [4:00 AM] and took over with CPR .[Named Fire Department] pronounced [declared the Resident deceased ] resident [Resident #6] At 410 am [4:10 AM]. [Named [NAME] Department] here @ [at] 415am [4:15 AM] and did report .All 3 family members notified @ 430 am [4:30 AM] with no answer form [from] anyone .Sons wife [Named Family Member #7] returned call to Facility @ 650am [6:50 AM] and was notified and states she will notify the rest of the family .Family asked to hold up on calling [Named ] Funeral until all the family arrive here. mssg [message] passed on to day nurse .Nurse Progress Note dated [DATE] at 10:23AM [Named] Funeral here to receive. Family sighned [signed] personal inventory sheet . There was no documentation of the time that Resident #6 was found unresponsive, and the time immediate CPR was initiated by the facility staff. Review of the Named Fire Department Prehospital Patient Report for Resident #6 dated [DATE], revealed .Chief [Primary] .Cardiac arrest/obvious death .Primary impression .Obvious death .Summary of Events . [Truck Number] arrived on scene and found 62 yof [year old female] laying supine in a bed unresponsive at a nursing home. Staff was performing cpr on the pt. Upon the arrival of [named Truck] the pt was pulseless and cold to the touch in a warm environment. Pt abdomen was very distended. A 3 lead was placed on the pt and asystole was the first monitored rhythm and was confirmed in leads I [one] II [two] and III [three]. The 3 lead was transmitted to the epcr [electronic patient care report] and a picture was uploaded. Nursing home staff last saw the pt alive at 1 am [1:00 AM]. Staff stated the pt was asleep but breathing when they last checked on her. No staff was able to tell [Named Truck number] when the last time they actually spoke to the pt. The crew [Fire Department crew] felt that with the assessment finding above and unknown downtime that resuscitation attempts were considered futile. Pt noted to not have vital signs compatible with life notes at 0410 [4:10 AM]. [Name Police Department] arrived on scene and was turned over to [Named Police Department] .Unit disp .0:358 [3:58 AM] .En route 04:05 [4:05 AM] .At Patient .04:07 [4:07 PM] .Reason CPR Discontinued .Obvious Signs of Death .Medical Assessment .Eye Assessment .Left .Non-Reactive .Right .Non-Reactive .Mental Status Assessment .Unresponsive .Skin Assessment .Cold . During an interview on [DATE] at 1:45 PM, CNA G was asked if he attended the Code for Resident #6. CNA G stated, .I went to the room .the nurse .2 CNAs [Named CNA H] .a female aide, [Named LPN Z] was his hall .other people came along with me .another nurse called 911 . CNA G was asked if Resident #6 had anything coming out her mouth. CNA G stated, .Yes, it looked like black BM [bowel movement]. CNA G was asked if Resident #6 was dirty/soiled. CNA G stated, .When I walked in .they were cleaning her up . CNA G was asked if anyone was doing CPR. CNA G stated, ' No. CNA G was asked if Resident #6 was breathing. CNA G stated, .No . she was a full code .we were short that night . [Named CNA H] was the aide on the hall .it appeared he [CNA H] did not do a round .I had to go and get another crash cart something was missing on the first crash cart . CNA G was asked if during the Codes was there and AED in the room. CNA G stated, No. CNA G was asked if he knew how to use the AED. CNA G stated yes .I was educated when I got certified . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #6's Code on [DATE]. LPN Z stated, . [Named CNA H] he found her .I was down the hall, and he got me .I immediately went to her [Resident #6] room and found her [the Resident] unresponsive . LPN Z was asked if he checked for a pulse. LPN Z stated, Yes .we started CPR .told aide in the room to tell the nurse to call the code . LPN Z was asked who started chest compressions. LPN Z stated, .I did .one of aides brought the crash cart down . LPN Z was asked who bagged Resident #6. LPN Z stated, .I don't remember . LPN Z was asked if they had to get another crash cart. LPN Z stated, Yes .there was something missing on the crash cart .a suction tubing .we had to suction her and cleaned her up . LPN Z was asked if they [staff] suctioned her [Resident #6] and cleaned her [the Resident] up during the code. LPN Z stated, Yes. LPN Z was asked if Resident #6 appeared as if she had been laying there for a while dirty with urine and bowel movement. LPN Z stated, .Yes .from looking at the pads and the bed .yes .I don't think it just happen [her being dirty] . LPN Z was asked what Resident #6 looked like when he entered the room. LPN Z stated, .She looked like herself .but not breathing . LPN Z was asked how often the aides made rounds. LPN Z stated, .They [CNAs] supposed to check them [Residents] every 2 hours . LPN Z was asked when the last time Resident #6 was checked. LPN Z stated, .When I come in at 11:00 PM .I checked everybody .I have [a] list of stuff to do to get started .I had to make out the assignments .look at MARs [Medication Administration Records] for medications .it takes me a minute .I have to stop and start all night long . LPN Z was asked what time he had started his medication pass. LPN Z stated, .At midnight . LPN Z was asked when was the last time he checked on Resident #6 before she was found unresponsive at 3:50 AM. LPN Z stated, .It had to be around 1:30 AM or 2:00 AM, before I went to the Code on the Crown Unit [for Resident #5 ' s code] . LPN Z was asked if the AED was in the room during each code for Residents #5 and #6. LPN Z stated, .No, we didn't [have the AED] . LPN Z was asked if other nurses came to the Code for Resident #6. LPN Z stated, .No other nurse came .they suppose to come, but that night neither one come to the Code .I went to the desk and worked on the paperwork . LPN Z was asked at any time did he tell or ask staff if they could handle the Code and that you were going to do the paperwork. LPN Z stated, .No .I did not leave until fire department relieved me . During a telephone interview on [DATE] at 8:50 AM, CNA H was asked what happened when he found Resident #6 unresponsive on [DATE], and when the last time he checked on the Resident. CNA H stated, .It was around 1:00 AM .I do my first round about 1:00 AM .I just went in and saw she [Resident #6] was asleep [did not verify she was breathing] .I went to check on the other patients [residents] .I round on the patients every 2 hours .in between checking the patients .I make sure they are okay .that night I had [Named Resident #6] . At 3 something .3:30 AM .I went to room . [room of Resident #6] to check on the patient .3:40 AM I found [Named Resident #6] unresponsive .when I found her .I called her [Resident #6] name .she [Resident #6] did not respond .I checked her pulse .she did not have a pulse .I ran to get [Named LPN Z] the nurse and he came in .we tried to find pulse .she was still unresponsive .he [LPN Z] did go to the nursing station and called the Code . CNA H was asked if Resident #6 was breathing. CNA H stated, .No ma'am. CNA H was asked what they did next. CNA H stated, .I left and got the crash cart .he [LPN Z] came back to the room and started bagging .another CNA came and did compression [Named CNA A, who was CPR certified] . CNA H was asked if Resident #6 had something coming out of her mouth. CNA H stated, Yes she did .she had thrown up when I found her .the emesis, I saw a little on the floor and a little on her .when [CNA H] tried to bag her it was coming out of her mouth . CNA H was asked if he thought to push the call light for help. CNA H stated, .No ma'am .I did not .when I saw she was unresponsive I went and got the nurse . CNA H was asked if he was CPR certified. CNA H stated, .Yes, ma'am I am . CNA H was asked if you find a resident with no pulse what should you do first. CNA H stated, .We are taught to do a sternal rub .I did that .I checked her pulse .I called her name and went and got [Named LPN Z] . CNA H was asked if he thought to start CPR and chest compression. CNA H stated, .I did not think to do chest compression .in that moment I wanted to go get the nurse . CNA H was asked who attended the Code. CNA H stated, [Named CNA A] . [Named LPN Z] . [Named CNA G ] . went to the nurse station . CNA H was asked if they were left alone in the room without a nurse. CNA H stated, Yes .we stayed there until the fire department came . [Named CNA A] grabbed the bag [ambu] and I ended up doing the compression . CNA H was asked if they had to suction Resident #6. CNA H stated, Yes . [Named LPN Z] did that part .it was a lot coming out of her mouth . CNA H was asked if RT came to the code. CNA H sated, .No ma'am .they did not . Review of CNA H employee file revealed there was CPR certification card that expired on [DATE]. CNA H failed to maintain their certification in accordance with facility policy. During a telephone interview on [DATE] at 4:31 AM, CNA A was asked about Resident #6's Code on [DATE], and who attended the Code. CNA A stated [TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to prevent accidents/hazards, provide education and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for falls, and failed to ensure a safe environment for 1 of 3 (Resident #3) residents sampled for elopement. The facility's failure to provide appropriate transfer with a mechanical lift resulted in actual harm when Resident #4 sustained a fall which resulted in a laceration to the forehead and required sutures. The findings include: 1. Review of the facility's policy titled, Assessing Falls and Their Causes, dated 2018, revealed .The purposes of this procedure are to provide guidelines for assisting a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .Performing a Post-Fall Evaluation .After a fall, a nurse and or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort . Review of the facility's policy titled, Safe Resident Handling/Transfers [Named Facility], dated 2/2014, revealed .it is the policy of this facility to ensure that the resident 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 .Mechanical lifting equipment or other approved transferring aides will be used based on the resident's needs to prevent manual lifting except in medical emergencies .Mechanical lift may include equipment such as full body lifts .The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacture's instruction on proper sling .Two staff members must be utilized when transferring residents with a mechanical lift .Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur .Staff members are expected to maintain compliance with safe handling/transfer practices . Review of the facility's policy titled, Elopements and Wandering Residents, dated 10/2010 and revised 3/2024, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person- centered plan of care addressing the unique factors contributing to wandering and elopement risk .Elopement .occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .The facility is equipped with door locks/alarms to help avoid elopements .Alarms are not a replacement for necessary supervision .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Hypertension and Rhabdomyolysis. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately impaired with no behaviors identified, and required Substantial/maximal assistance with chair/bed-to-chair transfer. Review of the Lift/Mobility Evaluation, dated 5/14/2024, revealed .Quarterly Evaluation .Can the resident safely ambulate and transfer independently or with supervision only .No .Can Resident ambulate but requires support for maintaining balance .No .Number of staff needed for resident movement with a mechanical lift .TWO . Review of the Fall Risk Evaluation ORIGINAL, dated 5/14/2024, revealed .Score .21 .High Risk .Medication use .Antiseizure .Antihypertensives .Narcotic's .Memory and Recall Ability .In the last 7 days .recalls three out of four of the following .current season .he .is in a nursing home .location of room .staff name/faces .Sometimes .Gait Analysis .Unable to independently come to a standing position .Requires hands-on assistance to move from place to place .Decrease in muscle coordination . Review of the Progress Note dated 5/29/2024 at 7:30 PM, documented by LPN F revealed .Called into room by CNA [Certified Nursing Assistant]. Resident [Resident #4] lying on floor on his left side. CNAs were transferring resident from chair to bed using the hoyer lift when the lift pad strap broke, and resident fell . He hit the left side of his head near his temple causing a hematoma. Scant amount of bleeding noted. Resident was able to move extremities as well as before he fell . Called FNP [Named Family Nurse Practitioner] .she gave orders to send him to [Named Hospital] for evaluation .Left message for his sister [Named Family Member #1] .Neuro checks in progress . Review of the (Named Emergency Transport Company) dated 5/29/2024, revealed .77 yr [year] old male to be transferred to [Named Hospital] pt [patient] presents with general weakness .Call Received 19:33 [7:33 PM] .On Scene 21:15 [9:15 PM] .Depart Scene 21:32 [9:32 PM] . Review of the undated Facility Summary completed by the [NAME] Unit Manager, revealed . Resident [Named Resident #4] fell [DATE] at around 7:30pm [7:30 PM] . Resident was in the process of being transferred from his bed to the shower stretcher at the time of the fall. Upon assessment from the nurse, the resident was noted with an abrasion to the left temporal [part of the brain] side of his head. Vitals obtained and the MD [Medical Director] informed of the fall and ordered for the resident to be sent to [Named Hospital] ER [emergency room ] for further evaluation. Resent [Resident #4] transferred to [Named Hospital] ER via [by] ambulance. Resident's family updated on the incident .Upon conclusion of the investigation, it was found that the staff's transferring technique may have contributed to the resident fall. Inservice was immediately put in place and staff was in serviced as well as demonstrated on how to properly transfer residents . The facility summary was contradictory to the progress note that revealed Resident #4 was being transferred from the chair to the bed. Review of the Hospital records dated 5/29/2024, revealed .The patient presents follow ing [following] fall .transferred from his nursing home for evaluation of a fall that resulted in a scalp laceration. The patient was being transferred to the bed and Hoyer lift when the mechanism broke down and he slowly went to the ground, striking his buttock and then striking his head against the w all [wall] .Trauma appears to be limited to the patient's scalp where he had a small laceration that was repaired without complication using 4 interrupted sutures .Follow up with .[Named Physician] in 2 days 6/1/2024 see your primary care doctor .7 days(s), For sutures removal or have your sutures removed at your facility . Review of the Incident Report dated 5/29/2024 at 7:30 PM, completed by LPN F, revealed .Resident [Resident #4] on floor lying on left .Strap on hoyer lift pad broke and resident fell .Resident Taken to Hospital .Injury Type .Hematoma .Top of Scalp .Skin Tear .Injuries Report Post Incident .Injury Type .Injury Location .No Injuries Observed Post Incident . Resident #4 sustained a Hematoma, skin tear, and was sent to the hospital and received 4 suture repairs to the scalp of the head. There was inaccurate documentation on the incident report. Review of the IN-SERVICE ATTENDANCE LOG, dated 5/30/2024, revealed .Transferring a client using a mechanical lift .Selecting correct sling Size when transferring .How to correctly use Mechanical lift when transferring .Skills check off using mechanical lift . The in-service log for using the mechanical lift showed only 19 of the 77 CNA Staff members attended the in-service on 5/30/2024. Review of the Nursing Progress Note dated 5/30/2024 at 3:30 AM, documented by LPN S revealed .Resident [Resident #4] arrived [back] to facility [from the hospital] via [by] ambulance services x [times] 2 transporters. Resident is AAO [awake, alert and oriented] 2-3 [person, place and time], Left side of temporal sutures placed d/t [due to] s/p [status post] fall. Resident has no c/o [complaint of] pain or discomfort to left side of forehead. Resident is lying awake in bed ADL's [Activity of Daily Living] performed, bed is in lowest position with call light within reach .Care plan ongoing. Family was notified (spouse) accompanied ambulance services back to facility . Review of the Fall Risk Evaluation ORIGINAL, dated 5/30/2024, revealed .Score .8 .Moderate Risk .Medication use [Blank] .Memory and Recall Ability .In the last 7 days .recalls three out of four of the following .current season .he .is in a nursing home .location of room .staff name/faces .Always .Gait Analysis .Unable to independently come to a standing position . Review of the Patient Lift SAFETY GUIDE, revealed .Perform Safety check .Before lifting the patient, perform safety check .Examine all hooks and fasteners to ensure they will not unhook during use .Double check position and stability of straps and other equipment before lifting patient .Ensure clips, latches and bars are securely fastened and structurally sound . There was no therapy referral made by the nursing staff for the post fall on 5/29/2024. Review of the Physician's Orders dated 6/24/2024 at 11:28 AM, completed by the Wound Care Nurse #1, revealed .Late entry for 6/13/2024 .Remove sutures for from head .resolved . Review of the Nursing Progress Note dated 6/24/2024 at 11:37 AM, completed by Wound Care Nurse #1, revealed .Late entry 6/13/2024 .New order to remove sutures from left lobe of head s/p [status post] fall with injury .Sutures x4 [times 4] removed from left lobe of head without difficulty. Skin intact with no s/s [signs and symptoms] infection to site. Denies pain/discomfort. Floor staff and UM [unit manager] aware . The facility failed to follow the hospital recommendations for suture removal in 7 days. The sutures were placed on 5/29/2024, should have been removed on 6/5/2024 and were not removed until 15 days later on 6/13/2024. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated May 2024 and June 2024, revealed no treatment in place to monitor the sutures in Resident #4's forehead. The facility failed to provide documentation that Resident #4's wound was monitored with treatments in place and care planned for infection. Observation on 6/24/2024 at 11:45 AM, in the personal room (off of the laundry) revealed a disposable transfer pad (inappropriate pad that was supposed to be removed from use) hanging on the shelf. During an interview on 6/20/2024 at 11:19 AM, Resident #4 was asked what happen during his fall from the lift. Resident #4 stated, .it broke [the pad] .the string broke . Resident #4 was asked if it was 1 or 2 aides that was helping with getting you back to bed. Resident #4 sated, .it was 1 aide .the aide on the night shift . Resident #4 was asked was it a male or female aide helping you back to bed. Resident #4 stated, .it was female . Resident #4 was asked if he got hurt during the fall. Resident #4 stated, Yes I got 4 stiches .and my back was sore . Resident #4 was if the nurse provided any pain medication. Resident #4 stated, Yes. Resident #4 was asked again how many aides were helping him get back to bed and Resident #4 confirmed it was only one aide using the lift for transfer and that and it usually is one aide that transfers him. During an interview on 6/20/2024 at 11:47 AM, the [NAME] Unit Manager was asked about Resident #4's fall with the lift and who was involved. The [NAME] Unit Manager stated, .The nurse on the shift was [Named (Licensed Practical Nurse) LPN F] .[Named CNA R] .the supervisor [Named RN Supervisor #3] she started the initial in-service when found that CNA [CNA R] was transferring improperly .they pulled her [CNA R] from his room and educated her .that is what I was told she [CNA R] called for assist the nurse and another CNA [CNA I] came and helped get the resident back to bed .contacted the MD [Medical Director] .orders received to send to the ER [emergency room ] . The [NAME] Unit Manager was asked if she was aware that Resident #4 had returned from the hospital with sutures. The [NAME] Unit Manager stated, He did. The [NAME] Unit Manager was asked if the aide had written a statement. The [NAME] Unit Manager stated, She did not . The [NAME] Unit Manager was asked if she obtained any statements from anyone. The [NAME] Unit Manager stated, .I can check .It could be in my office .I can double check .I did get a verbal statement .I asked her what happened . The [NAME] Unit Manager was asked if she had documentation of the verbal statements. The [NAME] Unit Manager stated, No. Observation and interview on 6/20/2024 at 11:59 AM, the [NAME] Unit Manager went to the nursing station to review Resident #4's chart and checked in her office for any written statements. The [NAME] Unit Manager was unable to provide statements from the staff members. The [NAME] Unit Manager was asked to review the post fall assessment and asked if it was accurate and should the medication be documented. The [NAME] Unit Manager stated, .On the post fall assessment I should have documented the medications . The [NAME] Unit Manager was asked would that change the fall assessment score. [NAME] Unit Manager stated, Yes. During an interview on 6/20/2024 at 3:11 PM, CNA R was asked about Resident #4's fall from the lift. CNA R stated, .I put the lift pad under him .I was assisting him back in the bed .the strap at the bottom of the pad broke .I told [Named CNA I] to watch him I'm going to get the nurse .[Named LPN F] was passing medications .I went to get her and tell her he [Resident #4] had fell [fallen] .he hit his head on the bottom of the lift on the left side . CNA R was asked if she wrote a statement of the incident. CNA R stated, .we gave it to the supervisor .3-11 supervisor .she did the in-service . CNA R was asked what type of lift pad she used for the transfer. CNA R stated, .it was the hospital lift pad .it was already under him .those are not the correct pad .those are the transfer pads .that is what they [staff] have been using .everybody has been using them . During an interview on 6/20/2024 at 4:10 PM, LPN F was asked about the fall from the lift with Resident #4. LPN F stated, .I was on the 200 hall and [Named CNA R] came and got me .she told me that he [Resident #4] had fell and the lift pad had broken .when I got there he was on the floor .the lift was open he was in between the lift .when I came in the room [Name CNA I] was in there with him .she was standing and talking to him . LPN F was asked if Resident #4 was alert and could tell you what happen. LPN F stated, Yes .he is alert enough . LPN F was asked if she had observed the lift pad used. LPN F stated, .Yes .it was hanging down .it was broken . LPN F was asked if Resident #4 stated there was only one aide in the room would it be truthful. LPN F stated, .If he said it, I don't think he would lie .I don't think he would make up anything . During an interview on 6/20/2024 at 4:22 PM, CNA I was asked to tell me about the time Resident #4 fell out the lift. CNA I stated, .I was standing at the door watching near the curtain that is near the door .[Named CNA R] she was operating the lift .it happen so fast I was just standing there .she was lifting him on the lift .she said oh the thing snapped .the strap on the lift pad .I'm going to go and get somebody . CNA I was asked was it the normal lift pad the facility used to lift/transfer the residents. CNA I stated, .We just use what is under them .he is not heavy enough to have 2 persons during the lift .it doesn't take 2 people to use the lift . CNA I was asked if she helped hook the resident up to the lift pad. CNA I stated, .No .I was not touching or operating the lift . CNA I was asked if Resident #4 was alert and able to tell someone what happened during the fall. CNA I stated, Yes. During a continued telephone interview on 6/20/2024 at 9:55 PM, CNA R was asked about the time when Resident #4 had a fall with the lift. CNA R stated, .She [CNA I] was by the door .it takes one person to use the lift .by him being small .I did not realize it [lift strap] had broken .she could not get to me fast enough .the thing at the end of the bed [air mattress pump] was in the way .by [the] time I tried to lower him down is when I notice it had broken .she could not get around fast enough .he hit [his] head on the side of the lift .she [CNA I] was going to be on the other side .she was going to assist me on the other side of the bed .that was the lift pads we had to use in the building .even restorative used the pads .everyone around here was using them .when he was sitting in the chair the lift pad was under him already . CNA R was asked who hooked the rings to the lift. CNA R stated, I did. CNA R was asked who operated the controls. CNA R stated, I did .I raised him up from the chair and the lift pad broke .she [CNA I] tried to come over there and she almost fell . Random observation in the resident's room on 6/24/2024 at 9:08 AM, with the Social Director and Resident #19 revealed The Social Director performed a BIMS assessment, Resident #19 had a BIMS score of 9 which indicated he was moderately impaired. During an interview on 6/21/2024 at 9:12 AM, Resident #19 [Roommate of Resident #4 and had a BIMS of 9, indicating he was moderately cognitively impaired] was asked if he remembered when Resident #4 had fallen out of the lift. Resident #19 stated, Yes. Resident #19 was asked how many staff members were assisting the resident during the transfer. Resident #19 stated, .It was one aide in the room to transfer him with the lift . Resident #19 was asked what position the resident was in during the fall out of the lift. Resident #19 stated, .the wheelchair was on the side of my bed facing the door and the lift was in front of him against the wall .she was going to put him to bed .the sling was against the back wall facing the chair .then the strap broke .he fell against the wall .then she ran and got this other lady to put him in the bed .he fell , bam it was so quick, it was not a slow thing the strap broke and bam, like that .another aide came to help, she is a heavy lady . Resident #19 was asked if the nurse came to check him. Resident #19 stated, .No .they [CNA I and R] moved him to the bed, and took the lift out .they should have never moved him and put him in the bed .they don't know if he broke his neck [during the fall] .when [Named LPN F] came he was in the bed .she went back to the desk to make out a report . During an interview on 6/21/2024 at 11:03 AM, the Human Resource Manager was asked how many CNAs the facility has on staff. The Human Resource Manager stated, .A total of 77 CNAs with regular, part time and PRN [as needed] staff . During an interview on 6/21/2024 at 2:08 PM, the Administrator was asked about the lift pads that were used on Resident #4. The Administrator stated, .They are lifting pads the EMS [emergency medical service] use .not aware they were leaving them behind . The Administrator was asked if she had educated all staff members on the correct lift pads. The Administrator stated, .Yes .and in orientation . The Administrator was asked how the lift pads/transfer pads get into the facility. The Administrator stated, .I don't know, the EMS [emergency medical system] leaves them behind .they are not used for multi-use . The Administrator was asked if each resident has their own lift pad. The Administrator stated .They found one and used it .it looks like a lift pad .until this occurrence we had no idea .that prompted us to do an investigation . The Administrator was asked what the root cause analysis was from the investigation. The Administrator stated, .staff was using a lift pad that malfunctioned .that is what was identified .he bumped his head .we sent him out .had daily QA [Quality Assurance] meeting .did a room sweep to make sure no improper pads . The Administrator was asked when operating a lift what is the process. The Administrator stated, .You have a CNA on each side make sure the sling is secure on the lift .one person at the control and one person supporting the lift pad . The Administrator was asked if they interviewed any other resident to see what happen. The Administrator stated, No. During an interview on 6/24/2024 at 10:49 AM, the Interim Director of Nursing (DON) was asked when Resident #4 returned from the hospital if the neurological (neuro) checks should be started back. The Interim DON stated, .the neuro check should have been started at 4:15 AM instead of 5:15 AM on return from the hospital . The Interim DON was asked should Resident #4 have treatments in place for the laceration with sutures. The Interim DON stated, Yes .should have consulted wound care .wound care, they evaluate the area and add a treatment as recommended . The Interim DON was asked should there be a care plan in place for the monitoring of the sutures. The Interim DON stated, Yes .monitored for any infection .keep clean and dry . During an interview on 6/24/2024 at 10:53 AM, Wound Care Nurse #1 was asked who removed the sutures from Resident #4's scalp. Wound Care Nurse #1 stated, .I just removed the sutures .the nurse told me he had sutures from a fall . The Wound Care Nurse was asked when she was notified that Resident #4 had sutures. The Wound Care Nurse #1 stated, .It was last week or the week before .I went and looked at them [sutures] and they were ready to be taken out .I removed 3 sutures .I was supposed to know when he came back from the hospital .I would do an order to clean and keep open to air and monitor for drainage .they may have called me and I forgot .I remember him falling .it was me, I dropped the ball . The Wound Care Nurse #1 was asked if the wound treatment was documented on the treatment administration records (TAR). The Wound Care Nurse #1 stated, .I did not put the orders in .no .it would be on the TAR's .I forgot to put the orders in for the removal of the sutures . The Wound Care Nurse was asked how long the sutures should have been monitored and a treatment in place. The Wound Care Nurse #1 stated, .Daily .on the average of 2-3 weeks . Observation and interview on 6/24/2024 at 11:49 AM, in the laundry room and the personal room, the Housekeeping Supervisor was asked about the lift pads. The Housekeeping Supervisor stated, .lift pad .we are supposed to throw away the ones that could not be used . The Housekeeping Supervisor was asked if he was informed on which lift pad to keep and which ones to throw away. The Housekeeping Supervisor stated, .No they did not tell me the ones to keep and the ones to throw away .when we wash them we put them in the personal room so when they [staff] needed them, they came and get them .the one in the personal room has been there for about a week .I don't know if it is the kind they can't use [the transfer pad] .they have not told me to throw it away .the ones in the laundry room, they [staff] are using . The Housekeeping Supervisor was asked if he and the staff members were educated on the correct lift pads. The Housekeeping Supervisor stated, .No ma'am .they never told me or the staff on the ones to keep and ones we could not keep . Observation in the personal room revealed one transfer pad hanging on the rack. The transfer pad was one of the pads that was not to be used with the lifts. Observation and interview on 6/24/2024 at 12:04 PM, in the personal room, the Interim DON was asked if they should have this transfer pad in the personal room. The Interim DON stated, .I don't think so . During an interview on 6/24/2024 at 2:58 PM, the Family Nurse Practitioner (FNP) #1 was asked when a resident is readmitted with sutures what should the staff members do. FNP #1 stated .Keep the wound clean with soap and water .report any signs and symptoms of infection .if edges separate need to be aware .any people who fall, I have to round on [that resident] the next day . The FNP #1 was asked how long the sutures should be in place with a scalp laceration. The FNP #1 stated, .Not more than 10 days or 2 weeks .I would check with the medical director to see what he wanted . Observation and interview in the resident's room on 6/24/2024 at 3:51 PM, LPN F was asked when they entered the room, where was Resident #4 positioned. LPN F stated, .He was on the floor between the bathroom and the painted part of the wall .lying on his left side . LPN F was asked how 2 staff members use the lift and what are their roles. LPN F stated, .One person is operating the lift, and the other person is holding on to pad to assist the resident to the bed . During a continued interview on 6/24/2024 at 3:56 PM, CNA I was asked if she was standing by the wall by the curtain near the door, and how was she able to assist with the transfer. CNA I stated, .I was waiting for her to put him over here [by the bed] .I was not assisting . I was watching . The CNA was asked who went for help when the resident had the fall from the lift. CNA I stated, . [Named CNA R] . During an interview on 6/25/2024 at 8:52 AM, the Social Director was asked to explain the coding of the BIMS score. The Social Director stated, .a BIMS score of 0-7 means the resident is severely impaired .a score of 8-12 means the resident is moderately confused a little, not all the way .they may not know the month, day, or the year it goes and come .the score of a 13-15 mean the resident is cognitively intact . During a continued interview on 6/25/2024 at 9:36 AM, the Interim DON was asked looking at the fall assessment documented on 5/30/2024 if it accurately reflected the documentation of the resident's medications. The Interim DON stated, No. The Interim DON was asked if the fall assessment was coded correctly. The DON stated, No. During an interview on 6/27/2024 at 8:01 AM, Family Nurse Practitioner (FNP) #1 was asked how the staff members should use the lift to transfer the residents. FNP #1 stated, .with 2 people .one on the left and one on the right side of the resident .one person is at the bedside securing the patient and the other person is operating the lift .it's teamwork .one person hooks up one side of the lift and the other person hooks up the other side of the lift . FNP #1 was asked what should happen when a resident has a fall in the facility. FNP #1 stated, .They should call for assistance .the nurse is notified immediately .the nurse goes in to assess .vital signs are taken .the neuro checks are started .check the blood sugar if needed .quick assessment .complete an incident report .notify NP . NP #1 was asked if she was notified 6/12/2024 of Resident #4's fall. The NP stated, .I was not .I would have seen her the next day .when I'm called, I add the patients to my rounds .they are the first person I see . FNP #1 was asked if the resident complains of pain in the knee, toes, shoulder, what should the staff do. NP #1 stated, .I would have gotten an x-ray . FNP #1 was asked what if the staff members stated the resident always complains of pain in her knees is that appropriate to ignore. FNP #1 stated, No .I would still address her pain and make sure nothing acute at this point . FNP #1 stated, .if the fall happen the previous day they should reflect the time and the date the patient had the fall then start the assessment from that point .discuss some type of education on reporting falls .something needs to happen .that is an omission .safety is very important .the falls can be considered a sentinel event .prevention and safety is the key and the nurse should have been notified, so she/he could have done an assessment . The facility failed to provide care for Resident #4 in an environment to prevent accident/hazards. The facility failed to complete a thorough investigation by obtaining witness statements and interviewing other alert residents to identify any potential issues with the lift transfer. The facility failed to in-service all staff on the proper way to use the lift with the correct lift pads. The facility's failure to use the appropriate lift pad and appropriate number of staff members for a resident transfer with a mechanical lift resulted in actual Harm to Resident #4 when 1 staff member transferred him with the mechanical lift, the lift pad broke, and Resident #4 fell and hit his head on the lift. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Psychosis, Insomnia, Cognitive Communication Deficit, Diabetes, Hypertension, and Malignant Neoplasm of Skin. Review of the Care Plan dated 12/20/2021, revealed Resident #3 was at Risk for Elopement related to Dementia with exit seeking behavior dated 12/20/2021 with a resolved date of 12/29/2021. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment and required verbal cues and/or touching/steadying/ and/or contact guard assistance as resident completes activity. Review of the facility's Incident Audit Report dated 5/26/2024 at 2:17 PM, revealed .Incident Details .Nursing Description .resident walked out of the facility's front door onto the parking lot at 12:31 [12:31 PM] resident exited the building going to the parking lot, walked down the sidewalk in front of the facility onto the parking lot. She was out of the building for approximately 5 minutes. A family of another resident helped resident back into the building at 12:36 [PM] .Person Preparing Report: [Named Interim Director of Nursing] . Review of the SBAR [Situation, Background, Assessment, Recommendation]-Physician Communication Tool dated 5/26/2024 at 5:59 PM, revealed resident exited the facility unattended .resident walked out of the facility's front door onto the parking lot at 12:31 [PM] resident exited the building going to the parking lot, walked down the sidewalk in front of the facility onto the parking lot. She [Resident #3] was out of the building for approximately 5 minutes. A family of another resident helped resident [Resident #3] back into the building at 12:36 [PM] .Signed By [Named Interim Director of Nursing] . Review of the revised Care Plan dated 5/26/2024, revealed Resident #3 was determined to be at Risk

Based on facility policy, medical review and interview, the facility failed to follow physician orders to administer Tylenol (a medication used for moderate pain) for 1 of 6 (Resident #14) reviewed for quality of care. The findings include: 1. Review of the facility policy titled, Administering Medications, dated 2012, revealed .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 2. Review of the medical record revealed Resident #14 was admitted on [DATE], with a readmission on 6/30/2022, with diagnoses including Osteoarthrosis, Chronic Obstructive Pulmonary Disease, Transient Ischemic Attack, and Pain. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BMS score of 3, which indicated she was cognitively impaired with no behaviors identified and required physical help for most activities of daily living (ADLs) and coded for a fall since admission times one. Review of the Fall Incident Report dated 6/13/2024 at 16:00 (4:00 PM), revealed .Resident fell off the side of bed during incontinent care. She was turning towards the right side and fell off the bed. Resident fell on right side of bed on stomach. Resident was assisted back to bed by nursing staff and neuro checks were started. No skin lesion, cuts, or bruises upon evaluation. Resident complaining of bilateral knee pain. Pain medications given . Review of the Medication Administration Record (MAR) dated June 2024, revealed there was no pain medication given at 4:00 PM according to incident report. During an interview on 6/24/2024 at 4:22 PM, Licensed Practical Nurse (LPN) C was asked about the nurse's note you documented you gave the pain medication at 4:00 PM, is that correct. LPN C stated, Yes .I gave it to her . LPN C was asked where he charted the medication. LPN C stated.I did not click it off on the prn [as needed] med [medication] record .it was a schedule dose at 9:00 PM, I gave it early, the Tylenol [used to treat mild to moderate pain] . LPN C was asked if he got an order to give the medication early at 4:00 PM on 6/13/2024. LPN C stated No. During an interview on 6/27/2024 at 8:01 AM, the Family Nurse Practitioner (FNP) was asked should the nursing staff chart pain medication that was given without a physician's order to give the medication early. The FNP stated No .what they should have done was to notify me .

Based on policy review, medical record review, observation, and interview, the facility failed to prevent accidents/hazards, provide education and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for falls, and failed to ensure a safe environment for 1 of 3 (Resident #3) residents sampled for elopement. The facility's failure to provide appropriate transfer with a mechanical lift resulted in actual harm when Resident #4 sustained a fall which resulted in a laceration to the forehead and required sutures. The findings include: 1. Review of the facility's policy titled, Assessing Falls and Their Causes, dated 2018, revealed .The purposes of this procedure are to provide guidelines for assisting a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .Performing a Post-Fall Evaluation .After a fall, a nurse and or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort . Review of the facility's policy titled, Safe Resident Handling/Transfers [Named Facility], dated 2/2014, revealed .it is the policy of this facility to ensure that the resident 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 .Mechanical lifting equipment or other approved transferring aides will be used based on the resident's needs to prevent manual lifting except in medical emergencies .Mechanical lift may include equipment such as full body lifts .The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacture's instruction on proper sling .Two staff members must be utilized when transferring residents with a mechanical lift .Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur .Staff members are expected to maintain compliance with safe handling/transfer practices . Review of the facility's policy titled, Elopements and Wandering Residents, dated 10/2010 and revised 3/2024, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person- centered plan of care addressing the unique factors contributing to wandering and elopement risk .Elopement .occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so .The facility is equipped with door locks/alarms to help avoid elopements .Alarms are not a replacement for necessary supervision .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Hypertension and Rhabdomyolysis. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately impaired with no behaviors identified, and required Substantial/maximal assistance with chair/bed-to-chair transfer. Review of the Lift/Mobility Evaluation, dated 5/14/2024, revealed .Quarterly Evaluation .Can the resident safely ambulate and transfer independently or with supervision only .No .Can Resident ambulate but requires support for maintaining balance .No .Number of staff needed for resident movement with a mechanical lift .TWO . Review of the Fall Risk Evaluation ORIGINAL, dated 5/14/2024, revealed .Score .21 .High Risk .Medication use .Antiseizure .Antihypertensives .Narcotic's .Memory and Recall Ability .In the last 7 days .recalls three out of four of the following .current season .he .is in a nursing home .location of room .staff name/faces .Sometimes .Gait Analysis .Unable to independently come to a standing position .Requires hands-on assistance to move from place to place .Decrease in muscle coordination . Review of the Progress Note dated 5/29/2024 at 7:30 PM, documented by LPN F revealed .Called into room by CNA [Certified Nursing Assistant]. Resident [Resident #4] lying on floor on his left side. CNAs were transferring resident from chair to bed using the hoyer lift when the lift pad strap broke, and resident fell. He hit the left side of his head near his temple causing a hematoma. Scant amount of bleeding noted. Resident was able to move extremities as well as before he fell. Called FNP [Named Family Nurse Practitioner] .she gave orders to send him to [Named Hospital] for evaluation .Left message for his sister [Named Family Member #1] .Neuro checks in progress . Review of the (Named Emergency Transport Company) dated 5/29/2024, revealed .77 yr [year] old male to be transferred to [Named Hospital] pt [patient] presents with general weakness .Call Received 19:33 [7:33 PM] .On Scene 21:15 [9:15 PM] .Depart Scene 21:32 [9:32 PM] . Review of the undated Facility Summary completed by the [NAME] Unit Manager, revealed . Resident [Named Resident #4] fell 5/29/2024 at around 7:30pm [7:30 PM] . Resident was in the process of being transferred from his bed to the shower stretcher at the time of the fall. Upon assessment from the nurse, the resident was noted with an abrasion to the left temporal [part of the brain] side of his head. Vitals obtained and the MD [Medical Director] informed of the fall and ordered for the resident to be sent to [Named Hospital] ER [Emergency Room] for further evaluation. Resent [Resident #4] transferred to [Named Hospital] ER via [by] ambulance. Resident's family updated on the incident .Upon conclusion of the investigation, it was found that the staff's transferring technique may have contributed to the resident fall. Inservice was immediately put in place and staff was in serviced as well as demonstrated on how to properly transfer residents . The facility summary was contradictory to the progress note that revealed Resident #4 was being transferred from the chair to the bed. Review of the Hospital records dated 5/29/2024, revealed .The patient presents follow ing [following] fall .transferred from his nursing home for evaluation of a fall that resulted in a scalp laceration. The patient was being transferred to the bed and Hoyer lift when the mechanism broke down and he slowly went to the ground, striking his buttock and then striking his head against the w all [wall] .Trauma appears to be limited to the patient's scalp where he had a small laceration that was repaired without complication using 4 interrupted sutures .Follow up with .[Named Physician] in 2 days 6/1/2024 see your primary care doctor .7 days(s), For sutures removal or have your sutures removed at your facility . Review of the Incident Report dated 5/29/2024 at 7:30 PM, completed by LPN F, revealed .Resident [Resident #4] on floor lying on left .Strap on hoyer lift pad broke and resident fell .Resident Taken to Hospital .Injury Type .Hematoma .Top of Scalp .Skin Tear .Injuries Report Post Incident .Injury Type .Injury Location .No Injuries Observed Post Incident . Resident #4 sustained a Hematoma, skin tear, and was sent to the hospital and received 4 suture repairs to the scalp of the head. There was inaccurate documentation on the incident report. Review of the IN-SERVICE ATTENDANCE LOG, dated 5/30/2024, revealed .Transferring a client using a mechanical lift .Selecting correct sling Size when transferring .How to correctly use Mechanical lift when transferring .Skills check off using mechanical lift . The in-service log for using the mechanical lift showed only 19 of the 77 CNA Staff members attended the in-service on 5/30/2024. Review of the Nursing Progress Note dated 5/30/2024 at 3:30 AM, documented by LPN S revealed .Resident [Resident #4] arrived [back] to facility [from the hospital] via [by] ambulance services x [times] 2 transporters. Resident is AAO [awake, alert and oriented] 2-3 [person, place and time], Left side of temporal sutures placed d/t [due to] s/p [status post] fall. Resident has no c/o [complaint of] pain or discomfort to left side of forehead. Resident is lying awake in bed ADL's [Activity of Daily Living] performed, bed is in lowest position with call light within reach .Care plan ongoing. Family was notified (spouse) accompanied ambulance services back to facility . Review of the Fall Risk Evaluation ORIGINAL, dated 5/30/2024, revealed .Score .8 .Moderate Risk .Medication use [Blank] .Memory and Recall Ability .In the last 7 days .recalls three out of four of the following .current season .he .is in a nursing home .location of room .staff name/faces .Always .Gait Analysis .Unable to independently come to a standing position . Review of the Patient Lift SAFETY GUIDE, revealed .Perform Safety check .Before lifting the patient, perform safety check .Examine all hooks and fasteners to ensure they will not unhook during use .Double check position and stability of straps and other equipment before lifting patient .Ensure clips, latches and bars are securely fastened and structurally sound . There was no therapy referral made by the nursing staff for the post fall on 5/29/2024. Review of the Physician's Orders dated 6/24/2024 at 11:28 AM, completed by the Wound Care Nurse #1, revealed .Late entry for 6/13/2024 .Remove sutures for from head .resolved . Review of the Nursing Progress Note dated 6/24/2024 at 11:37 AM, completed by Wound Care Nurse #1, revealed .Late entry 6/13/2024 .New order to remove sutures from left lobe of head s/p [status post] fall with injury .Sutures x4 [times 4] removed from left lobe of head without difficulty. Skin intact with no s/s [signs and symptoms] infection to site. Denies pain/discomfort. Floor staff and UM [unit manager] aware . The facility failed to follow the hospital recommendations for suture removal in 7 days. The sutures were placed on 5/29/2024, should have been removed on 6/5/2024 and were not removed until 15 days later on 6/13/2024. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated May 2024 and June 2024, revealed no treatment in place to monitor the sutures in Resident #4's forehead. The facility failed to provide documentation that Resident #4's wound was monitored with treatments in place and care planned for infection. Observation on 6/24/2024 at 11:45 AM, in the personal room (off of the laundry) revealed a disposable transfer pad (inappropriate pad that was supposed to be removed from use) hanging on the shelf. During an interview on 6/20/2024 at 11:19 AM, Resident #4 was asked what happen during his fall from the lift. Resident #4 stated, .it broke [the pad] .the string broke . Resident #4 was asked if it was 1 or 2 aides that was helping with getting you back to bed. Resident #4 sated, .it was 1 aide .the aide on the night shift . Resident #4 was asked was it a male or female aide helping you back to bed. Resident #4 stated, .it was female . Resident #4 was asked if he got hurt during the fall. Resident #4 stated, Yes I got 4 stiches .and my back was sore . Resident #4 was if the nurse provided any pain medication. Resident #4 stated, Yes. Resident #4 was asked again how many aides were helping him get back to bed and Resident #4 confirmed it was only one aide using the lift for transfer and that and it usually is one aide that transfers him. During an interview on 6/20/2024 at 11:47 AM, the [NAME] Unit Manager was asked about Resident #4's fall with the lift and who was involved. The [NAME] Unit Manager stated, .The nurse on the shift was [Named (Licensed Practical Nurse) LPN F] .[Named CNA R] .the supervisor [Named RN Supervisor #3] she started the initial in-service when found that CNA [CNA R] was transferring improperly .they pulled her [CNA R] from his room and educated her .that is what I was told she [CNA R] called for assist the nurse and another CNA [CNA I] came and helped get the resident back to bed .contacted the MD [Medical Director] .orders received to send to the ER [Emergency Room] . The [NAME] Unit Manager was asked if she was aware that Resident #4 had returned from the hospital with sutures. The [NAME] Unit Manager stated, He did. The [NAME] Unit Manager was asked if the aide had written a statement. The [NAME] Unit Manager stated, She did not . The [NAME] Unit Manager was asked if she obtained any statements from anyone. The [NAME] Unit Manager stated, .I can check .It could be in my office .I can double check .I did get a verbal statement .I asked her what happened . The [NAME] Unit Manager was asked if she had documentation of the verbal statements. The [NAME] Unit Manager stated, No. Observation and interview on 6/20/2024 at 11:59 AM, the [NAME] Unit Manager went to the nursing station to review Resident #4's chart and checked in her office for any written statements. The [NAME] Unit Manager was unable to provide statements from the staff members. The [NAME] Unit Manager was asked to review the post fall assessment and asked if it was accurate and should the medication be documented. The [NAME] Unit Manager stated, .On the post fall assessment I should have documented the medications . The [NAME] Unit Manager was asked would that change the fall assessment score. [NAME] Unit Manager stated, Yes. During an interview on 6/20/2024 at 3:11 PM, CNA R was asked about Resident #4's fall from the lift. CNA R stated, .I put the lift pad under him .I was assisting him back in the bed .the strap at the bottom of the pad broke .I told [Named CNA I] to watch him I'm going to get the nurse .[Named LPN F] was passing medications .I went to get her and tell her he [Resident #4] had fell [fallen] .he hit his head on the bottom of the lift on the left side . CNA R was asked if she wrote a statement of the incident. CNA R stated, .we gave it to the supervisor .3-11 supervisor .she did the in-service . CNA R was asked what type of lift pad she used for the transfer. CNA R stated, .it was the hospital lift pad .it was already under him .those are not the correct pad .those are the transfer pads .that is what they [staff] have been using .everybody has been using them . During an interview on 6/20/2024 at 4:10 PM, LPN F was asked about the fall from the lift with Resident #4. LPN F stated, .I was on the 200 hall and [Named CNA R] came and got me .she told me that he [Resident #4] had fell and the lift pad had broken .when I got there he was on the floor .the lift was open he was in between the lift .when I came in the room [Name CNA I] was in there with him .she was standing and talking to him . LPN F was asked if Resident #4 was alert and could tell you what happen. LPN F stated, Yes .he is alert enough . LPN F was asked if she had observed the lift pad used. LPN F stated, .Yes .it was hanging down .it was broken . LPN F was asked if Resident #4 stated there was only one aide in the room would it be truthful. LPN F stated, .If he said it, I don't think he would lie .I don't think he would make up anything . During an interview on 6/20/2024 at 4:22 PM, CNA I was asked to tell me about the time Resident #4 fell out the lift. CNA I stated, .I was standing at the door watching near the curtain that is near the door .[Named CNA R] she was operating the lift .it happen so fast I was just standing there .she was lifting him on the lift .she said oh the thing snapped .the strap on the lift pad .I'm going to go and get somebody . CNA I was asked was it the normal lift pad the facility used to lift/transfer the residents. CNA I stated, .We just use what is under them .he is not heavy enough to have 2 persons during the lift .it doesn't take 2 people to use the lift . CNA I was asked if she helped hook the resident up to the lift pad. CNA I stated, .No .I was not touching or operating the lift . CNA I was asked if Resident #4 was alert and able to tell someone what happened during the fall. CNA I stated, Yes. During a continued telephone interview on 6/20/2024 at 9:55 PM, CNA R was asked about the time when Resident #4 had a fall with the lift. CNA R stated, .She [CNA I] was by the door .it takes one person to use the lift .by him being small .I did not realize it [lift strap] had broken .she could not get to me fast enough .the thing at the end of the bed [air mattress pump] was in the way .by [the] time I tried to lower him down is when I notice it had broken .she could not get around fast enough .he hit [his] head on the side of the lift .she [CNA I] was going to be on the other side .she was going to assist me on the other side of the bed .that was the lift pads we had to use in the building .even restorative used the pads .everyone around here was using them .when he was sitting in the chair the lift pad was under him already . CNA R was asked who hooked the rings to the lift. CNA R stated, I did. CNA R was asked who operated the controls. CNA R stated, I did .I raised him up from the chair and the lift pad broke .she [CNA I] tried to come over there and she almost fell . Random observation in the resident's room on 6/24/2024 at 9:08 AM, with the Social Director and Resident #19 revealed The Social Director performed a BIMS assessment, Resident #19 had a BIMS score of 9 which indicated he was moderately impaired. During an interview on 6/21/2024 at 9:12 AM, Resident #19 [Roommate of Resident #4 and had a BIMS of 9, indicating he was moderately cognitively impaired] was asked if he remembered when Resident #4 had fallen out of the lift. Resident #19 stated, Yes. Resident #19 was asked how many staff members were assisting the resident during the transfer. Resident #19 stated, .It was one aide in the room to transfer him with the lift . Resident #19 was asked what position the resident was in during the fall out of the lift. Resident #19 stated, .the wheelchair was on the side of my bed facing the door and the lift was in front of him against the wall .she was going to put him to bed .the sling was against the back wall facing the chair .then the strap broke .he fell against the wall .then she ran and got this other lady to put him in the bed .he fell, bam it was so quick, it was not a slow thing the strap broke and bam, like that .another aide came to help, she is a heavy lady . Resident #19 was asked if the nurse came to check him. Resident #19 stated, .No .they [CNA I and R] moved him to the bed, and took the lift out .they should have never moved him and put him in the bed .they don't know if he broke his neck [during the fall] .when [Named LPN F] came he was in the bed .she went back to the desk to make out a report . During an interview on 6/21/2024 at 11:03 AM, the Human Resource Manager was asked how many CNAs the facility has on staff. The Human Resource Manager stated, .A total of 77 CNAs with regular, part time and PRN [as needed] staff . During an interview on 6/21/2024 at 2:08 PM, the Administrator was asked about the lift pads that were used on Resident #4. The Administrator stated, .They are lifting pads the EMS [emergency medical service] use .not aware they were leaving them behind . The Administrator was asked if she had educated all staff members on the correct lift pads. The Administrator stated, .Yes .and in orientation . The Administrator was asked how the lift pads/transfer pads get into the facility. The Administrator stated, .I don't know, the EMS [emergency medical system] leaves them behind .they are not used for multi-use . The Administrator was asked if each resident has their own lift pad. The Administrator stated .They found one and used it .it looks like a lift pad .until this occurrence we had no idea .that prompted us to do an investigation . The Administrator was asked what the root cause analysis was from the investigation. The Administrator stated, .staff was using a lift pad that malfunctioned .that is what was identified .he bumped his head .we sent him out .had daily QA [Quality Assurance] meeting .did a room sweep to make sure no improper pads . The Administrator was asked when operating a lift what is the process. The Administrator stated, .You have a CNA on each side make sure the sling is secure on the lift .one person at the control and one person supporting the lift pad . The Administrator was asked if they interviewed any other resident to see what happen. The Administrator stated, No. During an interview on 6/24/2024 at 10:49 AM, the Interim Director of Nursing (DON) was asked when Resident #4 returned from the hospital if the neurological (neuro) checks should be started back. The Interim DON stated, .the neuro check should have been started at 4:15 AM instead of 5:15 AM on return from the hospital . The Interim DON was asked should Resident #4 have treatments in place for the laceration with sutures. The Interim DON stated, Yes .should have consulted wound care .wound care, they evaluate the area and add a treatment as recommended . The Interim DON was asked should there be a care plan in place for the monitoring of the sutures. The Interim DON stated, Yes .monitored for any infection .keep clean and dry . During an interview on 6/24/2024 at 10:53 AM, Wound Care Nurse #1 was asked who removed the sutures from Resident #4's scalp. Wound Care Nurse #1 stated, .I just removed the sutures .the nurse told me he had sutures from a fall . The Wound Care Nurse was asked when she was notified that Resident #4 had sutures. The Wound Care Nurse #1 stated, .It was last week or the week before .I went and looked at them [sutures] and they were ready to be taken out .I removed 3 sutures .I was supposed to know when he came back from the hospital .I would do an order to clean and keep open to air and monitor for drainage .they may have called me and I forgot .I remember him falling .it was me, I dropped the ball . The Wound Care Nurse #1 was asked if the wound treatment was documented on the treatment administration records (TAR). The Wound Care Nurse #1 stated, .I did not put the orders in .no .it would be on the TAR's .I forgot to put the orders in for the removal of the sutures . The Wound Care Nurse was asked how long the sutures should have been monitored and a treatment in place. The Wound Care Nurse #1 stated, .Daily .on the average of 2-3 weeks . Observation and interview on 6/24/2024 at 11:49 AM, in the laundry room and the personal room, the Housekeeping Supervisor was asked about the lift pads. The Housekeeping Supervisor stated, .lift pad .we are supposed to throw away the ones that could not be used . The Housekeeping Supervisor was asked if he was informed on which lift pad to keep and which ones to throw away. The Housekeeping Supervisor stated, .No they did not tell me the ones to keep and the ones to throw away .when we wash them we put them in the personal room so when they [staff] needed them, they came and get them .the one in the personal room has been there for about a week .I don't know if it is the kind they can't use [the transfer pad] .they have not told me to throw it away .the ones in the laundry room, they [staff] are using . The Housekeeping Supervisor was asked if he and the staff members were educated on the correct lift pads. The Housekeeping Supervisor stated, .No ma'am .they never told me or the staff on the ones to keep and ones we could not keep . Observation in the personal room revealed one transfer pad hanging on the rack. The transfer pad was one of the pads that was not to be used with the lifts. Observation and interview on 6/24/2024 at 12:04 PM, in the personal room, the Interim DON was asked if they should have this transfer pad in the personal room. The Interim DON stated, .I don't think so . During an interview on 6/24/2024 at 2:58 PM, the Family Nurse Practitioner (FNP) #1 was asked when a resident is readmitted with sutures what should the staff members do. FNP #1 stated .Keep the wound clean with soap and water .report any signs and symptoms of infection .if edges separate need to be aware .any people who fall, I have to round on [that resident] the next day . The FNP #1 was asked how long the sutures should be in place with a scalp laceration. The FNP #1 stated, .Not more than 10 days or 2 weeks .I would check with the medical director to see what he wanted . Observation and interview in the resident's room on 6/24/2024 at 3:51 PM, LPN F was asked when they entered the room, where was Resident #4 positioned. LPN F stated, .He was on the floor between the bathroom and the painted part of the wall .lying on his left side . LPN F was asked how 2 staff members use the lift and what are their roles. LPN F stated, .One person is operating the lift, and the other person is holding on to pad to assist the resident to the bed . During a continued interview on 6/24/2024 at 3:56 PM, CNA I was asked if she was standing by the wall by the curtain near the door, and how was she able to assist with the transfer. CNA I stated, .I was waiting for her to put him over here [by the bed] .I was not assisting . I was watching . The CNA was asked who went for help when the resident had the fall from the lift. CNA I stated, . [Named CNA R] . During an interview on 6/25/2024 at 8:52 AM, the Social Director was asked to explain the coding of the BIMS score. The Social Director stated, .a BIMS score of 0-7 means the resident is severely impaired .a score of 8-12 means the resident is moderately confused a little, not all the way .they may not know the month, day, or the year it goes and come .the score of a 13-15 mean the resident is cognitively intact . During a continued interview on 6/25/2024 at 9:36 AM, the Interim DON was asked looking at the fall assessment documented on 5/30/2024 if it accurately reflected the documentation of the resident's medications. The Interim DON stated, No. The Interim DON was asked if the fall assessment was coded correctly. The DON stated, No. During an interview on 6/27/2024 at 8:01 AM, Family Nurse Practitioner (FNP) #1 was asked how the staff members should use the lift to transfer the residents. FNP #1 stated, .with 2 people .one on the left and one on the right side of the resident .one person is at the bedside securing the patient and the other person is operating the lift .it's teamwork .one person hooks up one side of the lift and the other person hooks up the other side of the lift . FNP #1 was asked what should happen when a resident has a fall in the facility. FNP #1 stated, .They should call for assistance .the nurse is notified immediately .the nurse goes in to assess .vital signs are taken .the neuro checks are started .check the blood sugar if needed .quick assessment .complete an incident report .notify NP . NP #1 was asked if she was notified 6/12/2024 of Resident #4's fall. The NP stated, .I was not .I would have seen her the next day .when I'm called, I add the patients to my rounds .they are the first person I see . FNP #1 was asked if the resident complains of pain in the knee, toes, shoulder, what should the staff do. NP #1 stated, .I would have gotten an x-ray . FNP #1 was asked what if the staff members stated the resident always complains of pain in her knees is that appropriate to ignore. FNP #1 stated, No .I would still address her pain and make sure nothing acute at this point . FNP #1 stated, .if the fall happen the previous day they should reflect the time and the date the patient had the fall then start the assessment from that point .discuss some type of education on reporting falls .something needs to happen .that is an omission .safety is very important .the falls can be considered a sentinel event .prevention and safety is the key and the nurse should have been notified, so she/he could have done an assessment . The facility failed to provide care for Resident #4 in an environment to prevent accident/hazards. The facility failed to complete a thorough investigation by obtaining witness statements and interviewing other alert residents to identify any potential issues with the lift transfer. The facility failed to in-service all staff on the proper way to use the lift with the correct lift pads. The facility's failure to use the appropriate lift pad and appropriate number of staff members for a resident transfer with a mechanical lift resulted in actual Harm to Resident #4 when 1 staff member transferred him with the mechanical lift, the lift pad broke, and Resident #4 fell and hit his head on the lift. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Psychosis, Insomnia, Cognitive Communication Deficit, Diabetes, Hypertension, and Malignant Neoplasm of Skin. Review of the Care Plan dated 12/20/2021, revealed Resident #3 was at Risk for Elopement related to Dementia with exit seeking behavior dated 12/20/2021 with a resolved date of 12/29/2021. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment and required verbal cues and/or touching/steadying/ and/or contact guard assistance as resident completes activity. Review of the facility's Incident Audit Report dated 5/26/2024 at 2:17 PM, revealed .Incident Details .Nursing Description .resident walked out of the facility's front door onto the parking lot at 12:31 [12:31 PM] resident exited the building going to the parking lot, walked down the sidewalk in front of the facility onto the parking lot. She was out of the building for approximately 5 minutes. A family of another resi[TRUNCATED]

Based on facility policy, medical review and interview, the facility failed to follow physician orders to administer Tylenol (a medication used for moderate pain) for 1 of 6 (Resident #14) reviewed for quality of care. The findings include: 1. Review of the facility policy titled, Administering Medications, dated 2012, revealed .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 2. Review of the medical record revealed Resident #14 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Osteoarthrosis, Chronic Obstructive Pulmonary Disease, Transient Ischemic Attack, and Pain. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BMS score of 3, which indicated she was cognitively impaired with no behaviors identified and required physical help for most activities of daily living (ADLs) and coded for a fall since admission times one. Review of the Fall Incident Report dated 6/13/2024 at 16:00 (4:00 PM), revealed .Resident fell off the side of bed during incontinent care. She was turning towards the right side and fell off the bed. Resident fell on right side of bed on stomach. Resident was assisted back to bed by nursing staff and neuro checks were started. No skin lesion, cuts, or bruises upon evaluation. Resident complaining of bilateral knee pain. Pain medications given . Review of the Medication Administration Record (MAR) dated June 2024, revealed there was no pain medication given at 4:00 PM according to incident report. During an interview on 6/24/2024 at 4:22 PM, Licensed Practical Nurse (LPN) C was asked about the nurse's note you documented you gave the pain medication at 4:00 PM, is that correct. LPN C stated, Yes .I gave it to her . LPN C was asked where he charted the medication. LPN C stated. .I did not click it off on the prn [as needed] med [medication] record .it was a schedule dose at 9:00 PM, I gave it early, the Tylenol [used to treat mild to moderate pain] . LPN C was asked if he got an order to give the medication early at 4:00 PM on 6/13/2024. LPN C stated No. During an interview on 6/27/2024 at 8:01 AM, the Family Nurse Practitioner (FNP) was asked should the nursing staff chart pain medication that was given without a physician's order to give the medication early. The FNP stated No .what they should have done was to notify me .

Based on policy review, medical record review, video surveillance review, observation, and interview the facility failed to maintain Contact Isolation with Droplet Precautions for 1 of 11 (Resident #5) Covid-positive residents reviewed for infection control. Resident #5 exited the COVID-19 isolation unit, attempted to exit the 500 hall door twice, was then placed at a nursing station outside of the COVID Unit by staff; Resident #5 was observed out of the COVID Unit walking on the 700 hall, and on the sidewalk outside the building without personal protective equipment (PPE). Three (3) of 3 staff members, (Certified Nursing Assistant (CNA) #1, Licensed Practical Nurse (LPN) #1 and #2) failed to wear PPE when providing care for Resident #5. The facility failure to contain COVID-19 and prevent exposure potentially affected other residents and staff on the 500 hall, 700 hall, and 800 hall. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/22/2022 at 3:57 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/29/2022 at 11:16 AM, and was validated onsite by the surveyors on 11/30/2022 -12/2/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, Policies and Practices-Infection Control, revealed, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .2. The objectives of our infection control policies and practices are to .Prevent, detect, investigate, and control infections in the facility . Review of the facility's undated policy titled, COVID-19 Management of Suspected or Confirmed Residents, revealed .Restrict residents with respiratory infections .to their rooms .If they leave the room, resident should be encouraged and assisted to wear a facemask . Review of the facility's undated policy titled DISCONTINUATION OF TRANSMISSION BASED PRECAUTION RELATED TO COVID -19, revealed .all residents tested positive .will be monitored closely to prevent spread of infection related to COVID-19 .PURPOSE: To protect all residents and staff and to keep all residents and staff away from contracting COVID-19 virus . Review of the facility's undated policy titled, .Personal Protective Equipment (PPE), revealed .To ensure that .PPE .is provided for all staff at the facility, including .facemasks, gloves, gowns, and eye protection .when interacting with COVID-19 suspected or confirmed residents .Prior to entering areas where residents are suspected or confirmed with COVID-19 .Education provided to staff on proper usage, procedure . Review of the facility's undated policy titled, .Contact Precautions, revealed .Transmission Based Precautions are designed for residents documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond stand precautions are needed to interrupt transmission . Review of the facility's undated policy titled .Personal Protective Equipment (PPE), revealed .Personnel will be trained on our infection control policies and practices caring for or encountering a COVID+ [positive] or COVID suspected or COVID unknown resident .FACE SHIELD OR GOGGLES .GLOVES .FIT-tested N95 RESPIRATOR .GOWN . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, and Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to anxiety and sadness related to isolation precautions related to COVID-19. Review of a physician's order dated 10/28/2022, revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive COVID test. Review of a Census Report dated 10/28/2022, revealed Resident #5's room was changed to the COVID Unit. Review of the facility's camera footage dated 10/30/2022 at 11:00 AM, revealed 2 staff members, LPN #1 and CNA #1, and Resident #5 standing in the hallway beside an exit door without full PPE. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am .on 700 hall x1 .on 500 hall door x 2 .found in .parking lot . Observation in the COVID Unit located on the 600 Hall on 11/7/2022 at 4:48 PM, revealed the Covid Unit had plastic barriers with zippers to provide Contact and Droplet Precaution isolation for COVID-positive residents. The barriers were located beginning at room [ROOM NUMBER] and ended at room [ROOM NUMBER] and at the exits to the 500 and 700 hall. During an interview on 11/8/2022 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated, .Resident #5 kept getting out of the COVID Unit .I had to assist to bring him back in .he was unzipping the plastic to go out of the unit, and I found him at the 500 hall exit door twice .I would go get him from the door and bring him back to the unit .once he got out and was found by a nurse walking around on the 700 hall .I don't know which way he got out of the unit that time, because I didn't see him .I did see him unzipping the barrier trying to get out . CNA #1 was asked if Resident #5 should have been out of the COVID Unit. She stated, .No, he should have stayed on the unit, but I couldn't keep my eyes on him. I had other residents . During an interview on 11/18/2022 at 1:04 PM, Licensed Practical Nurse (LPN) #1 stated, I was the nurse on the COVID Unit. He [Resident #5] had gotten out .found him out of the COVID Unit attempting to get out the exit door across from the DON's office on the 500 hall .we would take him back in the unit, and before you knew it, he was out again .we were doing our best to keep him on the unit .I sat him at the desk for a short time just to keep an eye on him .but I could not keep a watch on him. That's when I sat him at the desk, after he had gotten out of the Covid Unit .I probably shouldn't have .but I did . During an interview on 11/21/2022 at 3:00 PM, the Interim DON/Infection Control Preventionist stated, .we had an outbreak of COVID-19 after staff and a large number of residents tested positive on 10/21/22 .we were trying to maintain the unit with designated staff to work only in the COVID unit . She was asked if a COVID-positive resident should be out of the COVID Unit without PPE walking the halls. She stated, .absolutely not .he should have remained isolated . should not be outside of the COVID Unit wandering around in patient areas on different halls . She was asked if a COVID-positive resident should be sitting at the desk with staff outside the COVID Unit. She stated, .no .a COVID-positive resident on COVID isolation precautions should not have been at the nurses' station outside of the Covid Unit .There should have been designated staff in the Covid Unit and not taking care of other residents outside of the Covid Unit. She confirmed staff should be wearing full PPE when caring for a COVID-positive resident in the Covid Unit or in contact with a COVID-positive resident. During a telephone interview on 11/22/2022 at 3:15 PM, LPN #2 stated, .I was sitting at the desk, and I saw him [Resident #5] walking. He did not have a mask on. He was coming from the 700 hall .I gave him a mask and assisted him back to the COVID Unit .I was the nurse on the other side .don't know which way he came from .I knew he was supposed to be on the COVID Unit . Refer to F-689, F-609, F-610, F-726, F-725, F-835 and F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. Resident #5, who was wandering out of Covid Unit, had completed his quarantine period as per facility protocol and discharged from the COVID Unit on 11/9/2022 with no signs and symptoms of COVID-19. Resident #5, who wandered outside the COVID Unit unsupervised was monitored closely for signs and symptoms of COVID and none reported. The surveyors verified on site by interview with the DON and Administrator 2. As of 11/23/2022, the facility had no Covid positive residents residing in the Covid Unit. All residents completed required quarantine period and were discharged out of Covid Unit. No new residents tested positive for Covid-19 and required isolation. This was validated onsite by surveyors through observation and census review. 3. If any residents test positive in the future, the Administrator/DON will review census and clinical acuity and staff accordingly. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing on the COVID Unit. Clinical acuity and the COVID Unit census will be reviewed by the Administrator/Don daily and staffed accordingly as follows: 1-5 residents minimum 1 nurse, 6-10 residents minimum 1 nurse and 1 CNA, 11-20 residents minimum 1 nurse and 2 CNA'S. Nurses/CNAs will ensure that all residents residing on the COVID Unit will follow the facility's protocol on PPE usage. The facility initiated every-30-minute checks on all residents at risk for elopement/wandering. This was validated onsite by surveyors through review of the COVID Unit census with the staffing assignment sheets, observation, and interviews. 4. The facility will ensure that adequate supervision for the residents including wandering residents residing on the COVID Unit are monitored closely by Nurses/CNAs designated to the COVID Unit to reduce the risk of exposure to COVID outside of the COVID Unit. Staff will monitor by every-30-minute checks on all residents at risk for elopement/wandering risk residents. Nursing staff will be in-serviced on additional infection control and transmission-based precautions by staff educator with a completion date of 11/23/2022. This was validated onsite by surveyors through review of COVID Unit census with staffing assignment sheets, review of in-service sign-in sheets, observation, and interviews. 5. The facility will ensure residents with active wandering behaviors residing on the COVID Unit are monitored and transmission-based precautions are maintained to ensure residents and staff are not exposed. Nurses/CNAs will ensure that all residents residing on the COVID Unit will follow the facility's protocol on PPE usage. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing on the COVID Unit to reduce the risk for active wandering residents leaving the COVID Unit unsupervised. This was validated by review of the COVID Unit census with staffing assignment sheets, review of in-service sign-in sheets, observation, and interviews conducted with facility staff, agency staff, DON, Staffing Coordinator and Administrator. The facility's noncompliance of F-880 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, job description review, staff personnel file review, medical record review, observation, and interview, the facility failed to ensure nursing staff were competent and proficient in practices to maintain residents' highest practical well-being and to prevent elopement, prevent the spread of infectious diseases, prevent significant weight loss, and ensure assessments were done timely and fall interventions were implemented. The failure of the facility to ensure competent nursing staff resulted in Immediate Jeopardy for 1 of 5 sampled residents (Resident #5) reviewed for accidents. Resident #5, a vulnerable resident with severe cognition impairment and a positive COVID-19 diagnosis, exited the COVID Unit barrier 3 times by unzipping the barrier, and then exited the facility unsupervised on [DATE]. Resident #5 was found by staff walking on the sidewalk into the parking lot, approximately 223 feet from the facility. Neither Resident #5, nor staff who interacted with him, were using Protective Personal Equipment (PPE), which had the potential to expose staff and other residents to COVID-19. The failure of the facility to ensure competent nursing staff resulted in actual harm for 1 of 3 sampled residents (Resident #3) reviewed for Social Services. Resident #3, a vulnerable resident with diagnoses of Depression, Dementia and COVID-19, sustained a significant weight loss of 7.8 percent (%) in 1 month, after having suicidal ideations and voiced that he wanted to die and would starve himself. Resident #3 was admitted and isolated in the COVID Unit on [DATE] and voiced to Social Services and his family of wanting to die and had suicidal ideations on [DATE]. Resident #3 frequently refused medications and meals, resulting in significant weight loss in 1 month. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on [DATE] at 4:41 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy existed [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on [DATE] and was validated onsite by the surveyors on [DATE] through [DATE] through policy review, review of education records, medical record review, observation, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, .Personal Protective Equipment, revealed, .To ensure that .PPE .is provided for all staff at the facility, including .facemasks, gloves, gowns, and eye protection .when interacting with COVID-19 suspected or confirmed residents .Prior to entering areas where residents are suspected or confirmed with COVID-19 .Education provided to staff on proper usage, procedure . Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed, .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, Revised ,d+[DATE], revealed, .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident . Review of the facility ' s policy titled, Fall Risk Assessment, revised [DATE], revealed, .The nursing staff .will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Upon admission, the nursing staff and physician will review a resident ' s record for a history of falls .nursing staff will ask the resident and his/her family about any history of the resident falling .staff and attending physician will .identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . 2. Review of the Social Worker Job Description revealed, .Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident ' s response to service .review nurses note to determine if the care plan is being followed . Review of the Social Service Director Job Description revealed, .to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis .make daily rounds to assure that social service personnel are preforming required duties and to assure that appropriate social service procedures are being rendered to meet the needs of the facility .Ensure that all social services personnel are aware of the care plan and that care plans are used in providing daily social service to the residents .review nurses ' notes to determine if the care plan is being followed .communicate with the medical staff, nursing staff . 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of [NAME] ' s Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review an elopement risk assessment dated [DATE] revealed Resident #5 had a score of 2 indicating at risk for elopement. Review of a physician ' s order dated [DATE], revealed Resident #5 had an order for a wander guard. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance walking in his room or in the corridor. Review of a physician ' s order dated [DATE] revealed Resident #5 had an order for contact isolation with droplet precautions r/t Covid positive. Review of a Progress Note dated [DATE] at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated [DATE] at 8:03 PM revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline . During a telephone interview on [DATE] at 9:25 AM, the physician stated, .not safe for [Resident #5] to be outside unsupervised .I was not aware of any attempts before this incident . 4. Review of the medical record review for Resident #3 showed an admitted [DATE] with diagnoses of Hypertension, Adult Failure to Thrive, Depression, Insomnia, Personal History of Covid-19, Dementia, Anxiety, Mood Disturbance and Psychotic Disturbance. Review of the physician ' s order dated [DATE] showed .Admit .on COVID Unit d/t [due to] + [positive] COVID test .q [every] 15-minute checks (suicidal ideations) . The facility was unable to provide documentation for the every-15-minute checks as ordered. Review of the admission MDS dated [DATE], showed a BIMS score of 7, which indicated severe cognition impairment, had symptoms of feeling depressed, feeling tired or having little energy, poor appetite or overeating, stated that life isn ' t worth living and wished for death or attempted to harm self, required assistance with activities of daily living, weighed 167 pounds, received oxygen therapy and isolation or quarantine for active infectious disease. Review of the Care Plan initiated date [DATE] showed, .exhibits sad moods .saying negative statements of wanting to die .Observe any changes .check throughout the day .making suicidal statements about killing himself .encourage family to visit often .encourage resident to attend activities .Refer to Psychiatric for evaluation as needed . Review of the Social Services note dated [DATE] showed, .resident began expressing suicidal ideations stating he wanted to die and not live anymore. The resident was refusing to eat, refusing meds removing his oxygen and telling his family and staff that he wanted to die. The SW told the family she would ask for a Psychiatric (Psych) referral for the resident .Window visits with daughter . The facility was unable to provide documentation of Social Services follow-up interventions for Resident #3 for Depression with suicidal ideations and refusal of mediations and meals from [DATE] until resident expired [DATE]. Review of the physician ' s order dated [DATE] showed, .psych [Psychiatric]-eval[evaluation] refusing to eat . Review of the [NAMED] PHYSICIANS ORDER FOR PSYMED SERVICES dated [DATE] documented .thoughts of dying .ordering referral for psychiatry services . The Psychiatric Nurse Practitioner did not see Resident #3 until [DATE], 13 days after Resident #3 expressed suicidal ideations and after the physician ordered the psychiatric services. Review of the Care Plan dated [DATE] showed, .at risk for loneliness, anxiety and sadness related to isolation precautions implemented due to COVID 19 .interventions .observe resident for S/S [Signs and Symptoms] of social isolation or .depression .Resident to talk or facetime family/friends as per resident/family request and as needed . Review of the significant change MDS dated [DATE], showed a BIMS score of 6 indicating severe cognition impairment, requires assistance with activities of daily living, weighed 140 pounds with loss of 5% or more in the last month, had 2 stage 2 pressure ulcers, and received antidepressant medication. Review of the physician ' s order dated [DATE], showed, .Palliative Care . Resident #3 expired on [DATE]. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses of Cancer of Larynx, Supraglottis and Pharynx, Dementia, Anxiety, Aphonia, and a History of COVID 19. Review of the quarterly MDS dated [DATE], revealed a BIMs score of 10, indicating moderate cognition impairment, required assistance with activities of daily living, had unclear speech, was sometimes understood, made needs known by pointing and use of electrolarynx, had moderately impaired vision, and had behaviors. Review of the Care Plan dated [DATE], revealed, .has a potential to demonstrate physical aggressive behavior .resident to resident altercation .Psych consult . During an interview on [DATE] at 10:51 AM, the PNP confirmed she did not see Resident #12, and that she was unaware she was supposed to see him. During an interview on [DATE] at 5:00 PM, the Social Services Director (SSD) confirmed she was unaware Resident #12 had not been seen by the PNP until the surveyor asked for the psychiatric note, and that follow-up notes should have been documented. The SSD was unable to provide the Psychiatric referral sheet for Resident #12. The SSD was asked if 2 residents were in an altercation, should Social Services evaluate and document both. The SSD stated, .yes, they should . Resident #12 was involved in a resident-to-resident altercation and hit another resident on [DATE]. The facility failed to provide Social Services monitoring and was unable to provide a psychiatric services referral documentation. 6. Medical record review revealed Resident #9 was admitted on [DATE], with diagnoses Cerebral Infarction, Anemia, History of Falling, Metabolic Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the admission fall risk assessment dated [DATE] revealed the assessment was incomplete. Review of the admission assessment dated [DATE] revealed assessment was not signed until [DATE]. Review of the baseline Care Plan dated [DATE] revealed Resident #9 was at risk for falls related to new and unfamiliar environment, poor safety awareness, unsteady gait and weakness. The interventions were to anticipate and meet resident ' s needs as needed and keep room free of clutter and obstacles that may pose trip hazards. Review of the MDS dated [DATE] revealed Resident #9 had a history of falls prior to admission. Review of the Incident Details Report dated [DATE] revealed, .CNA [Certified Nursing Assistant] called for the nurse to come to the resident ' s room. Resident was found on the floor .resident has right side head injury with a raised area over the eye .hematoma forehead . Resident #9 ' s admission assessment and fall risk assessment were not completed. The baseline care plan did not include person centered measurable interventions to prevent falls. Resident #9 fell on [DATE] and sustained a hematoma to the right side of her face. During an interview on [DATE] at 11:31 AM, the Interim DON stated, .the admission assessment should be completed within 24 hours of admission .fall risk assessments are completed upon admission and when a fall occurs . The Interim DON confirmed Resident #9 ' s admission assessment was not completed within 24 hours of admission and the admission fall risk assessment was not completed. 7. Review of a closed medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Anemia, Cerebral Infarction, and Esophagitis. Review of the fall risk assessment dated [DATE], revealed Resident #2 was assessed at moderate risk for falls. Review of the admission MDS dated [DATE], revealed Resident #2 was assessed with a BIMS of 11 indicating moderate cognitive impairment for decision making. Resident #2 required assistance with activities of daily living. Review of the Care Plan revised [DATE], revealed fall interventions to anticipate and meet resident's needs, and physical therapy to evaluate and treat as ordered and as needed. Review of the Incidents by Incident Type report dated [DATE] through [DATE], revealed Resident #2 was not listed as having a fall on [DATE]. During an interview on [DATE] at 10:54 AM, the DON confirmed Resident #2 had a fall on [DATE]. The DON stated, The CNA did not report the fall to the charge nurse .I received the information on [DATE] .in-serviced staff .talked to them about reporting falls .didn't have them sign anything .a fall investigation was completed the next day .a fall risk assessment was not completed after the fall . There were no noted injuries to Resident #2. During a telephone interview on [DATE] at 10:37 AM, CNA #3 stated, .yes [Resident #2] was in the floor I helped [CNA #4 and #5] get her up into the wheelchair .no I did not report it to the nurse . Review of personnel files for CNA #3, CNA #4, and CNA #5 on [DATE], revealed there were no disciplinary actions or education provided related to reporting falls. During an interview on [DATE] at 11:05 AM, the DON confirmed the fall investigation was not signed by the staff completing the investigation. During a telephone interview on [DATE] at 3:40 PM, the Chief Operations Officer stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . 8. Observation on [DATE] at 2:15 PM, revealed LPN #3 on 200 hall Nurses ' Station sitting at the computer with her eyes closed and nodding her head asleep at the desk. During an interview on [DATE] at 3:50 PM, the Interim DON stated, .staff should not be sleeping while working here at this facility .I have spoke [spoken] with LPN #3, and she has begged me for another chance . Observation on [DATE] at 1:50 PM, revealed CNA #2 sitting outside of a room on the 800 hall in a chair beside a linen cart with her head slumped over and eyes closed. During an interview on [DATE] at 2:10 PM, CNA #2 stated, .I apologize for sleeping. I ' ve been here since yesterday . During an interview on [DATE] at 12:55 PM, the Administrator stated, .it is not acceptable for staff to be sleeping on duty . The surveyors verified the Allegation of Compliance Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility will conduct an audit to ensure admission assessments were completed on all new admissions for the past 30 days. This audit will be completed by [DATE]. The DON/ADON/Unit Managers will be responsible. Any missing assessments will be completed immediately. The surveyors reviewed the audit form. The surveyors interviewed the DON, the Assistant Director of Nursing (ADON) and the Unit Managers regarding admission assessments, reviewed Resident #9 ' s assessments to ensure completion. 2. The facility will conduct an audit to ensure fall assessments were completed upon admission and following fall incidents for the past 30 days. This audit will be completed by [DATE]. The DON/ADON/Unit Managers will be responsible. Any missing fall risk assessments will be completed immediately. The surveyors interviewed the DON, the ADON, and the Unit Managers regarding admission fall risk assessments. 3. All employees were educated on incident and accident supervision. All staff have been educated on Incidents and Accidents, and monitoring has been completed. Education included thorough and timely completion of resident assessments, monitoring, and provision of safety for all residents, and thorough investigations of all incidents and accidents to include all potential witness statements in the event of elopement. The surveyors interviewed staff on all shifts, reviewed the in-service education and sign-in sheet. 4. The Administrator/DON have been consulted regarding proper reporting in a timely manner per state regulation and conducting thorough investigations with all Incidents and Accidents. The ADON/Unit Managers were educated on proper monitoring and supervision, incidents and accidents, proper investigating and reporting. Unit Managers were educated on proper and thorough assessments to be completed in a timely manner. The surveyors interviewed the Administrator, the DON, the ADON and the Unit Managers regarding proper reporting, investigation, supervision, and monitoring. 5. DON/ADON/Unit Managers will audit and review any uncompleted assessments daily in the clinical meetings. The findings will be reported to the monthly QAPI committee meetings for follow-up. The surveyors interviewed the Administrator, the DON, the ADON and the Unit Managers regarding proper reporting, investigation, supervision and monitoring. The facility's noncompliance of F-726 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, Quality Assurance Performance Improvement (QAPI) Committee meeting review, job description review, and interview, the QAPI committee failed to ensure an effective QAPI program that identified opportunities for improvement related to resident safety and infection control, and failed to implement performance improvement activities in order to provide a safe environment for residents, prevent the spread of infections, and ensure systems and processes were in place and were consistently followed by staff and administration. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure the facility was administered in a manner to use its resources effectively and efficiently. The failure of the QAPI committee to ensure systems and processes were in place and consistently followed by staff and administration placed Resident #5, a COVID-positive resident with exit-seeking behaviors, in Immediate Jeopardy when he exited the COVID Unit barriers 3 times, and then exited the facility unsupervised. Staff was unaware Resident #5 was missing from the facility until he was seen by a staff member walking outside the facility, down the sidewalk and into the back parking lot approximately 223 feet from the 800 hall exit door. Contact isolation was not maintained, which had the potential to spread COVID-19 infection to staff and residents. The failure of the QAPI committee to ensure systems and processes were in place and consistently followed by staff and administration resulted in actual harm for Resident #3, who sustained a 7.8 percent weight loss in 1 month. Resident #3 admitted with Depression, Dementia and a positive COVID diagnosis. He was admitted to the COVID Unit in contact isolation and voiced suicidal ideations 3 days after admission by stating he wanted to die and would starve himself. The facility was unable to provide documentation of follow-up by Social Services for Resident #3. Resident #3 was not provided needed psychiatric services for days after expression of suicidal ideations. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 12/2/2022 at 8:52 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610 and F-689, F-725, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689, at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 8/30/2021 for deficiencies related to F-600, F-610, F-689, F-725, F-726, F-835 and F-867. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy existed 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/2/2022 at 8:52 PM. The Removal Plan for QAPI was validated by the surveyors with additional education put in place on 12/2/2022 and the removal of the F600, F609, F610, F689, F725, F726, F835, and F880 IJs. The findings include: Review of the facility policy titled, QA [Quality Assurance] Committee-Role of the Quality Assessment and Assurance Coordinator, revised 11/2010, revealed, .Duties and responsibilities of the Quality Assessment and Assurance Program include, but are not limited to: .Meeting with the Quality Assessment and Assurance Committee monthly to review all assessment tools designed, all data collection reports, and all activities regarding quality assessment and assurance as carried out by departments, services, or committees which have a direct impact on resident care and safety .planning developing, organizing, implementing, coordinating, and directing the Quality Assessment and Assurance program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Evaluating programs and effecting changes as necessary to improve programs and assuring compliance with regulatory requirements .Assisting department directors in developing and implementing appropriate plans of action to correct identified deficiencies .Scheduling committee meetings and notifying members of such meetings .Assisting in developing follow-up procedures for monitoring identified problem areas . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed, .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Complete and file an incident report; and Document relevant information in the resident's medical record . Review of the Administrator Job Description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Committee Functions Serve on various committees of the Facility (i.e. Infection Control, Quality Assurance and Assessment, etc. and provide written and oral reports of such committee meetings to the VP [Vice President] of Operations .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the Facility's committee as necessary . Review of the Director of Nursing Services Job Description, signed by the Director of Nursing on 3/16/2020, revealed, .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Duties and responsibilities .Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified deficiencies . Review of the QAPI meeting minutes provided by the Administrator, revealed a QAPI Committee meeting was held on 10/21/2022, to address a COVID-19 outbreak in the facility, and a recommendation was made for designated staffing for the COVID Unit to reduce further spread of the virus with staff and residents. The designated staff should consist of 1 nurse, 1 certified nursing assistant (CNA) and 1 housekeeper on the COVID Unit. On 10/30/2022, this was not followed, as staff assigned to the COVID Unit also cared for residents outside the COVID Unit on other halls. The QAPI meeting held on 10/31/2022, did not address designated staffing of the COVID Unit. There was no immediate action taken by the QAPI Committee to staff the COVID Unit with designated staff until 11/10/2022. During an interview on 11/9/2022 at 12:27 PM, the COO stated, .when I was notified, I told them [Administrator and DON] on 10/31/22 .They told me that a resident was found outside .told them to continue the investigation and get statements .on Wednesday [11/2/2022] I told them to report it, and I was under the assumption it was reported Wednesday [11/2/2022] . During an interview on 11/8/2022 at 4:36 PM, the Administrator stated, During our QAPI [meeting] on 10/21 [2022], we had a meeting regarding the COVID outbreak. We decided that we would have designated staffing in the Covid Unit: 1 nurse, 1 CNA, and 1 housekeeper . The Administrator was asked if the designated staff assigned to the COVID Unit also had to work outside the Covid Unit on the day of the elopement [10/30/2022]. The Administrator stated, .I don't think so .the staff had redirected the resident [Resident #5] several times that day and prevented him from getting out. The Administrator confirmed she had not reviewed the staff assignments for 10/30/2022. The Administrator was asked what the root cause analysis was determined for Resident #5's elopement incident during the QAPI meeting on 10/31. The Administrator stated, He [Resident #5] wanted to exit the facility to go see his brother. The root cause analysis for QAPI on 10/21 was staffing due to outbreak [COVID-19] .We were to have some people work the Unit [Covid Unit] designated only to COVID [Unit] unless call ins. During an interview on 11/8/2022 at 4:36 PM, the DON stated, .to be honest with you, we hadn't looked at the staffing .I told the Staffing Coordinator a couple of weeks ago that we need designated staff to staff the Covid Unit only .The DON was asked if the fact that Resident #5 was positive for COVID should not have been considered an incident [of potential COVID-19 exposure]. The DON was asked if the Supervisor should have collected statements when Resident #5 got out of the door. The DON confirmed that Resident #5's exit from the COVID Unit and exit from the facility should have been considered an incident. The DON stated, .I can see where you are coming from . The DON confirmed the Registered Nurse (RN) Supervisor (RN #1) should have gotten statements. During an interview on 11/21/2022 at 3:40 PM, the Chief Operating Officer (COO) stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . Interview on 12/2/2022 at 5:20 PM, the Interim DON confirmed there were some issues with the psychiatric referrals that were identified yesterday [12/1/2022]. The DON stated, .We are finding out that the orders are written, but they are not being seen immediately after the order is written .there is a delay in services . The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staff supervision to protect vulnerable residents from neglect and unsafe elopement episodes. Refer to F600. The QAPI committee failed to maintain oversight, establish and implement policies and procedures to ensure incidents of elopement and neglect were reported to the State Survey Agency. Refer to F609. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure incidents of elopement were thoroughly investigated. Refer to F-610. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure elopement incidents were prevented, identified, and thoroughly investigated. Refer to F-689. The facility failed to provide sufficient nursing staff to adequately supervise a vulnerable resident with severe cognition impairment, wandering and elopement behaviors, a positive COVID diagnosis from exiting the COVID Unit 3 different times, and then exited the facility unsupervised and without Personal Protective Equipment (PPE) in place. Refer to F725. The facility failed to ensure licensed nurses had the competencies and skill sets necessary to perform assessments and complete fall risk assessments for residents with impaired safety awareness. According to the investigation, Resident #5, who was positive for COVID-19 exited the COVID Unit barrier 3 times by unzipping the barrier, and then exited the facility unsupervised on 10/30/2022. Resident #5 was found by staff walking on the sidewalk into the parking lot, approximately 223 feet from the facility. Neither Resident #5, nor staff who interacted with him, were using Protective Personal Equipment (PPE), which had the potential to expose staff and other residents to COVID-19. The facility's failure to ensure staff had the competencies and skill sets necessary to ensure residents having immediate needs for psychiatric services, received such services in a timely manner. This failure resulted in actual harm when Resident #3, a vulnerable resident with diagnoses of Depression, Dementia and COVID-19, sustained a significant weight loss of 7.8 percent (%) in 1 month, after having suicidal ideations and voiced that he wanted to die and would starve himself. Resident #3 was admitted and isolated in the COVID Unit on 8/9/2022. Resident #3 voiced to Social Services and his family of wanting to die and had suicidal ideations on 8/12/2022. Resident #3 refused medications and meals, resulting in significant weight loss in 1 month. The facility was unable to provide documentation for Social Service monitoring or follow-up. The facility's failed to ensure licensed nurses had the competencies and skill sets necessary to perform and complete admission assessments and fall risk assessments on admission for Resident #9 and Resident #2. Refer to F726. The QAPI committee failed to maintain oversight, failed to establish and implement policies and procedures to ensure effective social services to maintain the highest practicable physical, mental, and psychosocial well-being for residents were provided. The facility's QAPI Committee failed to identify the systemic issues of psych services referrals not being processed timely and the social services system failure to include documentation, visits, referrals and meeting the needs of residents with agitation and suicidal threats. Refer to F745. The QAPI Committee failed to maintain oversight, failed to establish and implement policies and procedures, failed to ensure Administration consistently followed policies and procedures, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Refer to F835. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure staff maintained appropriate transmission-based precautions for infectious diseases, and failed to ensure staff used proper PPE when caring for residents with known infectious COVID-19. The facility's QAPI Committee failed to identify, investigate, analyze and evaluate the incident of Resident #5 (a COVID positive resident) exiting the COVID Unit multiple times and having the potential to expose other residents and staff when the resident eloped. Refer to F-880. The surveyors verified the Removal through observations, review of audits, meeting minutes, and staff interviews as follows: 1. All employees including QAPI team members were in-serviced on 11/11/2022 on how to properly identify residents who were wanderers/exit-seekers and elopement risk along with review on wanderers, exit-seekers and residents at risk for elopement, incidents and accidents, and thorough investigation and reporting. The Administrator/DON/ADON were consulted on 11/17/2022 regarding incidents and accidents, adequate and through investigation and proper reporting to the proper agencies in a timely manner. All employees, including QAPI team members, were in-serviced on 11/11/2022 on who to report to if a resident was identified as going out of the facility unsupervised, and how and when to start an investigation. Administrator/DON/ADON to go over daily staffing the day before with the Staffing Coordinator (SDC), and each morning with the QAPI team members to ensure adequate and competent staff facility-wide, including the COVID Unit, based on acuity and census. Administrator/DON/ADON check staffing daily to ensure there is dedicated staff members on the COVID Unit to reduce the risk of exposure to other residents and staff for COVID 19. Administrator consulted DON/ADON/Social Services on prompt procedure regarding psychiatric referrals and residents being seen by psychiatric services in a timely manner. All non-emergent behavioral referrals and residents being seen by psychiatric services within the week and all emergency cases will be attended by Primary Care Provider (PCP). Psychiatric service providers will be notified via telephone regarding transfers to hospitals. 2. The DON in serviced ADON/SDC and Unit Managers on 12/01/2022 regarding completion of all new admissions, readmissions and any assessments that are warranted per resident change of condition. 3. The facility immediately reviewed policies and procedures with all staff regarding incidents and accidents, thorough investigation and reporting to proper authorities in a timely manner on 11/11/2022. DON/ADON put a monthly calendar in place to ensure that a Manager on Duty is in place including weekends and holidays. In the event that there is any change of condition or occurrences concerning any residents at the facility, it will be thoroughly investigated and reported timely. Administrator/DON/Unit managers review all occurrences, change of condition, and all assessments, including new admissions, readmissions and any assessments warranted by change of condition or occurrences in the morning QAPI meetings. DON/ADON/SW/UM will review all psychiatric referrals in the morning QAPI meetings to ensure all referrals are processed and residents are seen by psychiatric services in a timely manner. Any negative findings will be corrected or completed immediately and brought to the next morning QAPI meeting to ensure completion and accuracy of assessments. The facility's noncompliance of F-867 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on the Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, medical record review, and interview, the facility Administration failed to provide supervision and oversight to prevent the potential for serious injury when Resident #5 exited the Covid Unit and eloped from the facility on 10/30/2022. Resident #5 walked outside the facility, and down the sidewalk toward a parking lot approximately 223 feet from the facility and was unsupervised for approximately 6 minutes. Administration failed to identify breaches in Infection Control practices when Licensed Practical Nurse (LPN) #1 and Certified Nurse Assistant (CNA) #1 were not wearing Personal Protective Equipment (PPE) when providing care for Resident #5, who was Covid Positive. Administration failed to identify incomplete admission and fall risk assessments, failed to ensure measurable and person-centered interventions were in place to prevent falls, and failed to provide in-service education for facility staff related to fall reporting for 2 of 3 sampled residents (Resident #9 and #2) reviewed for falls. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Interim Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 12/2/2022 at 8:52 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-725, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 8/30/2021 for deficiencies related to F-600, F-610, F-689, F-725, F-726, F-835 and F-867. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy was existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 at 12:44 PM, and was validated onsite by the surveyors on 12/1/2022 - 12/2/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the BENHA revealed the Administrator had an employment date of 7/6/2020. Review of the Administrator job description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions .Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the VP [Vice President] of Operations .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility .realize the importance of teamwork .Review the Facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations .Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures .Represent the Facility in dealings with outside agencies, including governmental agencies .Participate in state/federal surveys of the facility .Assist in providing survey team members with additional information during the survey .Review deficiencies noted during the exit conference .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their departments to assist in eliminating and correcting problem areas .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments or corrections .Inform the Medical Director of all suspected or known incidents of resident abuse .Ensure the building and grounds are maintained in good repair .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program .Specific Requirements .Must have a thorough knowledge of OBRA [Omnibus Budget Reconciliation Act] regulations, the survey process, survey tag numbers, and quality measures .Must be able to communicate policies, procedures, regulations, reports .to government agencies and personnel . Review of the Director of Nursing Services job description, signed by the DON on 3/16/2020, revealed .The primary purpose of your position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by the Facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & [and] Assurance Committee (QAPI) in developing and implementing appropriate plans of action to correct identified deficiencies .Make daily rounds of your unit/shift to ensure that assigned CNAs [Certified Nursing Assistants] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Make changes to assignments based upon resident needs .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents .Assign a sufficient number of LPNs [Licensed Practical Nurses] and RNs [Registered Nurses] for each tour of duty to ensure that quality care is maintained .Assign a sufficient number of CNAs for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care .Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department .Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies .Review and revise care plans and assessments as necessary .Report all allegations of resident abuse .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During an interview on 11/3/2022 at 11:17 AM, the DON stated, .I was notified the day [Resident #5] exited the facility .the investigation wasn't started until 10/31/2022, and it has not been reported . During an interview on 11/3/2022 at 11:17 AM, the Administrator stated, .the investigation started on 10/31/2022 after the morning meeting .I notified the [Chief Operating Officer] and was told to continue the investigation and collect statements .the COO agreed it was not a reportable incident at this point . During an interview on 11/8/2022 at 4:36 PM, the DON stated, .I did not direct the RN [Registered Nurse] Supervisor to gather statements the day she notified me of the incident . During and interview on 11/9/2022 at 11:00 AM, the Administrator confirmed staffing concerns had not been investigated until 11/8/2022. During an interview on 11/9/2022 at 12:27 PM, the COO stated, .I was notified of the incident on [10/31/2022] and directed them [Administration] to continue the investigation and collect statements .I spoke with Administrator on Wednesday [11/22/2022] and directed them to report the incident into [Incident Reporting System]. I assumed they had reported it that day . During an interview on 11/10/2022 at 10:54 AM, the Administrator stated, .the DON should have come in .gave directions about getting staff statements .the investigation was not started immediately .on Monday [10/31/2022] the only information we had was RN #1's statement that was based on what she was told .Monday I told the DON an incident report and a head-to-toe assessment needed to be completed . During an interview on 11/21/2022 at 3:30 PM, the COO stated, .incidents should be reported to the DON then to the Administrator .the DON took it upon herself to not report the incident to the Administrator .statements should be obtained immediately .incident reports should be completed by the charge nurse . During an interview on 11/22/2022 at 3:40 PM, the Administrator stated, .this is the 3rd elopement for us .this is the same thing that happened last year [2021]. The [DON] failed to notify me about the incident when it happened .I am supposed to be notified of these incidents .did not report it timely because did not think it was reportable since staff had their eyes on him .now were are finding out statements and assessments that should have been done but were not .and I'm just finding out about them . During an interview on 11/22/2022 at 3:50 PM, the Interim DON stated, .admission assessments should be completed within 24 hours of admission .fall risk assessments are completed upon admission .and after a fall . The facility's noncompliance of F-835 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on job description review, facility staffing schedules, daily staffing sheet, punched detailed report review, agency time detailed report review, and interview, the facility failed to provide sufficient nursing staff to ensure supervision of residents. The facility's failure to ensure sufficient staffing for adequate resident supervision resulted in Immediate Jeopardy for 1 of 5 sampled residents (Resident #5) when a vulnerable resident with severe cognition impairment with wandering and elopement behaviors, and a positive COVID diagnosis, exited the COVID Unit 3 different times, and then exited the facility and was found by staff in the parking lot unsupervised and without Personal Protective Equipment (PPE) in place. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 11/21/2033 at 4:41 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-725. The facility was cited at F-725 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 PM, and was validated onsite by the surveyors on 11/30/2022 through 12/1/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the Administrator Job Description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all time .Personnel Functions .Ensure that an adequate number of appropriately trained licensed professional and non-professional personnel are on duty at all times to meet the needs of the residents. Ensure that appropriate staffing level information is posted on a daily basis. Review and check competence of work force and make necessary adjustments or corrections as required or that may become necessary . Review of the Director of Nursing Services Job Description dated 3/16/2020, revealed, .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Administrative Function .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator or his/her designee to ensure that accurate staffing information is posted .Personnel Functions Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents. Supervise and assist scheduling of employees within established state guidelines .Assign a sufficient number of LPN's [Licensed Practical Nurse] and RNs [Registered Nurse] for each tour of duty to ensure that quality care is maintained. Assign a sufficient number of CNAs/GNAs [Geriatric Nurse Aide] as applicable for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Nursing Care Functions .Provide the Administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs . 2. Review of the Midnight Census Report and Daily Schedule dated 10/30/2022 revealed a total census of 148 residents. A total of 49 residents resided on the 100 and 200 Halls. A total of 49 residents resided on the 300 and 400 Halls, and a total of 30 residents resided on the 500 and 600 Halls (11 residents resided on the COVID Unit, rooms 606-617). A total of 20 residents resided on the 800 Hall. Daily Schedule revealed on the day shift (6:45 AM-3:15 PM) on 10/30/2022, 6 Licensed Practical Nurses (LPNs) were scheduled. 3. Review of the Daily Assignment Sheets dated 10/30/2022, revealed day shift (6:45 AM-3:15 PM) assignments showed 1 Certified Nursing Assistant (CAN) for rooms 500-504 and 600-605; 1 CNA for rooms 505-512 and 811w (window)-817; 1 CNA for (COVID Unit) rooms 606-617; and 1 CNA for rooms 800-811d (door). 4. Review of the Daily Staffing Sheet, Punched Detailed Report, Agency Time Detailed Report dated 10/30/2022, revealed 0700 days 8 CNAs with 1 CNA clocking punch time at 10:05 AM and 1 CNA clocking punched out time at 12:58 PM. 5. During an interview on 11/8/2022 at 4:36 PM, the Administrator stated, .during the QAPI (Quality Assurance Performance Improvement) [meeting] on 10/21[2022], we had a meeting regarding the COVID outbreak .we would have designated staffing in the Covid Unit: 1 nurse, 1 CNA, and 1 housekeeper .the day of the elopement [10/30/22], there should have been designated staff in the COVID Unit .staff had to work outside the Covid Unit picking up other residents .if someone called in, that staff had to cover .there was [were] 11 residents on the COVID Unit that day . The Administrator confirmed that the nurse and CNA had other residents assigned outside of the Covid Unit, and were not designated only to the COVID Unit stating, .we shot ourselves in the foot when we put that in place .with the staffing challenges .the DON should provide the oversight for the staffing, but that wasn't done . During an interview on 11/8/2022 at 1:01 PM, CNA #1 stated, .I was assigned the COVID Unit and provided care to residents assigned outside of the COVID Unit on another hall .it was hard for me to keep eyes on him [Resident #5] .he was up wandering around and going out of the COVID Unit .I brought him back in the unit several times .then I got a call he was out in the parking lot .there was no way I could have watched him closely, because I had other residents outside the COVID Unit . CNA #1 confirmed the assignment sheet was inaccurate, and that due to a call-in, she was assigned other residents outside of the COVID Unit. During an interview on 11/8/2022 at 3:00 PM, the DON stated, .I told the Staffing Coordinator a couple of weeks ago that we need designated staff to staff the Covid Unit only .If someone calls in, then the staff from the Covid Unit will have to cover .there should have been a nurse and CNA assigned to the COVID Unit . During an interview on 11/18/2022 at 1:04 PM, the LPN #1 stated, .I was not aware that there was designated staff for the COVID Unit .I had the COVID Unit and provided care to residents outside of the COVID Unit on another hall .me and the other nurse split the halls .had rooms on the 500 and the 600 hall [COVID Unit] .we were trying to do the best that day we could .it was very hard to manage [named Resident #5]. He kept getting out of the [Covid] Unit .I probably shouldn't have sat him at the desk since he was COVID-positive . During an interview on 12/1/22 at 1:00 PM, the Staffing Coordinator stated, .we had call-outs from staff and agency staff that day [10/30/2022] at the last minute, and staff that had promised to work left their shifts early .we were short [short-staffed] .not sure if the Charge Nurse who made the assignments knew to staff the COVID Unit with designated staff . The Staffing Coordinator confirmed the nurse and CNA were not designated to only the COVID Unit. The Staffing Coordinator confirmed the daily assignment sheet was inaccurate and did not reflect the actual assignments or schedule. The surveyors verified the Removal Plan by: 1. The facility will provide 1 nurse and 1 CNA for every 10 residents in the COVID Unit each shift. Documentation was provided which showed the nurse-to-patient ratio. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing was available. This will be discussed daily during morning meetings, during the day, and again at the end of the day. This was validated by the surveyors through observation and review of the daily assignment sheets. Clinical acuity and the COVID Unit census will be reviewed by Administrator/DON daily and staffed accordingly as follows: 1-5 residents minimum 1 nurse 6-10 residents minimum 1 nurse and 1 CNA 11-20 residents minimum 1 nurse and 2 CNAs 2. Facility initiated every-30-minute checks on Resident #5, who exited the COVID Unit unsupervised. The facility initiated every-30-minute check on all residents with exit seeking behaviors or at elopement risks. This was validated by surveyors through review of the 30-minute check sheets. Unit Managers will monitor and audit every-30-minute checks daily on all exit seeking residents. Findings will be reviewed and reported in the morning meetings daily. Resident added to the wander list since audit started. This was validated by surveyors through review of 30-minute check sheets of all wandering and exit-seeking residents and review of audits and interviews with Unit Managers. 3. All facility staff were educated on incidents/accidents and supervision. This was validated by surveyors through interviews with agency and facility staff conducted on all shifts, and sign-in sheets were reviewed for all staff and agency staff. 4. Administrator/DON/ADON will monitor staffing each morning in the morning meetings to ensure adequate staffing is provided for the COVID Unit specifically and for the facility in general. This was validated by surveyors through review of the COVID Unit census with staffing assignment sheets and observations. 5. Administrator/DON/ADON will review staffing for the following day with the Staffing Coordinator on the previous day before posting to ensure adequate staff members are scheduled daily. This was validated by surveyors through review of daily staff postings and schedules. 6. Administrator/DON and Staffing Coordinator will review daily PPD and take action to replace call outs, including use of agency staff, as-needed (PRN) staff, and management staff to ensure adequate staffing is available for the COVID Unit specifically, and the facility in general, each day in the morning meetings. This was validated by surveyors through review of staff postings and schedules, and interviews. The facility's noncompliance of F-725 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, observation and interview the facility failed to ensure a safe environment to prevent an incident of elopement for 1 of 3 (Resident #5) sampled residents reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) when a cognitively impaired resident exited the facility without authorization or staff supervision. The facility was unaware the resident had exited the facility until a housekeeper looked out a window and saw the resident walking on the sidewalk outside of the facility toward the parking area. The facility failed to ensure fall risk assessments were completed for 2 of 3 sampled residents (Resident #9 and Resident #2) reviewed for falls. The failure of the facility to implement measurable interventions resulted in actual harm when Resident #9 had a fall with a major injury. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing, and the Chief Clinical Officer were notified of the Immediate Jeopardy on 11/10/2022 at 3:44 PM, in the conference room of the facility. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 10/30/2022 through 11/18/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 and was validated onsite by the surveyors on 11/17/2022 through 11/18/2022 by policy review, medical record review, observation, review of education records, auditing tools, and staff and resident interviews. The findings include: 1. Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed, .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, Revised 8/2014, revealed, .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident . Review of the facility's policy titled, Fall Risk Assessment, revised March 2018, revealed, .The nursing staff .will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Upon admission, the nursing staff and physician will review a resident's record for a history of falls .nursing staff will ask the resident and his/her family about any history of the resident falling .staff and attending physician will .identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was care planned at risk for elopement related to poor safety awareness related to his admission diagnosis of WERNICKE'S ENCEPHALOPATHY (a degenerative brain disorder). The goal was for Resident #5 to remain safely on facility property until a safe discharge was possible. Interventions included assess/observe patterns of exit-seeking behavior and remove/eliminate triggers when possible, check wander guard placement every shift, consult psychiatric and/or psychology services as ordered by physician, encourage participation and interactions that decrease anxiety and exit seeking, place resident's picture in elopement binders throughout the facility and notify receptionist/security staff, redirect resident away from exits as needed, a wander guard to be placed for resident safety, and avoid leaving Resident #5 unattended or unobserved for long periods of time. Review of an elopement risk assessment dated [DATE], revealed Resident #5 had a score of 2, which indicated he was at risk for elopement. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a physician's order dated 10/28/2022, revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive Covid diagnosis. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed, .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed, .exit seeking x [times] 3 left COVID hall x 2 this am [morning] set off the alarm to door on 700 hall x 1 .set off alarm on 500 hall door x 2 .found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed, .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . The cognitively impaired resident (Resident #5) exited the Covid Unit several times prior to exiting the facility (elopement) unsupervised on 10/30/2022. The facility failed to implement interventions that prevented the resident from exiting the facility. Review of a Progress Note dated 10/31/2022 at 8:03 PM, revealed, .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . Observation of the area outside of the 700 hall exit door on 11/8/2022 beginning at 1:45 PM, with the Maintenance Director and the Speech Therapist, revealed a concrete sidewalk around the building, which was noted with several areas of a 3 1/2 inch descent to the ground. There was a 3-foot 3 inch ditch running parallel to the sidewalk, and the sidewalk was covered in small round nuts which caused an uneven walking surface. It was approximately 274 feet from the 700 hall exit door to the sidewalk where Resident #5 was seen by the housekeeping staff. There was a sidewalk from the 800 hall exit door to the parking lot. The parking lot was located approximately 223 feet from where the resident was seen by the housekeeping staff, as measured by the Speech Therapist. During a telephone interview on 12/2/2022 at 9:25 AM, the physician stated, .not safe for [Resident #5] to be outside unsupervised .I was not aware of any attempts before this incident . 3. Medical record reviewed revealed Resident #9 was admitted on [DATE], with diagnoses of Cerebral Infarction, Anemia, History of Falling, Metabolic Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the admission fall risk assessment dated [DATE], revealed the assessment was incomplete. Review of the admission assessment dated [DATE], revealed the assessment was not signed until 11/15/2022. Review of the baseline care plan dated 11/4/2022, revealed Resident #9 is at risk for falls related to the new and unfamiliar environment, poor safety awareness, and unsteady gait with weakness. The interventions included anticipate and meet resident's needs as needed and keep the room free of clutter and obstacles that may pose trip hazards. Review of the admission MDS dated [DATE], revealed Resident #9 was assessed by staff as having severe cognitive impairment for decision making, had trouble concentrating, exhibited behaviors including rejection of care and wandering, required one-person limited assistance with activities of daily living, and had a history of falls prior to admission. Review of the Incident Details Report dated 11/10/2022, revealed, .CNA [Certified Nursing Assistant] called for the nurse to come to the resident's room. Resident was found on the floor .resident has right side head injury with a raised area over the eye .hematoma forehead . Resident #9's admission assessment and fall risk assessment was not completed. The baseline care plan did not include person centered measurable interventions to prevent falls. Resident #9 fell on [DATE] and sustained a hematoma to the right side of her face. During an interview on 11/17/2022 at 11:31 AM, the Interim DON stated, .the admission assessment should be completed within 24 hours of admission .fall risk assessments are completed upon admission and when a fall occurs The Interim DON confirmed Resident #9's admission assessment was not completed within 24 hours of admission and the admission fall risk assessment was not completed. 4. Review of a closed medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Anemia, Cerebral Infarction, and Esophagitis. Review of the fall risk assessment dated [DATE], revealed Resident #2 was assessed at moderate risk for falls. Review of the admission MDS dated [DATE], revealed Resident #2 was assessed with a BIMS of 11 indicating moderate cognitive impairment for decision making. Resident #2 required assistance with activities of daily living. Review of the Care Plan revised 10/21/2022, revealed fall interventions to anticipate and meet resident's needs, and physical therapy to evaluate and treat as ordered and as needed. Review of the Incidents by Incident Type report dated 8/1/2022 through 12/2/2022, revealed Resident #2 was not listed as having a fall on 10/25/2022. During an interview on 11/16/2022 at 10:54 AM, the DON confirmed Resident #2 had a fall on 10/25/2022. The DON stated, The CNA did not report the fall to the charge nurse .I received the information on 10/26/2022 .in-serviced staff .talked to them about reporting falls .didn't have them sign anything .a fall investigation was completed the next day .a fall risk assessment was not completed after the fall . There were no noted injuries to Resident #2. During a telephone interview on 11/23/2022 at 10:37 AM, CNA #3 stated, .yes [Resident #2] was in the floor I helped [CNA #4 and #5] get her up into the wheelchair .no I did not report it to the nurse . Review of personnel files for CNA #3, CNA #4, and CNA #5 on 11/15/2022, revealed there were no disciplinary actions or education provided related to reporting falls. During an interview on 11/16/2022 at 11:05 AM, the DON confirmed the fall investigation was not signed by the staff completing the investigation. During a telephone interview on 11/21/2022 at 3:40 PM, the Chief Operations Officer stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility immediately called ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with department heads and QAPI team members at 4:00 PM on 11-10-2022. During the QAPI meeting a root cause analysis was completed pertaining to Resident #5 that exited the COVID-19 Unit and facility without staff knowledge. Root cause identification included: Resident who was moved in to the Covid Unit, was trying to get out of the area. The resident was looking to meet with his brother outside the building. He was a cognitively impaired resident and moved to a new environment on the Covid Unit. The surveyors reviewed the QAPI meeting minutes and interviewed the Administrator and the DON. 2. A new elopement assessment on Resident #5 that was identified as being outside without staff supervision was completed on 10-31-2022. The surveyors reviewed the elopement risk assessment. 3. A body audit was completed 10-31-2022 on Resident #5 that was identified as being outside without staff supervision with no negative findings. The surveyors reviewed the body audit and interviewed the DON. 4. The resident that was identified as being outside without staff supervision (Resident #5) was placed on every 30-minute checks. Every 30-minute checks were initiated at 11:15 AM on 10/30/2022. The every-30-minute check sheet was reviewed, and staff was interviewed about the every-30-minute checks. Every resident who was identified as at risk for exit-seeking was placed on 30-minute checks on 11/11/2022 at 5:00 PM, and continued. The surveyors reviewed the 30-minute check sheets for all residents and observed checks being completed. The surveyors interviewed direct care staff regarding the 30-minute checks. 5. The Care Plan was updated with new interventions in place for Resident #5 that was identified as being outside without staff supervision. New interventions included: Psychiatric evaluation and consultation, face time with family member (s) every 30-minute check. The surveyors interviewed the Psychiatric Nurse Practitioner and reviewed the Social Services note regarding the phone call with family member. 6. Maintenance staff checked all exit doors and alarms for proper functioning on 10-30-2022. The surveyors reviewed the exit door checks and interviewed the Maintenance Director. 7. Elopement drills were conducted on following dates with good response: 10/31/2022 at 3:21 PM for the 3-11 evening shift; 11/9/2022 at 11:20 AM for the 7-3 day shift; and 11/14/2022 at 6:18 AM for the 11-7 night shift. The surveyors observed the elopement drill on 11/9/2022 day shift and reviewed the sign in sheet. 8. The facility conducted a QAPI meeting regarding the 10-30-2022 incident on the resident identified as being outside without staff supervision. The surveyors reviewed the QAPI meeting form, the sign-in sheet, and interviewed the Administrator and Director of Nursing. 9. The resident identified as being outside without supervision (Resident #5) was discharged from the COVID-19 Unit on 11-9-2022 after completing quarantine time. The surveyors confirmed the resident was no longer residing in the COVID-19 unit. 10. A psychiatric evaluation was completed on 11-10-2022 on the resident identified as being outside without supervision (Resident #5). The surveyors interviewed the Psychiatric Nurse Practitioner and reviewed the progress note from the 11-10-2022 visit. 11. All residents that would like to participate in facetime and phone calls on the COVID-19 Unit will be offered. Every resident currently in the Covid Unit were offered facetime/phone calls on 11/12/2022. Every resident will be offered facetime/phone calls with family members at least weekly and as needed. Social Worker/Activities staff will visit the residents with an iPad or cell phone and coordinate calls. The surveyors reviewed the log sheet of residents offered and those that participated in a facetime/phone call. The surveyors interviewed the Social Worker and Activities Director regarding facetime/phone calls for residents on the Covid Unit. 12. The facility will ensure sufficient staff and supervision on the COVID-19 Unit for all residents. Staffing needs will be determined based on the census and acuity in the Covid Unit. The goal will be to have at least 1 nurse for the COVID Unit and 1 CNA for every 10 residents. The surveyors interviewed the Staffing Coordinator, Administrator and the Interim Administrator regarding Covid Unit staffing. 13. The facility immediately started in-services and education on neglect and accidents on 10-31-2022 and is ongoing. All facility employees are required to attend in-services/education regarding neglect and accidents. In-service education started 10/30/2022 and will be continued to attain over 100% compliance by 11/15/2022. Employees who are on vacation, family medical leave, or are scheduled as-needed will be required to complete the training prior to return to work. The surveyors reviewed the education, reviewed the sign-in sheets, and interviewed staff on all shifts. 14. The facility will audit all exit-seeking/elopement risk residents every shift by conducting every-30-minute checks. Findings will be reviewed in the daily morning meetings. Charge Nurse/designee will conduct audits for exit-seeking/elopement risk residents. The surveyors reviewed the audit form and interviewed Administration and facility staff regarding audits and morning meetings. The facility's noncompliance of F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, observation and interview the facility failed to thoroughly investigate an incident of elopement for 1 of 3 sampled residents (Resident #5) reviewed for elopement and wandering. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy when Resident #5 eloped from the Covid Unit, exited the facility, and walked unsupervised down a sidewalk toward a parking area. The vulnerable, confused resident ambulated approximately 223 feet from the facility unsupervised. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/16/2022 at 5:19 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/22/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 AM, and was validated onsite by the surveyors on 11/21/2021 and 11/22/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, INCIDENT REPORT-DOCUMENTATION, INVESTIGATING, AND REPORTING, revised 9/20/2021, revealed, .all accidents or incidents involving residents .shall be investigated and reported to the administrator . Review of the facility's undated policy titled, Accident & Incident Documentation & Investigation Resident Incident, revealed .The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director .The Licensed Nurse .is responsible for initiating/completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. Review of the facility's undated policy titled, Abuse Prevention, revealed, .The Executive Director and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse .if such incidents occur or are discovered after hours, the Executive Director and Director of Nursing Services must be called .and informed of such incident .The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, at risk for falls, impaired cognitive function and at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician' order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a Covid positive diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . Review of a Progress Note dated 10/31/2022 at 8:03 PM, revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . During an interview on 11/3/2022 at 11:18 AM, the DON and the Administrator confirmed the camera footage had not been reviewed to determine where Resident #5 went out of the facility or what time he was last captured on video in the facility. During an interview on 11/7/2022 at 1:40 PM, the Administrator stated, .we have talked to all of the staff .he was seen by staff outside .eyes on him the whole time he was outside .I have the typed-up account of the reenactment done with the Housekeeper. That is all I have related to the investigation involving [Resident #5] . During an interview on 11/8/2022 at 4:36 PM, the DON confirmed she had not directed the Registered Nurse (RN) supervisor to obtain statements from the facility staff or to complete an incident report. During an interview on 11/7/2022 at 4:50 PM, the Administrator stated, .I did find some pictures on my phone of the incident .not able to save a video of the incident .just able to see still pictures of the camera footage .did not review them until today . On 11/8/2022 the Administrator provided screenshots of Resident #5 inside the facility and outside of the facility. The Administrator confirmed there were no staff outside with Resident #5. During an interview on 11/9/2022 at 11:00 AM, the Administrator stated, .the investigation of the incident is ongoing. We are not finished .the Staffing Coordinator worked that day . During an interview on 11/9/2022 at 11:10 AM, the Staffing Coordinator stated, .I worked that day. I turned the alarm off to the 800 hall exit door .I did not write a statement until today, because they [Administrator and DON] did not know I worked . On 11/9/2022 the Administrator provided still photos of the camera footage. The Administrator stated, We're not able to get a copy of the video, only still photos of the video . The Administrator was not able to provide the photos on a storage device. The Administrator stated, .I'm not able to extract the pictures . During an interview on 11/10/2022 at 10:15 AM, the Administrator confirmed there was no staff outside with the resident. Refer to F-600, F-609, F-689, F-725, F-726, F-835, F-867 and F-880. The surveyors verified the Removal Plan by: 1. The facility conducted ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) with the management team on 11/16/2022 at 6:00 PM, and completed a root cause analysis. Root cause identification included: Late reporting and not conducting a thorough investigation. The facility received conflicting statements from different employees, creating a delay in collecting statements and information from employees. The surveyors reviewed the QAPI meeting minutes and sign-in sheet, and interviewed the Administrator and the DON. 2. The facility reported the elopement incident to the Tennessee Department of Health on 11/3/2022 regarding the cognitively impaired resident (Resident #5) that was identified as being found outside unsupervised. The surveyors reviewed the Incident Reporting System information sheet and interviewed the DON. 3. The Administrator/DON will review all incidents and accidents for the last 30 days to ensure that any incident that was considered a reportable event by the state and federal regulations was reported appropriately. The surveyors reviewed the audit form and interviewed the Administrator and DON. 4. All incidents will be reported timely to all appropriate agencies within 24 hours of occurrence regarding any incident that could result in harm or death. The Administrator or the DON/designee will be responsible for reporting to all appropriate agencies. Designee by title includes ADON, In-service Coordinator, Unit Managers and Weekend Supervisor. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. Incident reporting system (IRS) reporting required over the weekends will be completed with assistance from the Administrator, DON or ADON. The surveyors interviewed the Administrator and DON regarding proper reporting timeframes. The surveyors reviewed the Manager on Duty form and interviewed staff responsible for investigation and reporting. Additional training on thorough investigation was provided to the Administrator, DON and additional members of the nursing management team including the ADON, In-service Coordinator and Unit Managers. The ADON, In-service Coordinator and Unit Managers have been assigned days as Manager on Duty (MOD) including holidays to be responsible for thorough investigation and reporting events timely. The surveyors reviewed the Manager on Duty roster and interviewed staff regarding their responsibility when on call. Staff were interviewed related to thorough investigations and reporting of events timely. 5. All missing statements were collected as part of the ongoing investigation by 11/3/2022 concerning Resident #5, who was identified as having exited the facility without staff knowledge. Resident #5 was placed on a every 30-minute checks. A psychiatric evaluation was completed. The Care Plan was updated with new interventions. In-service education to prevent neglect and accidents was completed for all staff members. Record review and observation were included as part of the investigation. The surveyors reviewed the investigation on 11/3/2022 and 12/1/2022. 6. The facility will ensure that all incidents with major injury will be reported within 2 hours and all other reportable events within 24 hours. The surveyors interviewed staff regarding reporting guidelines. In addition to the Administrator and DON, additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers were also trained on incident investigation and reporting. This training included reporting requirements within 2 hours and within 24 hours. The Weekend Supervisor will be trained on incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. The surveyors interviewed the Administrator, the DON, and Unit Managers regarding investigation and reporting. The surveyors reviewed a facility reported incident that occurred on 11/20/2022. The facility added additional users to the Incident Reporting System (IRS allows maximum 4 users) with the capability for remote accessing and reporting as needed. Additional training on thorough investigation and reporting will be provided to the Administrator, DON, and additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers. The surveyors interviewed the Administrator, the DON, the Unit Managers, and the ADON. 7. The Consultant will educate the Administrator and DON regarding proper reporting and thorough investigating which include collecting witness statements timely. The surveyors interviewed the Administrator and DON regarding proper reporting and thorough investigation of incidents. 8. The Administrator/DON/ADON will be contacted via phone by the Nursing Supervisor/Charge Nurse if any incident that required IRS reporting for guidance. The surveyors interviewed Charge Nurses from all shifts, the Administrator, the DON and the ADON regarding reporting. 9. The Administrator/Designee will audit all reportable events daily during morning meetings and report findings to the QAPI committee. Designee by title includes the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisors. Unit managers will bring incident information daily to the morning meetings for review by the Administrator. In the absence of the Administrator, the DON will be responsible for reviewing incidents in the morning meetings. If both are unavailable, the chain of command will be the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisors. Responsibilities are assigned specifically. The surveyors interviewed the Administrator, the DON, the ADON and Unit Managers regarding reportable events audits during morning meetings. The facility's noncompliance of F-610 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, and interview, the facility failed to report incidents of elopement for 1 of 3 sampled residents (Resident #5) reviewed for wandering and elopement. The facility's failure to report an incident of elopement and neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #5 exited the facility on 10/30/2022 without staff knowledge or supervision. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/16/2022 at 5:19 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/22/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 AM, and was validated onsite by the surveyors on 11/21/2021 and 11/22/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, .ABUSE PREVENTION, revealed .Alleged violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .to other officials .including State Survey Agency .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of an elopement risk assessment dated [DATE] revealed Resident #5 was assessed at risk for elopement. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, was at risk for falls, had impaired cognitive function, and was at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 was severely cognitively impaired for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician's order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a Covid-positive diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . During an interview on 11/3/2022 at 11:18 AM, the DON stated, .Sunday [10/30/2022] a resident [Resident #5] left the building, I was notified by the RN [Registered Nurse] supervisor. She said eyes were on him the entire time .Had a QAPI [Quality Assurance Performance Improvement] meeting on Monday [10/31/2022], Activity Director was in the meeting and said nothing when we discussed the incident .determined since staff had eyes on him, it was not reportable at that time . During an interview on 11/3/2022 at 11:25 AM, the Administrator stated, .the incident has not been reported .I notified the COO [Chief Operations Officer] and agreed not reportable since staff had eyes on him . During an interview on 11/8/2022 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated, .I did not know he was outside of the facility until [Activities Director] called and told me he was outside . During an interview on 11/8/2022 at 1:28 PM, the Housekeeper stated, .I was in a resident room on the 800 hall .saw the resident [Resident #5] walking outside on the sidewalk toward the parking lot .he was by himself . During an interview on 11/9/2022 at 11:10 AM, the Activity Director stated, .I saw him [Resident #5] walking down the sidewalk alone .I called [CNA #1] told her he was outside .I didn't see him walk out the door . The facility was unable to provide evidence that staff saw Resident #5 exit the building on 10/30/2022. He was found outside the facility alone and unsupervised. During an interview on 11/9/2022 at 12:28 PM, the Chief Clinical Officer (CCO) stated, .my understanding was the incident was reported on Wednesday [11/2/2022] . During an interview on 12/2/2022 at 11:53 AM, the Administrator stated .this incident should have been reported earlier . Refer to F-600, F-610, F-689, F-725, F-726, F-880, F-835, F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility conducted ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with the management team on 11/16/2022 at 6:00 PM, and completed a root cause analysis. Root cause identification included late reporting and failure to conduct a thorough investigation. The facility received conflicting statements from different employees, which caused a delay in collecting statements and information from employees. The surveyors reviewed the QAPI meeting minutes and sign-in sheet and interviewed the Administrator and the DON. 2. The facility reported the incident to the Tennessee Department of Health on 11/3/2022 regarding the cognitively impaired resident (Resident #5) that was identified as being found outside unsupervised. The surveyors reviewed the Incident Reporting System information sheet and interviewed the DON. 3. The Administrator/DON will review all incidents and accidents for the last 30 days to ensure that any incident that was considered a reportable event by the state and federal regulations was reported appropriately. The surveyors reviewed the audit form and interviewed the Administrator and DON. 4. All incidents will be reported timely to all appropriate agencies within 24 hours of occurrence regarding any incident that could result in harm or death. The Administrator or the DON/designee will be responsible for reporting to all appropriate agencies. Designee by title includes ADON, In-service Coordinator, Unit Managers and Weekend Supervisor. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. Incident reporting system (IRS) reporting required over the weekends will be completed with assistance from the Administrator, DON or ADON. The ADON, In-service Coordinator and Unit Managers have been assigned days as Manager on Duty (MOD) including holidays to be responsible for thorough investigation and reporting events timely. The surveyors interviewed the Administrator and DON regarding proper reporting timeframes. The surveyors reviewed the Manager on Duty form and interviewed staff responsible for investigation and reporting. 5. The Administrator and DON were trained by the Consultant regarding thorough investigation and reporting to the appropriate agencies timely. The Administrator and DON are responsible for timely reporting in addition to the responsibilities of the Designees. The surveyors interviewed the Administrator and DON regarding investigation and timely reporting of incidents. 6. The facility will ensure that all incidents with major injury will be reported within 2 hours and all other reportable events within 24 hours. The surveyors interviewed the Administrator, the DON and the Unit Managers regarding reporting of incidents. In addition to the Administrator and DON, additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers were also trained on incident investigation and reporting. This training included reporting requirements within two hours and within 24 hours. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. The surveyors interviewed the ADON and Unit Managers regarding investigation and reporting. The facility added additional users to the incident reporting system (IRS allows maximum 4 users) with the capability for remote accessing and reporting as needed. Additional training on thorough investigation and reporting will be provided to the Administrator, DON, and additional members of the nursing management team including the ADON, In-service Coordinator, and Unit Managers. The surveyors verified through interview with the Administrator, the DON, and the Unit Managers. 7. The Administrator/DON/ADON will be contacted via phone by Nursing Supervisor/Charge Nurse if any incident that required IRS reporting for guidance. The surveyors interviewed Charge Nurses on all shifts. This was verified by interview with the DON and Administrator and review of a facility reported incident that occurred on 11/20/2022. 8. The Administrator/Designee will audit all reportable events daily during morning meetings and report findings to the QAPI committee. Designee by title includes ADON, In-service Coordinator, Unit Manager and Weekend Supervisor. Unit Managers will bring incident information daily to the morning meetings for review by the Administrator. In the absence of the Administrator, the DON will be responsible for reviewing incidents in the morning meetings. If both are unavailable, the chain of command will be the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisor. Responsibilities are assigned specifically. The surveyors interviewed the DON, the ADON, and Unit Managers and reviewed in-service sign in sheets. This was verified by interview, review of a reported incident, review of in-service sheets and interview with facility and agency staff on all shifts. The facility's noncompliance of F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, medical record review, observation, and interview, the facility failed to ensure a resident's right to be free from abuse neglect for 1 of 3 sampled residents (Resident #5) reviewed for wandering/elopement behaviors, when Resident #5 exited the COVID 19 isolation area, then exited the facility without staff awareness, walked down a sidewalk. Resident #5 traveled approximately 223 feet. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Clinical Officer (COO) were notified of the Immediate Jeopardy on 11/10/2033 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/17/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 at 12:44 PM, and was validated onsite by the surveyors on 11/16/2022 and 11/17/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, .Abuse Prevention, revealed, .Neglect: A failure of the facility, it's employees, or services provided .to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility .It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment . Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency . 2. Review of the BENHA form revealed the Administrator had an employment date of 7/6/2020. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of an elopement risk assessment dated [DATE] revealed Resident #5 was assessed at risk for elopement. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, was at risk for falls, had impaired cognitive function and was at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 was severely cognitively impaired for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician's order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive Covid diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . Review of a Progress Note dated 10/31/2022 at 8:03 PM revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . During an interview on 11/8/2022 at 12:58 PM, CNA #1 stated, .yes, I was assigned to care for [Resident #5] on 10/30/2022 .he had got out of the unit a couple of times that day .I helped the nurse get him back in the COVID unit about 20 minutes after that I got a phone call from the [Activities Director] telling me he was outside . During an interview on 11/8/2022 at 1:28 PM, the Housekeeper stated, .I was in a resident room on the 800 hall .I didn't hear an alarm sounding .I looked out the window .saw the resident [Resident #5] walking outside on the sidewalk .I didn't see him walk out a door . During an interview on 11/9/22 at 11:10 AM, the Activity Director stated, .I saw him [Resident #5] walking down the sidewalk alone .I called [CNA #1] told her he was outside .I didn't see him walk out the door . During an interview on 11/10/2022 at 10:54 AM, the Administrator confirmed Resident #5 had exited the Covid Unit several times on 10/30/22. The Administrator further confirmed staff had not initiated every 30-minute checks until after the elopement. During a telephone interview on 11/10/2022 at 11:43 AM, LPN #1 stated, .yes, I was [Resident #5's] charge nurse on 10/30/2022, he got off of the Covid Unit several times. Two times he tried to get out on the 500 hall .I escorted him back to the Unit, then the 500 hall [exit] door alarm was sounding .he was trying to go out the door .took him back to the Covid Unit .then I found him at the [exit] door across from the DON office. I tried to get him back to the Unit, but he didn't want to go .so I had to get help from the CNA to get him back in the Covid Unit .I didn't see him go out the door .I didn't see him outside, I didn't see them bring him back in .I was told by staff he was outside . The facility staff assigned direct care for Resident #5 were aware he had exited the Covid Isolation Unit and had attempted to exit the facility several times during their shift. The direct care staff were unaware that he had exited the Covid Isolation Unit and was outside of the facility unsupervised. During a telephone interview on 11/14/2022 at 12:23 PM, Registered Nurse (RN) #1 stated, .I was told about the incident .it was secondhand information .someone alerted me that a resident was outside of the facility. We went outside to search, and when we came back, he was already back in the facility .there were no alarms sounding . During an interview on 12/2/2022 at 10:29 AM, the Administrator stated, .One (1) on 1 supervision would be warranted . Refer to F-609, F-610, F-689, F-725, F-726, F-880, F-835, F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility immediately called an ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with department heads and QAPI team members at 4:00 PM on 11/10/2022. During the QAPI meeting a root cause analysis was completed pertaining to the resident that exited the COVID Unit and facility without staff knowledge (Resident #5). Root cause identification included: Resident #5 who was moved to the Covid Unit, was trying to get out of the area. Resident #5 was looking to meet with his brother outside the building. He was a cognitively impaired resident who was moved to a new environment on the Covid Unit. The surveyors reviewed the QAPI meeting sign-in sheet, the minutes of the meeting and interviewed the DON and the Administrator. 2. New elopement assessment on Resident #5, who was identified as being outside without staff supervision was completed on 10/31/2022. The surveyors reviewed the elopement risk assessment. 3. A body audit was completed on 10/31/2022 on Resident #5, who was identified as being outside without staff supervision with no negative findings. The surveyors reviewed the body audit and interviewed the DON. 4. Resident #5, who was identified as being outside without staff supervision was placed on every 30-minute checks. The surveyors reviewed the every-30-minute check log and interviewed the Unit Manager. The every-30-minute checks were initiated at 11:15 AM on 10/30/2022. Every resident who was identified as at-risk for exit-seeking was placed on 30-minute checks on 11/11/2022 at 5:00 PM and continued. The surveyors reviewed the every-30-minute check sheets for residents identified as being at-risk for exit-seeking and interviewed staff. 5. The Care Plan was updated with new interventions for Resident #5, who was identified as being outside without staff supervision. New interventions included: Psychiatric evaluation and consultation. Face time with family member(s), and every 30-minute checks. The Care Plan was reviewed with the new interventions. The Psychiatric Nurse Practitioner was interviewed to verify the consultation was completed. The Psychiatric Nurse Practitioner progress note dated 11/10/2022 was reviewed by the surveyors. 6. Maintenance staff checked all exit doors and alarms for proper functioning on 10/30/2022. The surveyors reviewed the exit door check sheet and interviewed the Director of Maintenance about the process for checking the exit doors. The surveyors verified doors and alarms were functioning properly for the 700 hall door, the 800 hall door, and the 500 hall door. 7. Elopement drills were conducted on following dates with good response. 10/31/2022 at 3:21 PM for the 3-11 evening shift, 11/9/2022 at 11:20 AM for the 7-3 day shift, and 11/14/2022 at 6:18 AM for the 11-7 night shift. The surveyors observed the elopement drill on 11/9/2022 and reviewed the elopement drill sign sheet. 8. The facility conducted QAPI meetings on 10/31/2022 and 11/10/2022 regarding the 10-30-2022 incident on Resident #5, who was identified as being outside without staff supervision. The surveyors reviewed the QAPI minutes and interviewed the DON and the Administrator. 9. Resident #5, who was identified as being outside without supervision, was discharged from the COVID Unit on 11/9/2022 after completing quarantine time. The surveyors verified by observing Resident # 5 in a room on the 800 hall. 10. A psychiatric evaluation on Resident #5, who was identified as being identified outside without supervision, was completed on 11/10/2022. The surveyors interviewed the Psychiatric Nurse Practitioner related to the 11/10/2022 evaluation. 11. All residents that would like to participate in facetime and phone calls on the COVID Unit will be offered these services. Every resident who was currently in the Covid Unit was offered facetime/phone calls on 11/12/2022. Every resident will be offered facetime/phone calls with family members at least weekly and as needed. The Social Worker/Activities staff will visit the resident with an iPad or cell phone and coordinate calls. The surveyors verified through interview with the Social Services Director and review of the form used to ensure residents were offered facetime/phone calls with family members. 12. The facility will ensure sufficient staff and supervision on the COVID Unit for all residents. Staffing needs will be determined based on the census and acuity in the Covid Unit. The goal will be to have at least one nurse for the Unit and one CNA for every 10 residents. The surveyors verified through interview with the Staffing Coordinator, Interim DON, and the Administrator. The surveyors reviewed the updated Covid Unit staffing policy. 13. The facility immediately started in-services and education on neglect and accidents on 10/31/2022 and is ongoing. All facility employees are required to attend in-services/education regarding neglect and accidents. In-service education started 10/30/2022 and will be continued to attain over 100% compliance by 11/15/2022. Employees who are on vacation, family medical leave or as needed (prn) staff will be required to complete the training prior to return to work. The surveyors reviewed the in-service education literature, reviewed the sign in sheets and interviewed staff on all shifts to verify. 14. The facility will audit all exit-seeking/elopement risk residents every shift by conducting every-30-minute checks. The findings will be reviewed in the daily morning meetings. The Charge Nurse/designee will conduct audits for exit-seeking/elopement risk residents. The surveyors interviewed the Charge Nurse and reviewed the audit tool. The facility's noncompliance of F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, review of the Social Worker job description, medical record review, and interview the facility failed to provide effective social services to maintain the highest practicable physical, mental, and psychosocial well-being for residents coping with Depression, social isolation, suicidal ideations, and exit-seeking and aggressive behaviors for 4 of 6 (Resident #3, #5, #9, and #12) sampled residents reviewed for Social Services. The failure of the facility to ensure Social Services provided or arranged needed mental and psychosocial services resulted in actual Harm to Resident #3. Resident #3 admitted with diagnoses of Depression, Dementia and COVID-19. He was admitted to the COVID Unit and placed in contact isolation. He voiced suicidal ideations 3 days after admission, stating he wanted to die, and that he would starve himself. Resident #3 refused medications and meals resulting in 7.8 percent (%) weight loss in 1 month. The facility was unable to provide documentation of Social Services follow-up related to Depression, suicidal ideations, refusal of medications/meals and weight loss. The findings include: 1. Review of the Social Service Policy dated [DATE], revealed, .will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Definitions: Medically-related social services are services provided by the facility's staff to assist residents in attainment or maintenance of a resident's highest practicable well-being .The social worker, or social service designee, will complete an initial .identifying any need for medically-related social services of the resident. Any need for medically related social services will be documented in the medical record .The social worker, or social service designee, will pursue the provision of any identified need for medically related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include .Providing or arranging for needed mental and psychosocial counseling services .identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident .Meeting the needs of residents who are .coping with stressful events .The facility should provide social services or obtain needed services from outside entities during situations that include .Expressions or indications of distress that affect the resident's mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer's disease and other dementia related diseases, schizophrenia, multiple sclerosis) .Difficulty coping with change or loss .change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one .Need for emotional support .The resident's plan of care will reflect any ongoing medically-related social service needs, and how these needs are being addressed .The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning . 2. Review of the Social Worker Job Description revealed, .the primary purpose of your position is to assist in planning, organizing, implementing, evaluating and directing .to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis .Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident's response to service .review nurses notes to determine if the care plan is being followed . 3. Review of the Social Service Director Job Description revealed, .the primary purpose of your position is to assist in planning, organizing, implementing, evaluating and directing .to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis .make daily rounds to assure that social service personnel are performing required duties and to assure that appropriate social service procedures are being rendered to meet the needs of the facility .Ensure that all social services personnel are aware of the care plan and that care plans are used in providing daily social service to the residents .review nurses' notes to determine if the care plan is being followed .communicate with the medical staff, nursing staff . 4. Review of the medical record revealed Resident # 3 was admitted to the facility on [DATE], with diagnoses of Depression, Dementia, Anxiety, Mood Disturbance, Psychotic Disturbance, Adult Failure to Thrive, Insomnia, Personal History of Covid-19, Disorder of Thyroid, and Hypertension. Review of the Physician's order dated [DATE] showed, .Admit .on COVID Unit d/t [due to] + [positive] COVID test .q[every] 15-minute checks (suicidal ideations) . The facility was unable to provide documentation of the every-15-minutes checks ordered on [DATE] due to suicidal ideations. Review of the admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognition impairment. The MDS revealed Resident #3 had symptoms present of feeling depressed, feeling tired or having little energy, poor appetite or overeating, stated that life wasn't worth living, wished for death or attempted to harm himself several days. The MDS revealed Resident #3 required assistance with bed mobility, dressing, toilet use, and personal hygiene, weighed 167 pounds, received oxygen therapy, and was in isolation or quarantine for active infectious disease. Review of the Care Plan dated [DATE], documented, .exhibits sad moods .saying negative statements of wanting to die .Observe any changes .psych [psychiatric services] as needed .check throughout the day .is making suicidal statements about killing himself with interventions .encourage family to visit often .encourage resident to attend activities .Refer to Psychiatric for evaluation as needed . Review of the Physician's order dated [DATE] showed, .psych eval [evaluation] .refusing to eat . Review of the [NAMED] PHYSICIANS ORDER FOR [Named psychiatric consult group] SERVICES dated [DATE] documented, .thoughts of dying .ordering referral for psychiatry services . Review of the Social Services note dated [DATE], showed, .resident began expressing suicidal ideations stating he wanted to die and not live anymore. The resident was refusing to eat, refusing meds [medications] removing his oxygen and telling his family and staff that he wanted to die. The SW [Social Worker] told the family she would ask for a Psychiatric (Psych) referral for the resident .Window visits with daughter. The facility was unable to provide documentation for Social Services follow-up interventions for Resident #3, who had a diagnosis of Depression, refusal of mediations/meals, and expressed suicidal ideations, from [DATE] until the resident expired on [DATE]. Review of the Care Plan dated [DATE], documented, .at risk for loneliness, anxiety and sadness related to isolation precautions .COVID 19 .Interventions .observe resident for S/S [Signs and Symptoms] of social isolation or .depression .Resident to talk or facetime family/friends as per resident/family request and as needed . Review of the Initial Psychiatric Evaluation dated [DATE] documented, .chief complaint/reason for referral .psychiatric evaluation and medication management .Upon approach patient guarded and became hostile during assessment .Remeron [an antidepressant medication also used to increase appetite] was initiated .clinical impression .patient with dementia and various medical ailments .will continue to monitor closely and support .Medication Orders/Recommendations Depakote Sprinkles [a medication used as a mood stabilizer] .follow up ,d+[DATE] weeks . Review of the Dietician note dated [DATE], documented, .Resident noted with weight loss of 4.5% x [times] 1 week to weight of 156.4# [pounds] .BMI [Body Mass index] of 20.0 [Normal adult BMI is 18.5 - 24.9] .receives a NAS [No added sodium] diet with poor po [oral] intake .resident has been refusing meals, meds and supplement .Ensure most days, but will refuse at times .Resident remains at increased risk for further weight loss due to refusal of meals, supplements . Review of the Psychiatric Follow Up Note dated [DATE] documented, .Patient resting upon approach, did not engage .Nurse reports patient with noncompliance refusing meds and continued poor appetite .continues agitations and combative behavior .symptoms not contained due to noncompliance .Follow up schedule ,d+[DATE] weeks .Medication orders/ Recommendation .Olanzapine [an antipsychotic medication] . There was no documentation of any psychiatric follow-up or visits after [DATE]. Review of the Dietician note dated [DATE], documented, .Resident has refused to be weighed for the weeks of [DATE] and [DATE] . Review of the Dietician note dated [DATE], documented, .weight loss of 7.3% x 1 month to weight of 140# .Resident often refuses to be weighed .BMI of 17.9, underweight .Resident receives a NAS diet with poor po intake noted .often refuses meals and meds . Review of the Physician's order dated [DATE], showed, .Admit to COVID Unit .roommate tested positive . Review of the significant change MDS dated [DATE], showed a BIMS score of 6, indicating severe cognition impairment, required assistance for bed mobility, dressing, toilet use, personal hygiene, and eating, weighed 140 pounds with a loss of 5% or more in the last month, had 2 stage 2 pressure ulcers, and received antidepressant medication. Review of the Physician's order dated [DATE], showed, .Palliative Care . Review of the Dietician note dated [DATE], documented, .Resident admitted to Palliative Care [DATE] .Weights have been DC'd [discontinued] .Resident continues with decreased po intake . Interview on [DATE] at 10:51 AM, the Psychiatric Nurse Practitioner (PNP) stated, .I got a referral about him [Resident #3] not eating .when I came to see, he was very hostile, so I ordered some medications to go along with what he was on .he was not suicidal during my initial visit .exhibiting aggressive and combative behavior .the problem I'm having is no documentation of behaviors, not getting referrals from the Social Worker. I have not attended any behavior meetings .don't know if they have them .the referrals are not getting sent into the office timely .the facility will want to send residents out [to Psychiatric Unit], but there is nothing charted in the notes, or either psych as not seen them .the Medical Doctor is being called for orders for behaviors instead of them calling me or letting me know .there is a problem with the documentation of behaviors by the nurses or whoever .They [facility] want to send them out .there is nothing documented to send them out . During an interview on [DATE] at 12:25 PM, the Social Services Director (SSD) confirmed there was no follow-up documentation regarding suicidal ideations, meal/medication refusals, and Depression for Resident #3. The SSD stated, .there should be documentation to show we followed up . The SSD confirmed there was a delay in referrals to psychiatric services. The Social Services Director stated, .the process is broken, we [Social Services] are not included in the clinical meeting, and some residents are not seen timely . During an interview on [DATE] at 5:00 PM, the SSD was asked if Resident #3 was seen [DATE] when the referral was made [DATE], and why he was seen. The SSD stated, The Psych NP seen [saw] him because he was not eating .There is a problem with the documentation, and what the NP is informed .There should have been follow-up documentation from Social Services regarding the suicidal ideations, at least daily checks . The SSD was asked if there was any documentation from Social Services to show follow-up, or where Social Services provided interventions to address the Depression and refusal of medications/meals. The SSD stated, .No there is not any .but definitely should have been . The SSD confirmed no one made rounds with the PNP, and if there had been follow-up documentation about Resident #3's suicidal ideations, then the PNP would have known to address this. The failure of the facility to ensure Social Services provided or arranged needed mental and psychosocial services resulted in actual Harm to Resident #3 when he suffered from a diagnosis of Depression, expressed suicidal ideations, refused to eat, and had a significant weight loss of 7.3% in 1 month. 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, and Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of the Care Plan dated [DATE], revealed Resident #5 was at risk for elopement related to poor safety awareness, was at risk for falls, had impaired cognitive function, and was at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID-19. Review of an elopement risk assessment dated [DATE] revealed Resident #5 was assessed at risk for elopement. Review of the admission MDS dated [DATE], revealed Resident #5 was severely cognitively impaired for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a physician's order dated [DATE] revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive Covid diagnosis. Review of a Progress Note dated [DATE] at 11:33 AM, revealed, .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a physician's order dated [DATE] revealed Resident #5 had an order for psychiatric services. Review of a Progress Note dated [DATE] at 8:03 PM, revealed, .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . Review of a physician's order dated [DATE] revealed Resident #5 had an order for psychiatric services to evaluate and treat for behavior. Review of a Social Services note dated [DATE] revealed, .visited with [Resident #5] to let him talk to his brother .he was glad to hear his voice . During an interview on [DATE] at 12:58 PM, CNA #1 stated, .yes, I was assigned to care for [Resident #5] on [DATE] .he had got out of the unit [Covid Unit] a couple of times that day .I helped the nurse get him back in the COVID unit .about 20 minutes after that I got a phone call from the [Activities Director] telling me he was outside . During an interview on [DATE] at 10:54 AM, the Administrator confirmed Resident #5 had exited the Covid Unit several times on [DATE]. During an interview on [DATE] at 10:51 AM, the PNP stated, I did not see, nor was I aware of the elopement [by Resident #5] on the 30th [[DATE]], until I was called and asked if I could make a note about him to get him sent out [to psychiatric unit] .I was in the building on the 10th [[DATE]], and no one said anything .I face timed him on the 11th [[DATE]] .I didn't know he had gotten out of the building, or that he had previously attempted to exit the facility .Residents can be sent out if they have COVID. There was no documentation of [Resident #5's exit-seeking] behaviors. That's the reason they [behavioral health facility] didn't accept him, not because he had COVID .you have to have documentation of behaviors when you want them sent out .The problem I'm having is no documentation of behaviors, not getting the referrals from the Social Worker .I've not attended any behavior meetings or been asked to .The system is broken . During an interview on [DATE] at 5:00 PM, the SSD confirmed Resident #5 was not seen by the PNP until [DATE], stating, We were not aware the resident hadn't been seen by Psych until we were asked for the notes .I don't know why he [Resident #5] was not seen by the Psych NP when she made rounds [[DATE]] .He should have been seen before the 10th [[DATE]] .We should have been following up . The facility failed to provide timely psychiatric services, Social Services monitoring regarding elopement or wandering behaviors and follow-up documentation for Resident #5 when he exited the facility unsupervised. Resident #5 was not seen by the PNP until [DATE], 12 days after the elopement incident occurred. 6. Medical record review revealed Resident #9 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Anemia, History of Falling, Metabolic Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the MDS dated [DATE], revealed Resident #9 was assessed by staff as having severe cognitive impairment for decision making, trouble concentrating, exhibited behaviors including rejection of care and wandering, and required one-person limited assistance with activities of daily living. Review of a physician's order dated [DATE], revealed a referral for psychiatric services for the diagnosis of Dementia. Review of the baseline Care Plan dated [DATE], revealed Resident #9 was at risk for loneliness, anxiety and sadness related to isolation precautions implemented due to COVID 19, with a goal of adherence to the Centers for Disease Control (CDC) COVID guidelines and to be free from signs and symptoms of social isolation. Interventions included Activities staff to visit as needed, observe Resident #9 for signs and symptoms of social isolation or of depression, and Resident #9 was to talk/facetime with family/friends as per resident/family request and as needed. Review of a physician's order dated [DATE], revealed, .Olanzapine [an antipsychotic medication] 5mg [milligrams] IM [intramuscular] q [every] 12hr [hours] prn [as needed] behavioral and psychological symptoms of dementia XXX[DATE] Risperdal [an antipsychotic medication] .25mg po [orally] bid [twice a day] XXX[DATE] .Risperdal .5mg po at bedtime . Review of a physician's order dated [DATE] revealed, .Megace [an appetite stimulating medication] for unspecified dementia . Review of a Social Services note dated [DATE] revealed, .Phone call made to [Resident Representative] in regards [Resident #9] .unable to reach anyone, no voicemail was set up. Will continue to assist as needed . During an interview on [DATE] at 5:00 PM, the Social Services Director (SSD) was asked for Resident #9's psychiatric referral. The SSD stated, It should be in the book, but it is not. There is no referral sheet . The SSD was asked how the PNP knew to see the residents without a referral sheet. The SSD stated, Probably not, because it has to be faxed over to her office to get on the list .she will see them if they are on her list .We do not know who is on her list when she comes or who is being seen .usually we get her notes within a week . The SSD was asked if she confirmed that Resident #9's orders were faxed. The SSD stated, .no, if the sheet is not in the book. I can't find a sheet for her .the sheet is the order. The SSD was asked if Social Services should follow up on referrals, psychiatric medications and behaviors. The SSD stated, Yes, we should have a system to know who is being seen by the Psych NP, and if there are any behaviors, but there is no communication with the clinical side, and the system is broken. We don't have an effective way of communicating with the Psych NP .we don't know who she has on her list, or who is being seen .most definitely we should be following up and making documentation on the resident .there are no Psych NP notes for [Resident #9] . Resident #9, a vulnerable resident with severe cognition impairment and diagnosed with Dementia, had antipsychotic medications ordered for behaviors and a physician's order for a psychiatric referral on [DATE]. The facility failed to provide an appropriate and timely psychiatric services referral, social services monitoring and follow-up documentation. Resident #9 was not seen by the PNP until [DATE], 19 days after the referral was made. 7. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses of Cancer of Larynx, Supraglottis and Pharynx, Dementia, Anxiety, Aphonia, and a History of COVID 19. Review of the quarerly MDS dated [DATE] revealed a BIMs score of 10, indicating moderate cognition impairment, required limited assistance with bed mobility, dressing and toilet use. The MDS revealed Resident #12 had unclear speech, was sometimes understood, made needs known by pointing and use of electrolarynx, had moderately impaired vision, and was being monitored every 30 minutes for behaviors. Review of the Care Plan dated [DATE], revealed, .has a potential to demonstrate physical aggressive behavior .resident to resident altercation .with interventions .Psych consult . During an interview on [DATE] at 10:51 AM, the PNP stated, .I did not get the referral for that resident [Resident #12]. I was in the building, and I saw the other resident the next day. I heard them [staff] talking at the desk, so I went to see him [the other resident involved in the altercation], but did not see [Resident #12] .he was not on my list to be seen .I don't have anything to say I need to see him . During an interview on [DATE] at 5:00 PM, the SSD confirmed the Psychiatric referral sheet could not be located. The SSD further confirmed she was unaware Resident #12 had not been seen by the PNP until the surveyor asked for the psychiatric note, and that follow-up notes should have been documented. The SSD was asked if 2 residents were in an altercation, should Social Services evaluate and document. The SSD stated, .yes, they should . During an interview on [DATE] at 3:00 PM, the Interim Director of Nursing (DON) confirmed the PNP should have evaluated Resident #12 after the resident-to-resident altercation incident on [DATE]. The Interim DON confirmed there was a systems problem regarding the process of getting psychiatric referrals and getting the residents seen timely by the PNP. The Interim DON further confirmed that residents receiving medications for behaviors and exhibiting behaviors should be discussed with the clinical staff and Social Services staff and relayed to psychiatric services. The Interim DON stated, I don't know where the break-down is, but this is definitely a problem. Resident #12 was involved in a resident-to-resident altercation and hit another resident on [DATE]. The facility failed to provide Social Services monitoring and was unable to provide psychiatric services referral documentation.

Based on policy review, elopement risk evaluation review, medical record review, observation, and interview, the facility failed to ensure licensed nurses had the competencies and skill sets necessary to perform assessments and complete elopement risk evaluations for residents with impaired safety awareness to assure safety and provide individualized care for 6 of 6 sampled residents (Resident #1, #2, #3, #4, #5, and #6) reviewed for elopement/wandering behaviors, which resulted in Immediate Jeopardy for Resident #1. Resident #1 eloped on a hot July day through an unlocked exit door on the 300 Hall, walked outside the facility, down the sidewalk and into the back parking lot, traveling approximately 63 feet from the facility. Resident #1 was unsupervised for approximately 35 minutes. The facility's failure to ensure licensed nurses had the competencies and skill sets necessary to perform assessments and complete elopement risk evaluations for residents with impaired safety awareness to assure safety and provide individualized care resulted in Immediate Jeopardy for Resident #2, #3, #4, #5, and #6. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on 8/27/2021 at 6:38 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy was effective 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on 8/28/2021, and was validated onsite by the surveyors on 8/29/2021 and 8/30/2021 through policy review, review of education records, medical record review, observation, and staff interviews. The findings include: The facility's undated policy titled, CLINICAL SERVICES Subject: Wander Guard [a bracelet device that will trigger the door to alarm when the resident gets too close to the door]/Secure Care Alarm, revealed .Residents that have been identified as an elopement risk will have a wander guard/secure care device applied to ensure their safety. Procedure: 1. A wander guard will be placed on resident. 2. The device will be checked for placement every shift by the licensed nurse and documented on the TAR [Treatment Administration Record] 3. Resident will be care planned for wandering . Review of the Elopement Risk Evaluation assessment, revealed .Please review all triggers. Residents that exhibit behaviors listed on assessment, have the physical ability to leave unassisted, have attempted elopement in the past, and/or have history of Substance Abuse or [CONDITION(S)] should be considered at risk for elopement . Review of the Assessment Scoring Categories for the Elopement Risk Evaluation assessments revealed a score of 0 indicated a low risk for elopement and a score of 4 indicated high risk for elopement. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Elopement Risk Evaluation assessment dated [DATE], revealed Resident #1 scored 0 on the risk evaluation. Documentation on the risk evaluation completed by the nurse did not include the resident ambulated independently, was unaware of safety needs, and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition for decision making and required staff supervision when walking in her room or in the corridor. Review of a Progress Note dated 6/27/2021 at 1:38 PM, revealed, .Wandering resident redirected to the 200 hall where her room was located twice before she wandered out of the exit at the end of the 300 hall . Resident #1 was brought back inside before she made it outside the door. Review of a Progress Note dated 6/27/2021 at 3:13 PM, revealed, .Resident walking away from 200 hall continued to redirect her back to 200 hall Resident stated, ' .going home' . There was no Elopement Risk Evaluation assessment completed after Resident #1 exhibited exit seeking behavior on 6/27/2021. Review of an Incident Audit Report dated 7/2/2021, revealed, Resident #1 exited the facility and was located in the parking lot by a therapy assistant. Review of a Progress Note dated 7/2/2021 revealed, a Certified Nursing Assistant (CNA) and Nurse escorted the back into the facility. Review of the vital signs history report revealed the only vital sign documented after the elopement incident on 7/2/2021 at 4:30 PM was a temperature of 97.3 at 7:22 PM, approximately 3 hours after Resident #1 was returned to the facility from the parking lot. During an interview on 8/23/2021 at 2:31 PM, the DON was asked if she observed any staff monitoring the 300 Hall exit door after Resident #1 exited through the door. She stated, No .I didn't see anybody. I saw staff up the hall picking up meal trays . Observation in the resident's room on 8/24/2021 at 12:15 PM, 8/25/2021 at 2:45 PM, and 8/26/2021 at 10:30 AM, revealed Resident #1 had a wander guard receiver tied on her right ankle with an elastic string from a face mask. During an interview on 8/26/2021 at 1:06 PM, the Unit Manager was asked when elopement risk assessments were completed for all the residents after Resident #1's elopement. She confirmed the facility had not performed elopement risk assessments for the other residents until 8/23/2021. When the Unit Manager was asked about Resident #1's wander guard receiver attached to the resident's ankle with an elastic string, the Unit Manager confirmed she could not find a wander guard strap and used an elastic string from a face mask to tie the wander guard receiver around Resident #1's ankle. The Unit Manager was asked if other exit doors were checked after the elopement to be certain the residents were safe. The Unit Manager stated, .I didn't tell anyone to go check the doors . During an interview on 8/29/2021 at 11:35 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #1's wander guard receiver was not attached correctly. She stated, .I don't know why it has that string, it's supposed to have a wander guard strap . During an interview on 8/30/2021 at 12:15 PM, the Unit Manager confirmed the only vital sign checked after Resident #1 eloped was a temperature, and that was done at 7:22 PM. She confirmed a complete set of vital signs and a complete head-to-toe assessment, which would include all vital signs, was not documented after Resident #1 eloped. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 had severely impaired cognition for decision making and ambulated independently. During the MDS assessment period, Resident #2 had wandering behaviors 4 to 6 days. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wander-guard to right ankle, every shift to prevent elopement. check placement q [every] shift . Review of the Treatment Administration Record (TAR) dated 8/1/2021-8/31/2021, revealed the wander guard placement was not checked on the night shift on 8/14/2021 and the evening shift on 8/16/2021. Review of the Elopement Risk Evaluations dated 6/12/2021 and 8/23/2021, revealed Resident #2 scored 2 on the risk evaluations. Documentation on the risk evaluations completed by the nurse did not include the resident ambulated independently, was unaware of safety needs, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised on 6/16/2021, revealed the resident had episodes of cutting off the wander-guard with a butter knife from the kitchen with interventions to check the wander guard every shift and as needed for placement and proper functioning. Observation in the resident's room on 8/24/2021 at 11:53 AM, revealed Resident #2 seated on the side of the bed eating lunch, alert with confusion, and had a wander guard bracelet right ankle. Resident #2 was asked if she had a bracelet on her ankle. The resident held up both arms, looked at her wrists and stated, Nope. Observation in the 500 Hall on 8/26/2021 at 12:40 PM, revealed Resident #2 standing in the doorway to her room. She ambulated independently to the end of the hallway and returned to her room after being redirected by CNA #1. Observation in the 500 Hall on 8/28/2021 at 12:45 PM, revealed Resident #2 ambulating in the hallway outside her room and walked independently to the end of the hallway near the exit door. The door alarm did not sound. She was redirected back to her room by LPN #3. Review of the medical record revealed, Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 was assessed to have a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment for decision making tasks. He required extensive assistance with transfers and ambulation but was able to propel himself independently in a wheelchair. Review of the Elopement Risk Evaluations dated 7/8/2021 and 8/23/2021, revealed Resident #3 scored 0 on the risk evaluation. Documentation on the risk evaluation completed by the nurse did not include the resident was independent with mobility in a wheelchair, was unaware of safety needs, or had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/24/2021 at 1:15 PM, LPN #4 was asked if Resident #3 could independently use a wheelchair for mobility. LPN #4 stated, He is confused. He comes out sometimes and walks the halls. We have to direct him back. He can't find his way back. He is not coherent .He uses his wheelchair by himself in his room, but he does come out and walk the halls at times . Observation on 8/24/2021 at 1:25 PM, revealed Resident #3 seated in a wheelchair at the doorway to his room. He was alert and confused. During an interview on 8/24/2021 at 5:15 PM, CNA #4 was asked if Resident #3 was alert and oriented. CNA #4 stated, He just knows he wants to walk. He walks in the halls. He is oriented to self only. No awareness of safety at all. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Care Plan dated 8/13/2021, revealed Resident #4 had a self-care deficit and was at risk for falls. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 had severely impaired cognition for decision making, required extensive assistance with transfers and ambulation, was able to propel the wheelchair independently. Review of the Elopement Risk Evaluation dated 8/13/2021 and 8/23/2021, revealed Resident #4 scored 0 on the risk evaluations. Documentation on the risk evaluations completed by the nurse did not include the resident had exit seeking behavior, wandered without purpose, was independent with mobility in a wheelchair, was unaware of safety needs, and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation near the 300 Hall Exit Door on 8/23/2021, revealed Resident #4 was pleasantly confused and propelled himself in his wheelchair. He spoke to Maintenance Assistant #2 and stated, .get that door fixed, cuz [because] I'm getting ready to leave . Observation in the resident's room on 8/24/2021 at 4:02 PM, revealed Resident #4 seated in a wheelchair. He pointed to a bare wall and stated, .use that phone .get my wife on the phone and she can come pick me up and drop me off . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #5 had severe cognitive impairment for decision making and required supervision when using a wheelchair. Review of the Elopement Risk Evaluation dated 6/20/2021, revealed Resident #5 scored 0 and on 8/23/2021 scored 1 on the risk evaluation. Documentation on the risk evaluation completed by the nurse did not include the resident was unaware of safety needs or had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/27/2021 at 3:07 PM, LPN #4 was asked if the 6/20/2021 and 8/23/2021 Elopement Risk Evaluations were accurate. LPN #4 confirmed the assessments were inaccurate and confirmed Resident #5 did not have good safety awareness and the resident had dementia. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #6 had moderate cognitive impairment for decision making and was independent in all activities of daily living. Review of the Elopement Risk Evaluation dated 6/2/2021, revealed Resident #6 scored 1 and on 8/23/2021 scored 0 on the risk evaluation. Documentation on the risk evaluation completed by the nurse did not include the resident was unaware of safety needs, independent in ambulation, or had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the doorway to the resident's room on 8/27/2021 at 4:10 PM, revealed Resident #6 standing. Resident #6 was repeatedly saying, money, my money . Resident #6 followed the surveyor from his room on the 400 Hall to the front of the building. A staff member told him he could not go into the lobby area to the business office. At that time CNA #3 stated, He wants some of his money. He tries to go through the door all the time to get to the business office that he calls the bank. During an interview on 8/25/2021 at 3:20 PM, LPN #1 was asked when elopement/wandering risk assessments were to be completed. LPN #3 stated, On admission or if they eloped or had verbalizations of leaving . LPN #3 was asked when a wander guard would be placed on a resident. LPN #3 stated, If the resident is going to the door and trying to open the door to leave .I have a wander guard on the cart. I would need to get a band. Not sure where the bands are kept. Maybe someone has one on another cart . During an interview on 8/25/2021 at 3:36 PM, the DON was asked when elopement/wandering risk assessments should be completed. The DON stated, On admission, if we identify someone trying to exit, and quarterly .Didn't see a need to do an assessment on all the residents . During an interview on 8/26/2021 at 1:10 PM, the DON was asked what the score on the Elopement Risk Evaluation indicated. The DON stated, We don't use a score. The computer generates and tells us if the resident is an exit seeking risk. It automatically tells us at the bottom. The DON was asked what the score for a wandering resident with a high risk of elopement would be. The DON stated, We don't use a score .If a resident is going to a door and trying to open the door to get out that would be a high risk. I didn't know there was a score . During an interview on 8/28/2021 at 1:55 PM, LPN #3 was asked if the wander guard bracelet device would trigger the exit doors to alarm. LPN #3 stated, .I've wondered about this alarm they use on the bracelets here. They don't cause the door to alarm and they don't cause the door to lock. They don't do anything. I've not been told exactly what the wander bracelet is for except if exit-seeking the resident is to have one on. We are to check to make sure it is on and working each shift . The surveyors verified the Removal Plan by: 1.The Administrator and DON will implement an audit form for any resident found to be exit seeking or wandering. The form will be on all Nurses' Stations where the resident resides. This was confirmed by review of the audit form and interview with the Administrator, DON, and Unit Manager. 2. An elopement book will be kept at each Nurses' Station with the resident name, picture, and room number. This was verified through interview with the staff at each Nurses' Station and observation of each elopement book. 3. The Administrator will review the elopement books for accuracy weekly. This was confirmed by interview with the Administrator. 4. A neon colored bracelet will be applied to the body of each exit seeking resident by 9/7/2021. Extra bracelets will be kept on each medication cart with a wander guard device. This was confirmed by interview with the DON, the Unit Manager, staff on all 3 shifts, and review of the invoice order for the neon colored bracelets. 5. Maintenance will be responsible for checking the outside grounds Monday-Friday and report any hazards to Administrator. This was confirmed by review of an audit form and interview with the Maintenance Director. 6. Starting 8/27/2021, all exit doors will be checked every 30 minutes for the next two weeks, and then will return to daily checks to ensure they are functioning properly. If doors are found not to be functioning properly, the Administrator and/or the DON will be notified, and someone will be assigned to monitor the doors until they are functioning properly. The surveyors reviewed the Door Check sheets to confirm the 30-minute checks were done. 7. On 8/29/2021 through 8/30/2021, staff were in-serviced on abuse, neglect, wandering residents, residents with exit seeking behaviors, those identified for elopement, to know whom and when to report abuse, and how to start an investigation. The surveyors reviewed the in-services and interviewed staff on all shifts. 8. On 8/26/2021, the Elopement Assessment Tool has been reviewed by the DON and the use of the tool will be in-serviced to all licensed nurses by 9/7/2021. The surveyors reviewed the Elopement Assessment Tool and interviewed nurses on all shifts. 9. On 8/29/2021 through 8/30/2021, staff received education on how to accurately complete the Elopement Risk Assessment. The surveyors reviewed the in-services and interviewed staff on all shifts. 10. On 8/29/2021 through 8/30/2021, the staff were in-serviced on door alarm sounds, and if the exit door alarm was activated, they are to go outside, search the grounds and staff inside the building will ensure all residents are in the facility. The surveyors reviewed the in-services and interviewed staff on all shifts. 11. The DON will review all new admissions and readmissions the next working day for elopement assessments to ensure timeliness and accuracy. If a resident is determined to be at elopement risk, the Care Plan will be implemented, and a wander guard will be placed on the resident. The surveyors reviewed the DON audits and interviewed the DON. 12. Any employee who is out on leave will be in-serviced prior to starting work. 13. The DON will monitor staff education by holding monthly mandatory in-services with staff identifying any concerns and review the policies. This was confirmed by interview with the DON. The next in-service was scheduled for 9/23/2021. The facility's noncompliance at F-726 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Quality Assurance Performance Improvement (QAPI) Committee meeting review, job description review, and interview, the QAPI committee failed to ensure systems and processes were in place and consistently followed by staff to address safe individualized resident care when the committee failed to ensure an effective QAPI program was implemented, failed to ensure the completion of a thorough investigation and reporting of an incident of elopement, and failed to use it's resources effectively in order to provide supervision and a safe environment for residents. The failure of the QAPI committee to ensure systems and processes were in place and systems were consistently followed by staff and administration placed Resident #1, a vulnerable resident with exit seeking behavior, in Immediate Jeopardy when Resident #1 eloped on a hot July day through an unlocked exit door on the 300 Hall, walked outside the facility, down the sidewalk and into the back parking lot, traveling approximately 63 feet from the facility. The facility staff were unaware the resident was missing from the facility for approximately 35 minutes. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/27/2021 at 6:38 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy was effective 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2021, and was validated onsite by the surveyors 8/29/2021 and 8/30/2021 through policy review, medical record review, observation, review of education records, and staff interviews. The findings include: Review of the facility policy titled QA [Quality Assurance] Committee-Role of the Quality Assessment and Assurance Coordinator, revised 11/2010, revealed .Duties and responsibilities of the Quality Assessment and Assurance Program include, but are not limited to: .Meeting with the Quality Assessment and Assurance Committee monthly to review all assessment tools designed, all data collection reports, and all activities regarding quality assessment and assurance as carried out by departments, services, or committees which have a direct impact on resident care and safety .planning developing, organizing, implementing, coordinating, and directing the Quality Assessment and Assurance program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Evaluating programs and effecting changes as necessary to improve programs and assuring compliance with regulatory requirements .Assisting department directors in developing and implementing appropriate plans of action to correct identified deficiencies .Scheduling committee meetings and notifying members of such meetings .Assisting in developing follow-up procedures for monitoring identified problem areas . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Complete and file an incident report; and Document relevant information in the resident's medical record . Review of the Administrator Job Description, signed by the Administrator on 7/6/2020, revealed .The primary purpose of your position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Committee Functions Serve on various committees of the Facility (i.e. Infection Control, Quality Assurance and Assessment, etc. and provide written and oral reports of such committee meetings to the VP [Vice President] of Operations .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the Facility's committee as necessary . Review of the Director of Nursing Services Job Description, signed by the Director of Nursing on 3/16/2020, revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Duties and responsibilities .Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified deficiencies . An ad hoc (when needed) QAPI meeting was not conducted immediately following the elopement of Resident #1. Review of the QAPI meeting minutes provided by the Administrator, revealed QAPI Committee meetings were held on 7/28/2021 and 8/23/2021. There was no immediate action taken by the QAPI Committee to keep all residents with wandering behaviors safe after the elopement of Resident #1 on 7/2/2021. During an interview on 8/23/2021 at 12:30 PM, the DON confirmed the elopement incident had not been reported to the State Agency. The DON stated, .I didn't know we had to [report]. She [Resident #1] didn't get off the property . During an interview on 8/23/2021 at 2:31 PM, the DON confirmed she had viewed the video camera footage after the elopement incident. The DON stated, .[Named Resident #1] exited from the therapy exit door on the video. If they [residents] don't get off the premises, it's not an elopement .I didn't keep the video because I didn't think I had to report it . During an interview on 8/25/2021 at 11:24 AM, the Administrator was asked if she reviewed the camera footage. The Administrator stated, I did not look at the camera footage. The cameras automatically erase after 5 days. When asked if the DON documented times of the elopement incident from the video footage, the Administrator stated, Not that I know of. I can ask her . The Administrator was asked what had been implemented after the incident occurred to provide a safe environment for residents that may wander and/or are exit seeking. The Administrator stated, .We QA'd [Quality Assurance] the doors. The doors malfunction at times by making a beeping noise. [Named Hall] [300 Hall], the therapy door, does that. This week we identified the service door was a problem. At times the doors may not latch. When asked which doors she was referring to, the Administrator stated, I'm not sure .We are replacing all the doors. One has been replaced . When asked which door had been replaced, the Administrator stated, I don't know .The nurse is making sure she is checking on all the residents more often. I don't know how often. [Named DON] has something in place for that .I do feel like we did what we could do. We put the wander guard on, and the notifications were made. We could have investigated more. We didn't consider it an elopement .I didn't know the regs [regulations] said potential. I thought the verbiage said likely. I didn't read the regs. I read it after [Named Surveyor] told us about it. During a telephone interview with the Medical Director on 8/27/2021 at 2:11 PM, the Medical Director was asked if a QAPI ad hoc meeting was held to discuss the elopement incident. She stated, .Probably called me that Tuesday [7/6/2021]. They said she [Resident #1] had gotten into the parking lot and they had gotten her and brought her back inside. When asked when she attended an ad hoc meeting, the Medical Director stated, Some days to a week, maybe 2 weeks. I had to do it by phone if I'm not mistaken. Discussed being able to watch that patient [Resident #1]. Wasn't told of anything else in place . When asked if there was any discussion about the function of the doors in the ad hoc meeting that was held 2 weeks later, the Medical Director stated, No. During an interview with the Administrator on 8/27/2021 at 3:42 PM, the Administrator was asked if a QAPI ad hoc meeting was held after the elopement incident on 7/2/2021. The Administrator stated, I don't know what date. When asked if other residents were assessed to determine risk of elopement after the incident occurred, the Administrator stated, I don't know .did frequent monitoring of [Named Resident #1] for July. When asked to define frequent, the Administrator stated, Not sure what [Named DON] put in place. I didn't question her . During an interview on 8/27/2021 at 5:35 PM, the Staff Development Coordinator confirmed the facility did not provide staff education about elopement and wandering residents after the elopement incident. The facility's QAPI Committee failed to identify the immediate need for an ad hoc meeting to discuss the resident elopement, failed to investigate the elopement thoroughly, failed to analyze the situation, and evaluate possible regulatory concerns related to Resident #1's elopement from the facility to ensure the safety of all residents with wandering and/or exit seeking behaviors. Refer to F-600, F-609, F-610, F-689, F-726, and F-835. The surveyors verified the Removal Plan by: 1. QAPI committee members will be in-serviced on how to properly identify residents with wandering/exit seeking behaviors and review the policy. QA committee members will be instructed on how to start an investigation. This was confirmed by interview with the Administrator and DON and review of the meeting sign-in sheet of committee members. 2. In the event of elopement, or any form of abuse, the Administrator and DON will discuss all components of the investigation to find ways to ensure the incident does not reoccur with other residents. This was confirmed by interview with the Administrator and DON. 3. Staff will be educated on how to use RATS (an acronym for Redirect, Ask questions, Tell Someone, write Statement). This was confirmed by interview with staff from all 3 shifts and review of the in-service sheet with employee signatures. 4. Maintenance will use REQQR (a web-based maintenance management tool) to track repairs and report. This was confirmed by interview with the Chief Operations Officer (COO), the Administrator and 3 Maintenance staff. 5. The COO will perform a QAPI in-service monthly and will be monitored by an outside consultant in the Corporate Compliance Company. This was confirmed by interview with the COO, the Corporate Compliance Consultant, and the Administrator. 6. Monthly audits will be conducted by the Corporate Compliance Company on incidents and accidents as oversight. This was confirmed by interview with the Corporate Compliance Consultant. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, medical record review, observation, and interview, the facility Administration failed to provide supervision and oversight to prevent the potential for serious injury and harm when Resident #1 eloped on a hot July day through an unlocked exit door on the 300 Hall, walked outside the facility, down the sidewalk, and into the back parking lot which was approximately 63 feet from the facility. Resident #1, a vulnerable and confused resident, was unsupervised for approximately 35 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/27/2021 at 6:38 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy was effective from 7/2/2021 through 8/30/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2021 at 5:38 PM, and was validated onsite by the surveyors on 8/29/2021 and 8/30/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the BENHA revealed the Administrator had an employment date of 7/6/2020. Review of the Administrator job description, signed by the Administrator on 7/6/2020, revealed .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions .Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the VP [Vice President] of Operations .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility .realize the importance of teamwork .Review the Facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations .Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures .Represent the Facility in dealings with outside agencies, including governmental agencies .Participate in state/federal surveys of the facility .Assist in providing survey team members with additional information during the survey .Review deficiencies noted during the exit conference .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their departments to assist in eliminating and correcting problem areas .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments or corrections .Inform the Medical Director of all suspected or known incidents of resident abuse .Ensure the building and grounds are maintained in good repair .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program .Specific Requirements .Must have a thorough knowledge of OBRA [Omnibus Budget Reconciliation Act] regulations, the survey process, survey tag numbers, and quality measures .Must be able to communicate policies, procedures, regulations, reports .to government agencies and personnel . Review of the Director of Nursing Services job description, signed by the DON on 3/16/2020, revealed .The primary purpose of your position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by the Facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & [and] Assurance Committee (QAPI) in developing and implementing appropriate plans of action to correct identified deficiencies .Make daily rounds of your unit/shift to ensure that assigned CNAs [Certified Nursing Assistants] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Make changes to assignments based upon resident needs .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents .Assign a sufficient number of LPNs [Licensed Practical Nurses] and RNs [Registered Nurses] for each tour of duty to ensure that quality care is maintained .Assign a sufficient number of CNAs for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care .Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department .Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies .Review and revise care plans and assessments as necessary .Report all allegations of resident abuse .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . The facility's partial investigation provided to the surveyors on 8/23/2021 at 12:05 PM included an Incident Audit Report dated 7/2/2021 that documented 4 accounts of the events of that day: a. The resident was observed in the parking lot unattended; an undated handwritten statement that the employee was leaving the facility, saw the resident in the parking lot, contacted the supervisor, and the secretary on the 300 Hall came to assist; b. An Elopement assessment dated [DATE], documented the resident was assessed, the Doctor of Nursing Practice, Psychologist and Responsible Party were notified, an Elopement/Wandering monitoring report was implemented, and an Elopement Risk assessment was completed; c. A Situation Background, Assessment Recommendation (SBAR - a short, organized and predictable flow of information between professionals) was completed. The Care Plan was updated, and the Incident was placed on the 24-hour report. d. An SBAR with documentation of Vital Signs. The facility's investigation did not include interviews/statements from other staff working on the day of the elopement, did not include interviews/statements from staff working on previous shifts, did not include elopement assessments of other residents, did not include monitoring all doors, and did not include interviews with the maintenance department staff regarding the doors. Resident #1 exited the facility into the facility parking lot unattended on 7/2/2021 and was unsupervised for approximately 35 minutes. Facility Administration failed to report the incident to the State Agency or Adult Protective Services and failed to conduct a thorough investigation after Resident #1 eloped from the facility. During an interview on 8/23/2021 at 12:30 PM, the Director of Nursing (DON) confirmed the facility had not reported the elopement and stated, .I didn't know we had to . During an interview on 8/23/2021 at 2:31 PM, the Director of Nursing (DON) confirmed she had reviewed video footage of Resident #1's elopement but had not saved the video recording of the elopement and confirmed she did not do a timeline of the incident based on the time stamps on the video. Observation on 8/23/2021 at 3:05 PM, at the Service Hall Exit Doors, with the Maintenance Director, revealed the exit doors would not lock and could be opened easily. He confirmed residents could pass through the double swinging doors and into the Service Hall. During an interview on 8/23/2021 at 3:35 PM, the DON, Unit Manager, and Administrator were asked what the facility implemented when they identified a malfunctioning exit door. The DON stated, .Until it gets fixed .observations of the hallways and the door . During an interview on 8/24/2021 at 5:30 PM regarding the regulations on neglect and elopement, the Administrator stated, .I didn't know the regulation changed. I hadn't read the regulations . During an interview on 8/24/2021 at 5:35 PM, the DON stated, .I didn't know the change in the regs [regulations] where .elopement is moving from a safe place to an unsafe place .I went by 2016 regs . During an interview on 8/25/2021 at 11:24 AM, the Administrator was asked if she had reviewed the video camera footage. She stated, I did not. I did not think about saving it . The Administrator was asked if the DON had written a timeline based on the time stamps on the video camera footage of the elopement. She stated, No . The Administrator stated, .from time to time one of those doors would malfunction. She was asked which doors malfunctioned. She stated, .it could be random, we've had to work on the [Named Hall] [300 Hall] door .with ya'll here, we identified the Service Hall Door .If the lock don't secure all the way it might make the door not close .At times the door may not latch . The Administrator was asked which doors do not latch. She stated, .I'm not sure .None of them are alarming at the [Nursing] station . The Administrator stated, We could have investigated more. We didn't consider it an elopement . During an interview on 8/25/2021 at 11:40 AM, the DON stated, .I don't read the regs .I'm being honest with you . During an interview on 8/25/2021 at 11:45 AM, the Administrator stated, .I didn't know the regs said potential. I thought the verbiage said likely. I didn't read the regs .I read it after the [Named Surveyor] told us about it . During an interview on 8/26/2021 at 2:20 PM, the Administrator was presented the IJ template for F-689. She looked at it and stated loudly, .We did everything .we are not going to take this IJ!!! She referred to the approximate amount of time the resident was missing and stated loudly, .approximate means exactly! The surveyor attempted to explain the definition of approximate, and the Administrator interrupted and shouted, .it means exactly! The Administrator placed both her arms on the conference table and leaned toward the surveyor and shouted, .we are in compliance! You are out of compliance! I am calling CMS [Center for Medicare Services] and your supervisors! She stormed out of the room, leaving the surveyors seated in the Conference Room with the 4 IJ templates for F-689, F-609, F-610, and F-867. During a telephone interview on 8/27/2021 at 2:11 PM, the Medical Director was asked when she was notified about Resident #1's elopement. She stated, .it was probably like that Tuesday [July 6, 2021]. She was asked what was reported to her. She stated, .They said the resident known to go up and down the hallway had gone out in the parking lot . The Medical Director was asked what the normal protocol was after a resident eloped. She stated, If something happens [Named DON] gives me a call .within the next day . During an interview with the Administrator on 8/27/2021 at 3:42 PM, the Administrator was asked if a Quality Assurance Performance Improvement (QAPI) ad hoc (when needed) meeting was held after the elopement incident on 7/2/2021. The Administrator stated, I don't know what date. When asked if other residents were assessed to determine the risk of elopement after the incident occurred, the Administrator stated, I don't know .did frequent monitoring of [Named Resident #1] for July. When asked to define frequent, the Administrator stated, Not sure what [Named DON] put in place. I didn't question her . During an interview on 8/27/2021 at 5:35 PM, the Staff Development Coordinator confirmed the facility did not provide staff education about elopement and wandering residents after the elopement incident. Administration failed to timely assess a resident with wandering and exit seeking behaviors, failed to ensure a safe environment for a wandering and exit seeking resident, failed to thoroughly investigate an incident of elopement, and failed to report the resident's elopement to the State Agency. Refer to F-600, F-609, F-610, F-689, F-726, and F-867. The surveyors verified the Removal Plan by: 1. On 8/27/2021, the Administrator will in-service the DON on when to report any form of abuse and how to complete a thorough investigation. The surveyors reviewed the education and interviewed the DON and Administrator. 2. The facility will utilize a Corporate Compliance Company to review incidents and accidents monthly as oversight. The Surveyors interviewed the Corporate Compliance Officer. 3. On 8/30/2021, Administration presented a plan for daily staff meetings to identify any risk of elopement/neglect/abuse. The surveyors reviewed the daily staff meeting minutes. 4. The Chief Operating Officer (COO) will educate and monitor the DON and Administrator weekly. The surveyors interviewed the COO. 5. All investigations will be addressed in monthly Quality Assurance Performance Improvement (QAPI) meetings and Ad Hoc will be done within 2 hours of the incident. The surveyors interviewed QAPI members. 6. The Administrator will round with Maintenance 3 times a week to ensure all exit doors are functioning properly. The surveyors interviewed the Administrator. 7. Meetings will be held Monday through Friday to identify any new possible elopement risk residents. The surveyors interviewed the Administrator. 8. On the weekends, the RN Supervisor will round to identify any possible wanderers and exit seeking residents. The surveyors interviewed the RN Supervisors. 9. Elopement/Exit Seeking/Wanderer audit form has been implemented to ensure compliance is met and maintained in order to ensure the policy and procedures are being adhered to. The surveyors reviewed the audit form. 10. The facility has established a system for all staff if a resident is found trying to exit the facility. The system is RATS (R-redirect the resident to a safe area, A-ask the residents questions concerning why they are trying to leave, T-tell your supervisor what you saw and write a statement, S-Supervisor/designee to start an investigation). The surveyors interviewed staff on all shifts. The facility's noncompliance at F-835 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on internet weather site, alarm system company letter, policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide supervision to prevent an incident of elopement, failed to ensure elopement risk assessments were accurate, and failed to ensure exit doors were secure for 1 of 6 sampled residents (Resident #1) reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy for Resident #1. On a hot July day Resident #1 eloped through an unlocked exit door on the 300 Hall, walked outside the facility, down the sidewalk and into the back parking lot, traveling approximately 63 feet from the facility. Resident #1, a vulnerable and confused resident, was unsupervised and without staff awareness Resident #1 was outside the facility for approximately 35 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 8/26/2021 at 3:16 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy for F-689 was effective 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy for F-689, was received on 8/28/2021 at 5:38 PM, and was validated onsite by the surveyors 8/29/2021 and 8/30/2021 through policy review, medical record review, observation, education records review, and staff interviews. The findings include: Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, Revised 8/2014, revealed .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident . Review of the facility's undated policy titled, CLINICAL SERVICES Subject: Wander Guard [a bracelet device that will trigger the door to alarm when the resident gets too close to the door]/Secure Care Alarm, revealed .Residents that have been identified as an elopement risk will have a wander guard/secure care device applied to ensure their safety . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia, Cerebral Infarction, [CONDITION(S)], and [CONDITION(S)]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition for decision making and required staff supervision when walking in her room or in the corridor. Review of a Progress Note dated 6/27/2021 at 1:38 PM, revealed .Wandering resident redirected to the 200 hall where her room was located twice before she wandered out of the exit at the end of the 300 hall. She was returned to the inside of the building before the exit door closed behind her . Review of a Progress Note dated 6/27/2021 at 3:13 PM, revealed .Resident [Resident #1] walking away from 200 hall continued to redirect her back to 200 hall Resident stated, ' .going home' . Review of the Elopement Risk Evaluation assessments revealed there was no Elopement Risk Evaluation completed after Resident #1's exit seeking behaviors on 6/27/2021. Review of an Incident Audit Report dated 7/2/2021, revealed .Resident seen outside by therapy assistance [assistant]. Per therapist .As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway .I immediately parked my vehicle and called my direct supervisor to inform her of what was taking place .Resident Description .I am trying to go over [to] my daughter [daughter's] house .I don't want to be here . Review of an undated Speech Language Pathologist Witness Statement, revealed .On Friday, July 2nd, at approximately 4:25p [4:25 PM], I was leaving the building for the day. As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway. I did not witness the resident exiting the building. I immediately parked my vehicle .called my direct supervisor to inform her of what was taking place. I made contact with the resident .asked if she was okay. Resident replied, 'I am looking for my truck' My direct supervisor .and the secretary on [Named Hall] [300 Hall] immediately came out to assist . Review of a Physician Communication Tool dated 7/2/2021, revealed the vital signs were recorded with the date they were obtained and were documented as: Date 3/16/2021 at 11:07 PM Oxygen Saturation 98%, Date 5/27/2021 at 4:15 PM Respiration 18 Date 7/1/2021 at 12:58 PM Pulse 87 Date 7/2/2021 at 9:47 AM Temperature 98.3 Date 7/2/2021 at 9:51 AM Blood Pressure 129/78 Review of the vital signs report revealed the only other vital sign documented for Resident #1 on 7/2/2021 was a temperature of 97.3 degrees Fahrenheit at 7:22 PM, approximately 3 hours after Resident #1 was returned to the facility from the parking lot. Review of a Progress Note dated 7/4/2021, revealed .Noted CNA [Certified Nursing Assistant] and Nurse escorting resident from behind the double doors of the service entrance. Noted the entrance door was open and staff was coming in with the trash bin from the kitchen . Review of the 300 Hall Secretary's Witness Statement dated 8/23/2021, revealed On July 2, 2021 around 4:30pm [4:30 PM] I [the secretary's name] heard the alarm going off .by the therapy room. I then went to the door. When I open [opened] the door, I seen [Named Resident #1] standing in the parking lot with [Named Speech Language Pathologist] . Review of the (Named Alarm System Company) letter to the facility dated 8/23/2021, revealed .Regarding: Wander Guard Door Station Repair .Please be advised that on July 29th, 2021, we received, and sent off for repair 2 Wander Guard Door Stations .The 3rd door [300 Hall] station we received was severely damaged, with what appeared to be, a coating of paint on 2/3 of the circuit board .The remaining units were sent in for repair on 7/29/2021 with an estimated turn around of 5-7 weeks .called .to request an updated date on when we might receive the repaired units back. As of this moment, 8/23/2021, we have not been notified of when we can expect them . Review of the recorded temperature data from the Memphis International Airport documented the temperature reached 85 degrees on July 2, 2021. During an interview on 8/23/2021 at 2:15 PM, the Rehabilitation Director stated, I was in my office and [Named Speech Language Pathologist] called me on my cell phone and notified me to make me aware [Named Resident #1] was in the parking lot .informed the secretary on [Named Hall] [300 Hall] why I was going out the door and she came out too. We saw [Named Resident #1] with [Named Speech Language Pathologist] . She said she told Resident #1 she needed to go back inside where it was safe because ' .It's a little warm out here' .I walked her to her room. She was tired, that distance from her room to outside was enough to get her fatigued .[Named CNA #2] watched her, then I went and told [Named Unit Manager] .She didn't know that she was out of the building . During an interview on 8/23/2021 at 2:31 PM, the DON confirmed she had reviewed video footage of Resident #1's elopement. She confirmed Resident #1 exited through the 300 Hall Exit Door next to the therapy department. She stated Resident #1 walked down the sidewalk toward the 300 Hall back door, then she saw the employees bring her inside. The DON was asked if she saw any staff at the 300 Hall Exit Door after Resident #1 exited through the door. She stated, No .I didn't see anybody. I saw staff up the hall picking up meal trays . She was asked if she saw anyone come to the door after Resident #1 exited the building. She stated, No. She confirmed she had not saved the video recording of the elopement and confirmed she did not do a timeline of the incident based on the time stamps on the video. Observation in the Main Dining Room on 8/23/2021 at 2:40 PM, revealed the Maintenance Director checking the Dining Room Exit Door. When he pushed the handle, the door alarmed. Dietary Aide #1 was seated at the kitchen door and did not respond to the alarm. She was asked if she heard the alarm. She stated, No. Observation on 8/23/2021 at 3:05 PM, with the Maintenance Director at the Service Hall Exit Doors, revealed the exit doors would not lock and could be opened easily. He confirmed maintenance staff were working on the doors. He confirmed residents could pass through the double swinging doors and into the Service Hall. Observation on 8/23/2021 at 3:35 PM with the Maintenance Director, at the 800 Hall Dining Room Door, revealed an unlocked padlock on the door. The Maintenance Director stated, .that is supposed to be locked at all times . He confirmed the 800 Hall Dining Room was under construction, there were construction materials in the Dining Room, and residents should not go into the 800 Hall Dining Room. During an interview on 8/23/2021 at 3:35 PM, with the DON, the Unit Manager, and the Administrator, they were asked what the facility implemented when they identified a malfunctioning exit door. The DON stated, .Until it gets fixed .observations of the hallways and the door . During an interview on 8/23/2021 at 4:30 PM, the 300 Hall Secretary stated, .I kept hearing the door alarm, I kept hearing the noise. I started walking that way, and I said, that's the door; no sooner I got to the door .the young lady from therapy .we seen her at the same time out in the parking lot . She confirmed Resident #1 stepped off the sidewalk and walked out into the middle of the parking lot. She stated, .she had got out 2 times .she got out again within the same hour. She got out the door and one of the nurses got her that time .just opened the door, that's when we realized that the door wasn't shutting properly. I really don't know, something with the handle on the door . Observation in the parking lot of the facility on 8/23/2021 at 4:45 PM, revealed the Speech Language Pathologist identified the area where Resident #1 was located after her elopement. The Rehabilitation Director placed red duct tape on the pavement in the middle of the parking lot to mark where Resident #1 was found. Observation in the parking lot of the facility on 8/24/2021 at 8:30 AM, the Physical Therapy Assistant measured the distance from the 300 Hall Exit Door to the marked area where Resident #1 was found after she eloped. The distance measured was approximately 63 feet. During an interview on 8/24/2021 at 10:47 AM, Maintenance Assistant #1 stated, .they called me and said a lady got out and we came up here and found that the door [300 Hall Exit Door] wasn't locking .When we got here, we went straight to the [300 Hall Exit Door] and it opened right up when we pushed it .Something was wrong with the keypad . Observation in the resident's room on 8/24/2021 at 12:15 PM, 8/25/2021 at 2:45 PM, and 8/26/2021 at 10:30 AM, revealed Resident #1 had a wander guard with an elastic string from a face mask, attached to her right ankle. During a telephone interview on 8/24/2021 at 2:20 PM, Licensed Practical Nurse (LPN) #1 confirmed she was the nurse on duty the evening Resident #1 eloped. She was asked when she last saw Resident #1 before she eloped. She stated, .I get 5 sugars [blood glucose checks] on that hall, she's one of them. I start at 3:30 PM .around 3:45 PM, was in room with her doing her sugar [blood glucose check] .next thing I know, they reported she was found in the parking lot . She confirmed it took approximately 5 minutes to perform a blood glucose check. She stated, .When they brought her back in, I checked her out .just wanted to make sure she was ok, it was hot out . During an interview on 8/25/2021 at 11:24 AM, the Administrator stated, .from time to time one of those doors would malfunction . She was asked which doors malfunctioned. She stated, .it could be random, we've had to work on the [Named Hall] [300 Hall] door .with ya'll here, we identified the Service Hall Door .If the lock don't secure all the way it might make the door not close .At times the door may not latch .It's an ongoing process, we've gotten several quotes .it's very expensive . The Administrator was asked which doors did not latch. She stated, .I'm not sure .None of them are alarming at the [Nursing] station . During an interview on 8/26/2021 at 9:55 AM, the Maintenance Director confirmed the 800 Hall Dining Room Exit Door was broken, but they kept a padlock with a combination on the door from the hallway into the Dining Room, so no one went in there as it was under construction. The Maintenance Director was asked about the 300 Hall Exit Door. He stated, .We had to fix it temporarily. When you came in, we determined it would not release in the 15 seconds, so we called [Named Alarm System Company]. [Named Maintenance Assistant #2] was supposed to fix it. They said they fixed it. We worked on that door when [Named Alarm System Company] came out, and they checked all the doors. You can put a Phillip's head screwdriver and go inside the keypad .we are going to put tamper proof screws on the keypads. They found that one box in the whole building had a tamper proof screw . He further stated, .You cannot leave a door that is not operating right without somebody watching it .If they [a resident] gets out of this building, it's nothing but trouble. The procedure, we got to watch a door if it's not working. I told [Named DON]. I don't know what's up .something's going on with these doors . Observation on 8/26/2021 at 10:15 AM, revealed the Maintenance Director was checking the door alarm. He pushed on the door and the alarm sounded. No one came out of the kitchen to check the door when the alarm sounded. The Maintenance Director went to the kitchen and asked the staff why they didn't check the alarm. They confirmed they could not hear it. During an interview on 8/26/2021 at 1:06 PM, the Unit Manager was asked when the facility completed elopement risk assessments for all the residents after Resident #1's elopement. She confirmed the facility had not done elopement risk assessments for other residents until 8/23/2021 (51 days after Resident #1 eloped from the facility). She was asked about Resident #1's wander guard receiver. She stated she could not find a wander guard strap and used an elastic string from a face mask to tie the wander guard receiver around Resident #1's ankle. She was asked if staff were to check the other doors after the elopement and stated, .I didn't tell anyone to go check the doors . During an interview on 8/26/2021 at 3:45 PM, the Chief Operating Officer referred to the documented temperature on the day Resident #1 eloped and stated, .84 degrees is not hot .old people like it hot . Observation at the 800 Hall Dining Room door on 8/26/2021 at 4:25 PM, revealed the padlock on the door was not locked and the door had been unsecured by staff. During a telephone interview on 8/27/2021 at 12:05 PM, CNA #1 confirmed she worked the evening Resident #1 eloped. She was asked when she last saw Resident #1 before she eloped. She stated, .I don't remember .she was always walking around in the halls . During a telephone interview on 8/27/2021 at 2:11 PM, the Medical Director was asked when she was notified of Resident #1's elopement. She stated, .it was probably like that Tuesday [7/6/2021]. She was asked what was reported to her. She stated, .They said the resident known to go up and down the hallway had gone out in the parking lot . The Medical Director was asked what the normal protocol was when a resident eloped, for example did they call her or document it in a book. She stated, If something happens [Named DON] gives me a call .within the next day . During an interview on 8/27/2021 at 2:18 PM, at the Service Hall Exit Door, Maintenance Assistant #2 stated it had not been manned when the vendors came, and they were buzzed in. He stated .when it's broken there's not always somebody standing at the doors in between the time it is reported and the time they work on it and get it fixed . During a telephone interview on 8/28/2021 at 10:29 AM, CNA #2 confirmed she was preparing to pass ice when she saw Resident #1 standing in the hall, leaning against the wall near her room, and the charge nurse was pushing the medication cart down the hall toward Resident #1's room. She stated, .She [Charge Nurse] was going to do the accuchecks [blood glucose checks]. It was about 3:30 [PM]. That's the last time I saw her [Resident #1] before they brought her back. She confirmed the next thing she remembered was about 4:20 PM when she and the therapist returned Resident #1 to her room. She took her to her room, had to change the resident's dress and brief because she was wet. She could not remember what kind of shoes she had on. She bathed her and prepared her for supper. Observation at the Dining Room Door on the 800 Hall on 8/28/2021 at 12:05 PM, revealed Maintenance Assistant #1 looked on the back of the padlock where the combination was written, used that combination to unlock the padlock and opened the dining room door. Inside the dining room was a piece of wood with nails sticking out, a large tube of caulk, containers of latex paint, a piece of wood with screws sticking out, and a container of antibacterial wipes. During an interview on 8/29/2021 at 11:35 AM, LPN #2 confirmed that Resident #1's wander guard receiver was not attached correctly. She stated, .I don't know why it has that string, it's supposed to have a wander guard strap . Observation in the resident's room on 8/29/2021 at 11:45 AM, revealed LPN #2 removed the string used to attach the wander guard receiver to Resident #1's right ankle and replaced it with the wander guard strap. Resident #1 was cooperative and smiled throughout the procedure. During an interview on 8/30/2021 at 12:15 PM, the Unit Manager confirmed the only vital sign obtained after Resident #1 eloped was a temperature, and that was obtained at 7:22 PM. She confirmed a complete set of vital signs were not documented as part of the full head-to-toe assessment after Resident #1 eloped and that a complete head-to-toe assessment would include all vital signs. During an interview on 8/30/2021 at 3:52 PM, the Administrator was asked if the combination to the padlock on the 800 Hall Dining Room Door should be written on the back of the lock. She stated, No, it shouldn't . She was asked if the padlock on the 800 Hall Dining Room Door should always be locked. She stated, Yes. Refer to F-600, F-609, F-610, F-725, F-726, F-835 and F-867. The surveyors verified the Removal Plan: 1. On 7/3/2021, Resident #1 was reassessed for elopement risk and was found to be at risk for elopement. Resident #1's Care Plan was updated to reflect elopement and a wander guard was placed on Resident #1 for safety. The surveyors reviewed the Elopement Assessment and Care Plan. 2. On 8/23/2021, all residents were assessed for elopement and no new resident was identified. The surveyors reviewed the Elopement Assessments. 3. On 7/2/2021, the door Resident #1 exited was found not to be latching and the door was immediately repaired. The surveyors checked the doors. 4. Starting 8/27/2021, all exit doors will be checked every 30 minutes for the next two weeks, and then will return to daily checks to ensure they are functioning properly. If doors are found not to be functioning properly, the Administrator and/or the DON will be notified, and someone will be assigned to monitor the doors until they are functioning properly. The surveyors reviewed the Door Check sheets to confirm the 30-minute checks were done. 5. On 8/29/2021 through 8/30/2021, staff were in-serviced on abuse, neglect, wandering residents, residents with exit seeking behaviors, those identified for elopement, to know whom and when to report abuse, and how to start an investigation. The surveyors reviewed the in-services and interviewed staff on all shifts. 6. On 8/26/2021, the Elopement Assessment Tool has been reviewed by the DON and the use of the tool will be in-serviced to all licensed nurses by 9/7/2021. The surveyors reviewed the Elopement Assessment Tool and interviewed nurses on all shifts. 7. On 8/29/2021 through 8/30/2021, staff received education on how to accurately complete the Elopement Risk Assessment. The surveyors reviewed the in-services and interviewed staff on all shifts. 8. On 8/29/2021 through 8/30/2021, the staff were in-serviced on door alarm sounds, and if the exit door alarm was activated, they are to go outside, search the grounds and staff inside the building will ensure all residents are in the facility. The surveyors reviewed the in-services and interviewed staff on all shifts. 9. The DON will review all new admissions and readmissions the next working day for elopement assessments to ensure timeliness and accuracy. If a resident is determined to be at elopement risk, the Care Plan will be implemented, and a wander guard will be placed on the resident. The surveyors reviewed the DON audits and interviewed the DON. 10. The facility will utilize the Corporate Compliance Company to review incidents and accidents monthly as oversite. The surveyors interviewed the Chief Operations Officer. 11. The Administrator and/or the DON and Unit Managers will review all incidents immediately by utilizing the incident/accident log and the log will be brought to the morning meeting. The surveyors reviewed the log and interviewed the DON. 12. Any employee who is out on leave will be in-serviced prior to starting work. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to thoroughly investigate an incident of elopement for 1 of 6 sampled residents (Resident #1) reviewed for elopement and wandering. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy when Resident #1 eloped through an unlocked exit door on the 300 Hall on a hot July day, walked outside the facility unsupervised, walked down the sidewalk, and into the back parking lot. The vulnerable, confused resident ambulated approximately 63 feet from the facility and was unsupervised for approximately 35 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/26/2021 at 3:16 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2021 at 5:38 PM, and was validated onsite by the surveyors 8/29/2021 and 8/30/2021 through policy review, medical record review, observation, education in-service records review, and staff interviews. The findings include: Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting, revised 7/2017, revealed .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator .The Nursing Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of accident or incident .The following data .shall be included .The circumstances surrounding the accident or incident .The name(s) of witnesses and their accounts of the accident or incident .The condition of the injured person, including his/her vital signs .Follow-up information .Other pertinent data .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident . Review of the facility's undated policy titled, .ABUSE PREVENTION, revealed .The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition for decision making and required staff supervision when walking in her room or in the corridor. The facility's investigation provided to the surveyors on 8/23/2021 at 12:05 PM, included: a. An Incident Audit Report dated 7/2/2021, revealed .Resident seen outside by therapy assistance [assistant]. Per therapist .As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway .I immediately parked my vehicle and called my direct supervisor to inform her of what was taking place .Resident Description .I am trying to go over my daughter [daughter's] house .I don't want to be here . b. 1 undated handwritten statement by the Speech Language Pathologist, revealed .On Friday, July 2nd, at approximately 4:25p [4:25 PM], I was leaving the building for the day. As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway. I did not witness the resident exiting the building. I immediately parked my vehicle .called my direct supervisor to inform her of what was taking place. I made contact with the resident .asked if she was okay. Resident replied 'I am looking for my truck' My direct supervisor .and the secretary on [Named Hall] [300 Hall] immediately came out to assist . c. An Elopement assessment dated [DATE], revealed .Immediate Action Taken .Assessed resident thoughts as to what she was trying to do. Notified DNP [Doctor of Nursing Practice], Psych [Psychologist], and RR [Responsible Party]. Elopement/Wandering monitoring report in place, Elopement Risk assessment completed. SBAR [Situation-Background-Assessment-Recommendation-a communication model to facilitate prompt and organized flow of information] completed. Care Plan updated, and Incident place [placed] on 24hr [24 hour] report . d. An SBAR - Physician Communication Tool dated 7/2/2021, revealed .Exited facility through 300 hall exit door .Vitals .Temperature .98.3 Date [obtained] .7/2/2021 at 09:47 AM .Pulse .87 . e. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wanderguard [a bracelet device that will trigger the door to alarm when the resident gets too close to the door] to right ankle . The facility's investigation of the elopement of Resident #1 on 7/2/2021 did not include interviews/statements from other staff working on the day of the elopement, did not include interviews/statements from staff working on previous shifts, did not include a full assessment of the resident after the elopement, did not include elopement or skin assessments of other residents, and did not include checking all the doors to be assured they could not be opened by the residents, and did not include interviews with the maintenance department staff regarding the security of the doors. During an interview on 8/23/2021 at 2:15 PM, the Rehabilitation Director stated the Speech Language Pathologist called her and stated Resident #1 was in the parking lot. The Rehabilitation Director proceeded to the parking lot with the secretary from 300 Hall to bring the resident back into the facility. They assisted the resident back into the facility and to her room. The Unit Manager was unaware the resident was not in the facility until was told by the Rehabilitation Director that the resident was back in her room. The Rehabilitation Director was asked if the facility asked her to write a statement of this event as part of the investigation. She stated, No. During an interview on 8/23/2021 at 2:31 PM, the Director of Nursing (DON) confirmed she watched video camera footage of Resident #1 exiting the building. She was asked if she had a copy of the video footage. She stated, .If they don't get off the premises, it's not an elopement .I didn't keep the video . During an interview on 8/23/2021 at 4:30 PM, the 300 Hall Secretary stated she kept hearing the door alarm and when she arrived at the door that was alarming a staff member from therapy stated Resident #1 was in the parking lot. There was no witness statement by the 300 Hall Secretary in the investigation provided by the facility of Resident #1's elopement on 7/2/2021. During an interview on 8/24/2021 at 10:47 AM, Maintenance Assistant #1 stated, .they called me and said a lady got out and we came up here and found that the door [300 Hall Exit Door] wasn't locking .When we got here, we went straight to the [300 Hall Exit Door] and it opened right up when we pushed it .Something was wrong with the keypad . There was no witness statement by Maintenance Assistant #1 in the investigation provided by the facility of Resident #1's elopement on 7/2/2021. During a telephone interview on 8/24/2021 at 2:20 PM, Licensed Practical Nurse (LPN) #1 confirmed she was the nurse on duty the evening Resident #1 eloped. She obtained a blood glucose test on Resident #1 around 3:45 PM and the resident was in her room at that time. She later became aware that Resident #1 was in the parking lot. She stated, .When they brought her back in, I checked her out .just wanted to make sure she was ok, it was hot out . There was no documentation of a witness statement by LPN #1 regarding the elopement of Resident #1 in the investigation provided by the facility of the resident's elopement on 7/2/2021. Observation in the facility parking lot on 8/23/2021 at 4:45 PM, revealed the Speech Language Pathologist identified the location in the center of the parking lot where Resident #1 was found. On 8/24/2021 at 8:30 AM, the Physical Therapy Assistant measured the distance from the 300 Hall Exit Door to the marked area where Resident #1 was found after she eloped. The distance measured was approximately 63 feet. During an interview on 8/25/2021 at 11:24 AM, the Administrator stated, .[Named DON] reviewed the camera and it showed where she went out . She was asked if she had reviewed the video camera footage. She stated, I did not. I did not think about saving it . The Administrator was asked if the DON had written a timeline based on the time stamps on the video camera footage of the elopement. She stated, No . The Administrator stated, .from time to time one of those doors would malfunction . She was asked which doors malfunctioned. She stated, .it could be random, we've had to work on the [Named Hall] [300 Hall] door .with ya'll here, we identified the Service Hall Door .If the lock don't secure all the way, it might make the door not close .At times the door may not latch . The Administrator was asked which doors do not latch. She stated, .I'm not sure .None of them are alarming at the [Nursing] station . The Administrator was asked if the facility had done a thorough investigation of the elopement. She stated, We could have investigated more. We didn't consider it an elopement . During an interview on 8/26/2021 at 9:55 AM, the Maintenance Director was asked about the 300 Hall Exit Door. He stated, .We had to fix it temporarily. When you came in, we determined it would not release in the 15 seconds, so we called [Named Alarm System Company]. [Named Maintenance Assistant #2] was supposed to fix it. They said they fixed it. We worked on that door when [Named Alarm System Company] came out, and they checked all the doors. You can put a Phillip's head screwdriver and go inside the keypad .we are going to put tamper proof screws on the keypads. They found that one box in the whole building had a tamper proof screw. He stated, .You cannot leave a door that is not operating right without somebody watching it . If they [a resident] gets out of this building, it's nothing but trouble. The procedure, we got to watch a door if it's not working. I told [Named DON]. I don't know what's up .something's going on with these doors . There was no documentation of a witness statement by the Maintenance Director regarding the elopement of Resident #1 in the investigation provided by the facility of the resident's elopement on 7/2/2021. During an interview on 8/26/2021 at 1:06 PM, the Unit Manager confirmed Elopement Risk Assessments had not been done on other residents as part of the elopement investigation. She confirmed they had been done on 8/23/2021, after the surveyor entered the facility. She was asked if her investigation included a timeline. She stated, I didn't do a timeline . She was asked if she had staff do a re-enactment of the elopement or checked the distance the resident traveled in the parking lot and she stated, .No, I didn't really know who all was involved . She was asked if she had obtained witness statements regarding when Resident #1 was last seen by staff. The Unit Manager stated, At that time I didn't. She was asked if she knew the 300 Hall Exit Door was malfunctioning. She stated, I don't recall checking the door myself. She was asked if she interviewed or obtained statements from the maintenance staff. She stated, I did not. She was asked if she obtained a statement from Resident #1's Charge Nurse on 7/2/2021. She stated, I did not. She was asked if she got statements from the Certified Nursing Assistants (CNAs) who worked that evening and she stated, I did not . She was asked if she had staff check the other doors after the resident eloped from the facility. She stated, I didn't tell anyone to go check the doors. She was asked what the facility had implemented to keep the residents safe, and she stated, .Walk these halls, listen, make sure they are in their rooms . There was no documentation of a witness statement by the Unit Manager regarding the elopement of Resident #1 in the investigation provided by the facility of the resident's elopement on 7/2/2021. During an interview on 8/27/2021 at 2:18 PM, at the Service Hall Exit Door, Maintenance Assistant #2 stated the exit door had .not been manned when the vendors came, and they were buzzed in . He stated that when the lock on the doors was broken there was not always somebody standing at the doors between the time it is reported and the time, they are able to repair it. During an interview on 8/27/2021 at 5:35 PM, the Staff Development Coordinator confirmed the facility did not provide staff education about elopement and wandering residents after the elopement. During a telephone interview on 8/28/2021 at 10:29 AM, CNA #2 confirmed she was preparing to pass ice to the residents when she saw Resident #1 standing in the hall leaning against the wall near her room, and the charge nurse preparing to do blood glucose checks on the residents. She stated it was about 3:30 PM and that was the last time she saw her before she was brought back into the facility. She was asked if anyone had asked her to write a statement regarding the events of that day. She stated, .they had me write it this past Thursday [8/26/2021] before I left, [Named DON] had me write it . During an interview on 8/30/2021 at 12:15 PM, the Unit Manager confirmed the only vital sign that was checked after Resident #1 eloped was a temperature, and that was done at 7:22 PM. She confirmed a complete set of vital signs were not documented as part of the full head-to-toe assessment after Resident #1 eloped. She confirmed that a complete set of vital signs is an important part of the head-to-toe assessment. Refer to F-600, F-609, F-689, F-725, F-726, F-835 and F-867. The facility verified the Removal Plan by: 1. Going forward the facility will complete a thorough investigation which will include getting statements from all staff involved in incidents, do a complete observation of the area, and staff to perform a re-enactment of elopement. The surveyors interviewed the Administrator and the DON. 2. On 8/29/2021 through 8/30/2021, the Chief Operating Officer in-serviced the DON on how to complete a thorough investigation, which includes getting statements from all staff at time of incident, perform a re-enactment, document the response, and the DON and/or the Administrator will review and discuss all the components of the investigation to find ways to ensure the incident does not reoccur with other residents. The surveyors interviewed the DON about conducting an investigation. 3. On 8/29/2021 through 8/30/2021, the Administrator and DON reviewed all incidents to determine whether to report the incident, utilizing the incident/accident log. The surveyors reviewed the incident/accident log and interviewed the Administrator and DON. 4. Starting 8/27/2021, all exit doors will be checked every 30 minutes for the next two weeks, and then will return to daily checks to ensure they are functioning properly. If doors are found not to be functioning properly, the Administrator and/or the DON will be notified, and someone will be assigned to monitor the doors until they are functioning properly. The surveyors reviewed the Door Check sheets to confirm the 30-minute checks were done. 5. The DON will review all new admissions and readmissions the next working day for elopement assessments to ensure timeliness and accuracy. If a resident is determined to be at elopement risk, the Care Plan will be implemented, and a wander guard will be placed on the resident. The surveyors reviewed the DON audits and interviewed the DON. 6. On 8/29/2021 through 8/30/2021, staff were in-serviced on abuse, neglect, wandering residents, residents with exit seeking behaviors, and those identified for elopement. The surveyors reviewed the in-services and interviewed staff on all shifts. 7. The facility will utilize the Corporate Compliance Company to review incidents and accidents monthly as oversite. The surveyors interviewed the Chief Operations Officer. 8. The Administrator and/or the DON and Unit Managers will review all incidents immediately by utilizing the incident/accident log and the log will be brought to the morning meeting. The surveyors reviewed the log and interviewed the DON. 9. Any employee who is out on leave will be in-serviced prior to starting work. Noncompliance of F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 1 of 6 sampled residents (Resident #1) reviewed for wandering and elopement. The facility's failure to report an incident of elopement and neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #1 eloped through an unlocked exit door on the 300 Hall, walked outside the facility unsupervised, down the sidewalk, and into the back parking lot on a hot July day. The distance the resident traveled was approximately 63 feet from the facility. Resident #1, a confused and vulnerable resident, was unsupervised and without staff awareness for approximately 35 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/26/2021 at 3:16 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2021 at 5:38 PM, and was validated onsite by the surveyors on 8/29/2021 and 8/30/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, .ABUSE PREVENTION, revealed .Alleged violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .to other officials .including State Survey Agency .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition for decision making and required staff supervision when walking in her room or in the corridor. Review of an Incident Audit Report dated 7/2/2021, revealed .Resident seen outside by therapy assistance [assistant]. Per therapist .As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway .I immediately parked my vehicle and called my direct supervisor to inform her of what was taking place .Resident Description .I am trying to go over my daughter [daughter's] house .I don't want to be here . Review of an undated Speech Language Pathologist Witness Statement, revealed the Speech Language Pathologist documented leaving the facility on 7/2/2021 at approximately 4:25 PM and observed a resident ambulating down the walkway into the parking lot. The Speech Language Pathologist notified her supervisor and facility employees came to assist the resident. Observation in the facility parking lot on 8/23/2021 at 4:45 PM, revealed the Speech Language Pathologist identified the location in the center of the parking lot where Resident #1 was found. On 8/24/2021 at 8:30 AM, the Physical Therapy Assistant measured the distance from the 300 Hall Exit Door to the marked area where Resident #1 was found after she eloped. The distance measured was approximately 63 feet. During an interview on 8/23/2021 at 12:30 PM, the Director of Nursing (DON) confirmed the facility had not reported the elopement and stated, .I didn't know we had to . During an interview on 8/24/2021 at 5:30 PM, the Administrator stated, .I didn't know the regulation changed. I hadn't read the regulations . During an interview on 8/24/2021 at 5:35 PM, the DON stated, .I didn't know the change in the regs [regulations] where it .elopement is moving from a safe place to an unsafe place .I went by 2016 regs . During an interview on 8/25/2021 at 11:40 AM, the DON stated, .I don't read the regs .I'm being honest with you . During an interview on 8/25/2021 at 11:45 AM, the Administrator stated, .I didn't know the regs said potential. I thought the verbiage said likely. I didn't read the regs .I read it after the [Named Surveyor] told us about it . Refer to F-600, F-610, and F-689. The surveyors verified the removal plan by: 1.The facility will report going forward any resident noted outside without proper supervision or being unattended. The Director of Nursing and/or the Administrator will report elopement to the state agency to include Adult Protective Services within 24 hours if no injuries occur, or 2 hours if serious injuries occur. The surveyors interviewed the Administrator and the DON. 2. On 8/29/2021 through 8/30/2021, staff were in-serviced on abuse, neglect, reporting requirements, wandering residents, residents exit seeking, and those identified for elopement. The surveyors reviewed the in-services and interviewed staff on all shifts. 3. The DON will review all new admissions and readmissions the next working day for elopement assessments to ensure timeliness and accuracy. If a resident is determined to be at elopement risk, the Care Plan will be implemented, and a wander guard will be placed on the resident. The surveyors reviewed the DON audits and interviewed the DON. 4. Starting 8/27/2021, all exit doors will be checked every 30 minutes for the next two weeks, and then will return to daily checks to ensure they are functioning properly. If doors are found not to be functioning properly, the Administrator and/or the DON will be notified, and someone will be assigned to monitor the doors until they are functioning properly. The surveyors reviewed the Door Check sheets to confirm the 30-minute checks were done. 5. On 8/29/2021 through 8/30/2021, the staff were in-serviced on door alarm sounds, and if the exit door has been activated, they are to go outside and search the grounds and staff inside the building will ensure all residents are accounted for. The surveyors reviewed the in-services and interviewed staff on all shifts. 6. The facility will utilize a Corporate Compliance Company monthly to review incident and accidents as oversight. The surveyors interviewed the Corporate Compliance Officer. 7. Any employee who is out on leave will be in-serviced prior to starting work. The facility's noncompliance at F-609 continues at a scope and severity of D for the monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent neglect of a vulnerable and confused resident for 1 of 6 sampled residents (Resident #1) reviewed for wandering/elopement behaviors, when Resident #1 eloped without staff awareness on a hot July day through an unlocked exit door on the 300 Hall, walked outside the facility, walked down the sidewalk and into the back parking lot, traveling approximately 63 feet from the facility. Resident #1 was unsupervised and without staff awareness for approximately 35 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/26/2021 at 3:16 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/2/2021 through 8/29/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/28/2021 at 5:38 PM, and was validated onsite by the surveyors on 8/29/2021 and 8/30/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, .ABUSE PREVENTION, revealed .Neglect: A failure of the facility, it's employees, or services provided .to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment . Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency . Review of the facility's undated policy titled, CLINICAL SERVICES Subject: Wander Guard [a bracelet device that will trigger the door to alarm when the resident gets too close to the door]/Secure Care Alarm, revealed .Residents that have been identified as an elopement risk will have a wander guard/secure care device applied to ensure their safety . Review of the BENHA form revealed the Administrator had an employment date of 7/6/2020. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired cognition for decision making and required staff supervision when walking in her room or in the corridor. Review of a Progress Note dated 6/27/2021 at 1:38 PM, revealed .Wandering resident redirected to the 200 hall where her room was located twice before she wandered out of the exit at the end of the 300 hall. She was returned to the inside of the building before the exit door closed behind her . Review of a Progress Note dated 6/27/2021 at 3:13 PM, revealed .Resident [Resident #1] walking away from 200 hall continued to redirect her back to 200 hall Resident stated .'going home' . Review of the Care Plan dated 7/2/2021, revealed Resident #1 was at risk for elopement and wandering, had a communication deficit, and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an Incident Audit Report dated 7/2/2021, revealed .Resident seen outside by therapy assistance [assistant]. Per therapist .As I was exiting the parking lot, I notice [noticed] a resident walking down the walkway .I immediately parked my vehicle and called my direct supervisor to inform her of what was taking place .Resident Description .I am trying to go over [to] my daughter [daughter's] house .I don't want to be here . Review of the vital signs report revealed the only vital sign documented on 7/2/2021 was a temperature reading of 97.3 at 7:22 PM, approximately 3 hours after Resident #1 was returned to the facility from the parking lot. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/23/2021 at 2:15 PM, the Rehabilitation Director confirmed she saw Resident #1 in the parking lot with the Speech Language Pathologist. She stated, .I walked her to her room. She was tired, that distance from her room to outside was enough to get her fatigued .I went and told [Named Unit Manager] .she didn't know that she was out of the building . During an interview on 8/23/2021 at 2:31 PM, the DON confirmed she had reviewed video footage of Resident #1's elopement. The DON confirmed she had not saved the recorded video footage of the elopement and confirmed she did not do a timeline of the incident based on the time stamps on the video footage. Observation in the parking lot on 8/23/2021 at 4:45 PM, revealed the Speech Language Pathologist identified the area where Resident #1 was located after her elopement. The Rehabilitation Director placed red duct tape on the pavement in the middle of the parking lot to mark where Resident #1 was found. Observation in the parking lot on 8/24/2021 at 8:30 AM, the Physical Therapy Assistant measured the distance from the 300 Hall Exit Door to the area where Resident #1 was found after she eloped. The distance was approximately 63 feet. Observation in the resident's room on 8/24/2021 at 12:15 PM, 8/25/2021 at 2:45 PM, and 8/26/2021 at 10:30 AM, revealed Resident #1 had a wander guard attached to her right ankle with an elastic string from a face mask. During a telephone interview on 8/24/2021 at 2:20 PM, Licensed Practical Nurse (LPN) #1 was asked when she last saw Resident #1 on the afternoon of 7/2/2021. LPN #1 stated, .around 3:45 PM, was in room with her doing her sugar [blood glucose check] .next thing I know, they reported she was found in the parking lot . She stated, .it was hot out . During an interview on 8/25/2021 at 11:24 AM, the Administrator stated, .we have been working on the doors .from time to time one of those doors would malfunction with ya'll here, we identified the Service Hall Door .If the lock don't secure all the way, it might make the door not close .At times the door may not latch .It's an ongoing process, we've gotten several quotes .it's very expensive . During an interview on 8/26/2021 at 9:55 AM, the Maintenance Director confirmed the 800 Hall Dining Room Exit Door was also broken and a padlock with a combination was kept on the door because it was under construction. The Maintenance Director was asked about the 300 Hall Exit Door. He stated, .We had to fix it temporarily. When you came in, we determined it would not release in the 15 seconds, so we called [Named Alarm System Company] . During an interview on 8/26/2021 at 1:06 PM, the Unit Manager was asked about Resident #1's wander guard, she stated she could not find a wander guard strap and used an elastic string from a face mask to tie the wander guard receiver around Resident #1's ankle. The Unit Manager also stated, .I didn't tell anyone to go check the doors [after the elopement incident] . During a telephone interview on 8/27/2021 at 12:05 PM, Certified Nursing Assistant (CNA) #1 confirmed she worked the evening shift on 7/2/2021 when Resident #1 eloped. She was asked when she last saw Resident #1 before she eloped. She stated, .I don't remember .she was always walking around in the halls . During a telephone interview on 8/28/2021 at 10:29 AM, CNA #2 was asked when she last saw Resident #1 on the afternoon of 7/2/2021, the day she eloped. CNA #2 stated, .It was about 3:30 [PM]. That's the last time I saw her before they brought her back. During an interview on 8/29/2021 at 11:35 AM, LPN #2 confirmed that Resident #1's wander guard receiver was not attached correctly. She stated, .I don't know why it has that string, it's supposed to have a wander guard strap . During an interview on 8/30/2021 at 12:15 PM, the Unit Manager confirmed the only vital sign that was checked after Resident #1 eloped was a temperature, and that was done at 7:22 PM. She confirmed a complete set of vital signs were not documented as part of the full head-to-toe assessment after Resident #1 eloped. The facility neglected to supervise and maintain safety for Resident #1, a cognitively impaired resident with wandering and exit seeking behaviors, which resulted in the resident exiting the facility unsupervised. Refer to F-689, F-609, F-610, F-726, F-725, F-835 and F-867. The surveyors verified the Removal Plan by: 1. On 7/3/2021, Resident #1 was reassessed for elopement risk and was found to be at risk for elopement. Resident #1's Care Plan was updated to reflect elopement and a wander guard was placed on Resident #1 for safety. The surveyors reviewed the Elopement Assessment and Care Plan. 2. On 8/23/2021, all residents were assessed for elopement and no new resident was identified. The surveyors reviewed the Elopement Assessments. 3. On 7/2/2021, the door Resident #1 exited was found not to be latching and the door was immediately repaired. The surveyors checked the doors. 4. Starting 8/27/2021, all exit doors will be checked every 30 minutes for the next two weeks, and then will return to daily checks to ensure they are functioning properly. If doors are found not to be functioning properly, the Administrator and/or the DON will be notified, and someone will be assigned to monitor the doors until they are functioning properly. The surveyors reviewed the Door Check sheets to confirm the 30-minute checks were done. 5. On 8/29/2021 through 8/30/2021 staff were in-serviced on abuse, neglect, wandering residents, residents with exit seeking behaviors, and those identified for elopement. The surveyors reviewed the in-services and interviewed staff on all shifts. 6. On 8/26/2021, the Elopement Assessment Tool has been reviewed by the DON and the use of the tool will be in-serviced to all licensed nurses by 9/7/2021. The surveyors reviewed the Elopement Assessment Tool and interviewed nurses on all shifts. 7. On 8/29/2021 through 8/30/2021, staff received education on how to accurately complete the Elopement Risk Assessment. The surveyors reviewed the in-services and interviewed staff on all shifts. 8. On 8/29/2021 through 8/30/2021, the staff were in-serviced on door alarm sounds, and if the exit door alarm was activated, they are to go outside, search the grounds and staff inside the building will ensure all residents are in the facility. The surveyors reviewed the in-services and interviewed staff on all shifts. 9. The DON will review all new admissions and readmissions the next working day for elopement assessments to ensure timeliness and accuracy. If a resident is determined to be at elopement risk, the Care Plan will be implemented, and a wander guard will be placed on the resident. The surveyors reviewed the DON audits and interviewed the DON. 10. Any employee who is out on leave will be in-serviced prior to starting work. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the Care Plan was revised for 1 of 4 sampled residents (Resident #1) reviewed for wandering, exit-seeking behaviors, and elopement. The facility failed to ensure the Care Plan was revised to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in Immediate Jeopardy for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-657 on 2/5/2020 at 2:45 PM, in the Conference Room. F-657 was cited at a scope and severity of J. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 to 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policy related to active exit-seeking behavior, assessments, inservice training records, and staff interviews. The findings include: Review of the facility's undated policy titled, Care Planning, showed that the facility should develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident needs and is developed for each resident. The comprehensive care plan is designed to identify problem areas, incorporate risk factors associated with identified problems. Areas of concern are triggered during the resident assessment before interventions are added to the care plan, interventions are designed after careful consideration between resident's problem areas and their causes. The care plan is developed within 7 days of completion of the comprehensive assessment. The nurses on the unit are responsible for all episodic care planning. Assessments of residents are ongoing and care plans are revised as information changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plan. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed to be severely impaired cognitively. Review of the Nurses' Notes dated 11/1/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. The Care Plan revised 11/1/2019 showed that Resident #1 was at risk of elopement and interventions of wanderguard placement and encourage participation and interactions that decrease anxiety and exit-seeking. Review of the Nurses' Notes dated 11/14/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. Review of the medical record showed Resident #1 was admitted to a psychiatric hospital from 11/14/2019 to 12/10/2019 related to yelling, screaming, and exit-seeking behavior. Review of the Comprehensive Care Plan revised 11/1/2019, showed that the Care Plan was not revised with new interventions for the exit-seeking behavior that occurred on 11/14/2019. Review of Resident #1's Social Services note dated 1/16/2020 documented, .exit (exited) the building .returned safely .according to officer they received a called (call) resident was picked up . Review of the Comprehensive Care Plan revised 1/23/2020, showed interventions for the elopement included: the fence was replaced, frequent checks of the resident's presence in the facility, and windows to be checked. The Care Plan did not show how often frequent checks should be done. Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview on 2/7/2020 at 2:02 PM, the Director of Nursing (DON) confirmed that Resident #1's Care Plan should have been revised after the elopement attempt on 11/14/2019. The facility failed to ensure the Care Plan was revised to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in IJ for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Refer to F-600, F-610, F-656, and F-689. The surveyors verified the Removal Plan by: 1. Resident #1's Care Plan has been updated with appropriate interventions. The surveyors reviewed Resident #1's Care Plan. 2. All residents will have a Care Plan initiated upon admission and when any episodes of exit-seeking/elopement are noted with appropriate interventions addressing the resident's needs. The surveyors interviewed staff on all shifts related to their responsibilities for care planning. 3. Residents with elopement/exit-seeking risks will be addressed in clinical meeting. Elopement risks will be added to the clinical report sheet. All residents with elopement risks will be audited during clinical meetings for appropriateness of interventions and submitted to the Quality Assurance Performance Committee. Clinical meetings are held Monday-Friday of each week. On 2/7/2020, Unit Managers/Designees have been in serviced on revising the Care Plan of elopement/exit-seeking risk residents with appropriate interventions. The surveyors reviewed the inservice sign in sheets, audit forms, interviewed staff on each shift, and interviewed the Unit Managers. Noncompliance of F-657 continued at a scope and severity D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment for 1 of 4 sampled residents (Resident #1) reviewed with exit-seeking behaviors. Resident #1 was a cognitively impaired, vulnerable resident with a history of wandering/exit seeking behaviors who eloped from the facility, which resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and failed to supervise Resident #1, who was missing for approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer approximately 1.3 miles from the facility. The officer had responded to a 911 call concerning a suspicious female knocking on the doors of houses in the area. Resident #1 crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in an IJ for Resident #1. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policies related to active exit-seeking behavior, assessments, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident, revised 4/30/2019, showed, .strive to prevent unsafe wandering .identify residents who are at risk for harm because of unsafe wandering (including elopement) .staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .a missing resident is considered a facility-wide emergency . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019 showed Resident #1 was at risk for elopement. Review of the Comprehensive Care Plan dated 8/6/2019, showed that the plan of care did not include interventions for Resident #1's assessed elopement risk. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed with [REDACTED]. Resident #1 required supervision and 1 person assistance with all activities of daily living, which included ambulation and locomotion on the unit in a wheelchair. Review of the Nurses' Notes dated 11/1/2019 at 1:30 PM, showed, .Door alarm heard sounding at the end of 700 Hall (Resident #1) pushing the emergency exit door open and exiting the building. Two staff aides noted running behind (Resident #1) . Review the Care Plan dated 8/6/2019 showed the plan of care was not revised for Resident #1's assessed elopement risk until this elopement attempt on 11/1/2019. Review of the Care Plan revised 11/1/2019, showed the resident was .at risk for elopement r/t (related to) poor safety awareness .will remain safely on facility property until safe discharge is possible .Interventions .assess skin under/near wander guard placement for irritation, breakdown and proper fit. Check wander guard placement every shift. Encourage participation and interactions that decreases anxiety and exit seeking . Review of the Nurses' Notes dated 11/14/2019, showed, .screaming and yelling loudly in the hallway .packed all of her belongings stating that she wanted to leave the facility. Resident held the exit door on the 700 hall until it opened and exited door .brought back into the facility by housekeeping aide and CNA (Certified Nursing Assistant) 600 hall .send resident to (Named) psychiatric hospital . Review of the Care Plan revised 11/1/2019, showed there were no new interventions added to the Care Plan after the elopement attempt on 11/14/2019. Review of the Psychiatric Follow Up Note dated 1/3/2020, showed Resident #1 was seen for worsening symptoms of anxiety, restlessness, and hyperactive behaviors. Resident #1 was anxious, delusional, flighty thoughts, and redirection was not effective. Resident #1 was identified to be clinically unstable, high acuity, and severe behavioral problems. Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed, .Resident (Resident #1) exit (exited) the building, upon return she was question (questioned) by social services .she don't (doesn't) recall her were (where) bouts (abouts) when asked did she leave the facility she stated no .when ask (asked) was she with a police officer she said I don't know what you talking about with a puzzle (puzzled) look on her face. Resident returned safely no complain (complaint) of pain or injury .According to the officer they received a called (call) resident was picked up she stated she lives at an address given to cop, resident was taken to address provide (provided) a male guy was there and he informed the officer that she lives in a nursing facility were (where) she returned . Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview conducted on 2/3/2020 at 3:00 PM, CNA #1, who was assigned to care for Resident #1 on 1/16/2020, stated, .I saw her at approximately 1:30 (PM) .did not see her when we changed shifts .I thought she was still in activities . During an interview on 2/3/2020 at 3:12 PM, the police officer stated, .not a police report because there was no crime committed .the 911 call came in at approximately 3:00 PM, the report was of a suspicious person, a female knocking on doors in the (Named Apartment Complex) .when I arrived I asked her (Resident #1) where she lived and she gave me an address on (Named Street) so I took her to the address .the gentleman living there knew her and said she resided at (Named Nursing Home) so I took her back to the nursing home .it was approximately 4:15 PM when I arrived at the facility . During an interview conducted on 2/4/2020 at 9:00 AM, the DON stated, .I didn't know (Resident #1 had eloped) until the officer brought her back . During an interview conducted on 2/4/2020 at 10:50 AM, the Administrator stated, .I didn't know until the police brought her back . The Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine the possible causes of the exit seeking behaviors. She stated she did not think these needed to be investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. During an interview conducted on 2/4/2020 at 2:20 PM, Licensed Practical Nurse (LPN) #1, who was the nurse coming on shift at 3:00 PM on 1/16/2020, stated, .I came on shift .I didn't see her (Resident #1) so I asked day shift nurse where she was, she (day shift nurse) said she (Resident #1) was in activities. I walked by the activity room but didn't see her . LPN #1 was asked when she knew that Resident #1 had eloped from the building. LPN #1 stated, .when I got back to the floor .around 4 (4:00 PM) .she was sitting at the Nurses' Station in wheelchair .since she has come back from (Named Psychiatric Hospital) she's had increased exit seeking behaviors . During an interview conducted on 2/4/2020 at 2:35 PM, Registered Nurse (RN) #1, who was the Unit Manager for the D (800) Hall on 1/16/2020, stated, .I didn't know (Resident #1 had eloped) until the police brought her back . Refer to F-600, F-610, F-656, and F-657. The surveyors verified the Removal Plan by: 1. Resident #1's window was secured with screw in window locks on each side of the window on 1/16/2020. All residents' windows have been checked and secured with screw in window locks. The surveyors viewed the window locks. 2. The opening in the fence has been secured with wood fencing. The surveyors viewed the fence secured with wood fencing. 3. Maintenance Director/Designee will perform weekly audits ongoing to ensure safety and security of windows and fence. Audits will be reported to Quality Assurance Performance Improvement Committee. The surveyors reviewed the audit tools and interviewed the Maintenance Director. 4. If a resident is found attempting to exit-seek/elope, resident will be redirected and interviewed to obtain reasons for exit-seeking/elopement to address residents' needs at that time. Statements from all staff caring for the resident will be obtained for the previous 72 hours. An elopement assessment will be updated and appropriate interventions care planned at that time. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation Inservice/Education has begun on all new implemented procedures and will continue until all current employees have been educated. Employees will not work until they have been in-serviced. Inservice/Education will also be ongoing to include, but not limited to all new employees. The surveyors viewed the new protocols and forms, and interviewed staff on all shifts. 6. The Director of Nursing, Assistant Director of Nursing, or Designee will ensure compliance with daily audits on protocols for exit seeking/eloping residents and report to Quality Performance Improvement Committee. The surveyors reviewed the audit tools and interviewed the DON. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, medical record review, facility investigation review, and interview, the Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and ensure training of staff, ensure staff supervision, ensure a safe environment, complete a thorough investigation of resident elopement, revise the resident's plan of care, and conduct a Quality Assurance and Performance Improvement (QAPI) Committee meeting. Administration's failure to ensure a safe environment placed 1 of 4 sampled residents (Resident #1) in Immediate Jeopardy when the resident, a cognitively impaired resident with known wandering and exit-seeking behaviors, was missing approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer 1.3 miles from the facility. Resident #1 had crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-835 on 2/9/2020 at 11:38 AM, in the Conference Room. The facility was cited F-600, F-610, F-656, F-657, F-689, F 835, and F-867 at a scope and severity of J. F-600, F-610, and F-689 are Substandard Quality of Care. A partial extended survey was conducted 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/10/2020 at 12:30 PM. The Removal Plan was validated onsite by the surveyors on 2/10/2020 through review of assessments and Care Plans, review of updated policies related to residents with active exit-seeking behaviors, newly developed auditing tools, in-service training records, and staff and Administration interviews. The findings include: Review of the facility's undated job description titled, Administrator, showed, .Purpose of Your Job Position .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority .As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Committee Functions .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Ensure that all employees, residents, visitors and the general public follow the Facility's established policies and procedures .Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the Facility .Assist the Quality Assurance and Assessment (currently known as the Quality Assurance and Performance Improvement (QAPI)) Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Review of the facility's undated job description titled, Director of Nursing Services, showed, .Purpose of Your Job Position .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical director to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority .As Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Personnel Functions .Ensure that CNAs (Certified Nursing Assistants)/GNAs (Graduate Nursing Assistants), department personnel, residents, and visitors follow the department's established policies and procedures at all times .Review and revise care plans and assessments as necessary, but at least quarterly . Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. During an interview on 2/7/2020 at 4:00 PM, the Administrator stated that her duties and responsibilities included ensuring the facility staff, residents, and anyone visiting the facility was safe. During an interview on 2/7/2020 at 6:20 PM, the Administrator stated that the facility was waiting until the State Survey Agency completed an investigation of the facility reported allegation of neglect related to Resident #1's elopement before calling an ad hoc meeting (a meeting to obtain information as the need arises). The Administrator also confirmed that the facility's QAPI Committee should have met as soon as possible after the elopement. During a telephone interview with the Medical Director on 2/9/2020 at 8:55 AM, the Medical Director confirmed she had not been informed that Resident #1 had eloped from the facility on 1/16/2020 for 1 or 2 days after the incident. Administration failed to ensure staff did not neglect their duties related to the supervision of a resident with a known history of wandering and exit-seeking behaviors. Refer to F-600 and F-689. Administration failed to ensure a thorough investigation was completed of a resident elopement from the facility. Refer to F-610. Administration failed to ensure the development and revision of Resident #1's Care Plan for elopement risk. Refer to F-656 and F-657. Administration failed to ensure a QAPI Committee meeting was held to identity, investigate, analyze, implement, and evaluate the need for corrective actions or performance improvement activities related to a resident's elopement from the facility. Refer to F-867. The surveyors verified the Removal Plan by: 1. Administration will ensure all incidents of elopement/exit seeking are thoroughly investigated to rule out staff neglect of a resident by including written statements from all parties involved. The surveyors interviewed Administration about thorough investigations related to elopement/exit seeking behaviors. 2. Administration will ensure the safety of all residents by using the newly developed Management Elopement/Exit-Seeking/Wanderers Audit Form. Administrator/Designee will have daily meetings with the DON and Assistant Director of Nursing (ADON) regarding updates on high risk elopement seeking residents. In the event of a weekend occurrence, the Administrator/Designee and DON and/or ADON will be in constant communication with staff. The surveyors reviewed the Audit form and interviewed staff responsible for performing the audits. 3. Administration has currently put measures in place to ensure staff accountability for resident care and safety by implementing an Elopement/Exit-Seeking Procedure and has educated/inserviced all staff. The consistency of procedures will be monitored by Administration weekly times four weeks and monthly ongoing. A new Management Elopement/Exit-Seeking/Wanderers Audit Form has been developed to ensure compliance is met and maintained. The surveyors reviewed inservice records, the audit form, and interviewed Administration and staff on all shifts. 4. Administration measurements will provide a method of monitoring all allegations of abuse and neglect to ensure thoroughness and completeness by having daily staff meetings with management. The staff meetings will address all elopement/exit-seeking behaviors and address preventive measures to redirect resident. Meetings will be held Monday-Friday. The surveyors interviewed the Administrative staff. 5. Management's systemic method of checks and balances now consists of a contracted compliance consulting company that will provide assessment of present operations inclusive of policies and procedures, documentation, communication, quality improvement and performance review, accident and incident investigation, abuse reporting and investigation, compliance and regulatory practices. The surveyors interviewed Administration. 6. Management has hired an additional Registered Nurse with clinical responsibilities of reviewing policy and procedures, review of corrective actions and performance of clinical staff in order to identify, investigate and analyze elopement/exit seeking residents' documentation and provide feedback and necessary resources to address and maintain compliance. All findings are to be reported to the QAPI Committee meeting monthly. The surveyors interviewed Administration. Noncompliance of F-835 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, facility investigation review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program recognized concerns related to potential staff neglect, the completion of a thorough investigation of an incident of elopement, resident assessment and care planning related to exit-seeking/wandering behaviors, and failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently in order to provide a safe environment for residents. Failure of the QAPI Committee to ensure systems and processes were in place, and systems were consistently followed by staff and Administration, and the failure to address quality concerns placed 1 of 4 sampled residents (Resident #1) in Immediate Jeopardy when the resident, a cognitively impaired resident with known wandering and exit-seeking behaviors, was missing approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer 1.3 miles from the facility. The officer had responded to a 911 call concerning a suspicious female knocking on the doors of houses in the area. Resident #1 had crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Administrator and Director of Nursing (DON) were notified of the IJ for F-865 on 2/9/2020 at 11:38 AM, in the Conference Room. The facility was cited F-600, F-610, F-656, F-657, F-689, F-835, and F-867 at a scope and severity of J. F-600, F-610, and F-689 are Substandard Quality of Care. A partial extended survey was conducted 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/10/2020 at 12:30 PM. The Removal Plan was validated onsite by the surveyors on 2/10/2020 through review of newly developed policies, procedures and auditing forms, inservice training records, assessment and Care Plan review, and interviews. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program's Statements and Guiding Principles, dated 11/21/2019, showed, .Addressing Care and Services: The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action .The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice and care transitions. These include, but are not limited to, customer service, care management, patient safety . Review of the facility's undated job description titled Administrator, showed, .Committee Functions .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Review of the facility's undated job description titled, Director of Nursing Services, showed, .Administrative Functions .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. During an interview on 2/7/2020 at 4:00 PM, the Administrator stated that herself, the DON, Medical Director, and all department managers attend the monthly QAPI meetings. An ad hoc (a meeting to obtain information as the need arises) QAPI meeting would be held if necessary. During an interview with the Administrator and the DON on 2/7/2020 at 6:20 PM, the Administrator confirmed an ad hoc QAPI meeting should be called for anything that may cause harm or has caused harm. When asked for clarification, the DON gave the example of elopement. The Administrator then stated that the facility was waiting until the State Survey Agency completed an investigation of the facility reported allegation of neglect related to Resident #1's elopement before calling the ad hoc meeting. The Administrator also confirmed that the facility's QAPI Committee should have met as soon as possible after the elopement. The facility's QAPI Committee failed to identify, investigate, analyze, implement, and evaluate possible regulatory compliance concerns related to Resident #1's elopement from the facility to ensure the safety of residents with wandering and/or exit-seeking behaviors. Refer to F-600, F-610, F-656, F-657, and F-689. The surveyors validated the Removal Plan by: 1. Ad hoc QAPI Committee meetings will be held to identify, investigate, analyze, implement, and evaluate corrective actions or performance improvement activities in addition to the monthly QAPI meetings to assure that all policies, procedures, and directions are followed for each elopement/exit-seeking/active wandering residents, are in compliance, and are maintained. The surveyors interviewed Administration. 2. An ad hoc QAPI meeting was to be conducted to discuss all elopement, exit-seeking/wandering residents on 2/10/2020 to identify potential opportunities for improvement and corrective actions. The surveyors interviewed management staff related to QAPI committee guidelines for meeting. 3. Management of systemic method of checks and balances as follows: a. The Chief Operating Officer (COO) will be immediately made aware of alleged abuses and incidents, and will be updated with all pertinent documentation. b. The DON/Assistant Director of Nursing (ADON) will ensure all steps of the elopement/exit seeking policy and procedures are being adhered to. c. The Administrator/Designee will have meetings with the DON/ADON to measure compliance of the elopement/exit-seeking policy and procedures. Meeting to take place Monday - Friday. In the event of a weekend occurrence, the Administrator/Designee and DON/ADON will be in constant communication. d. The QAPI Committee will meet weekly for 4 weeks and monthly ongoing to oversee that all elopement/exit-seeking measures are executed appropriately and to ensure the continued safety of all residents. e. As an additional method of inservice, education and resource, the facility's contracted corporate compliance company will be consulted monthly, and as needed, to ensure proper elopement/exit-seeking methods are identified, met, and maintained. f. All elopement/exit-seeking residents will be reported to the monthly QAPI Committee. g. If any resident is reported to be exit-seeking or has eloped, the facility will have a QAPI meeting without delay to discuss all policies, procedures, and directions for each resident. The surveyors reviewed audit tools, and interviewed the Administrator, DON, ADON and the COO related to how information will be gathered for QAPI meetings. 4. An Abuse and Compliance Committee was initiated on 2/9/2020 to oversee that all policies, procedures, practices, and investigations are executed effectively. The Abuse and Compliance Committee members will meet weekly for 4 weeks and monthly ongoing and will include but not limited to the following: Administrator, DON/ADON/Designee, COO, Medical Director, facility/Staff Liaison, Minimum Data Set (MDS) Director, and Social Services Director (SSD). The committee will serve as a compliance/oversight team to ensure that all elopement and exit-seeking procedures that were implemented are 100 percent in compliance and maintained. A Resident Occurrence Form was developed for Alleged Abuse and will be utilized to identify, measure, and ensure that all interventions related to previous and current occurrences are aligned with facility's goals related to resident safety. Findings will be reported to the QAPI Committee. The surveyors reviewed the resident occurrence form and interviewed the Administrator, DON, ADON, and COO. 5. Administration will ensure that each resident will have a plan of care and will be updated with individualized interventions to help modify the behavior for exit-seeking, eloping and wandering residents. The Care Plan will be updated with any new occurrences and staff will be informed of the interventions put in place. The surveyors reviewed updated care plans and interviewed staff on all shifts regarding their responsibilities for care plan interventions. 6. Administration will ensure that the SSD or Designee updates and maintains a current listing and binder of all exit-seeking, elopement and wandering residents located throughout the facility. The systemic actions will look comprehensively across all involved systems to prevent future events and promote sustained improvement. The surveyors reviewed current binder for at risk residents and interviewed staff on all shifts related to the elopement, wandering/exit-seeking book. Noncompliance at F-867 continues at a scope and severity of D for the monitoring and effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 4 sampled residents (Resident #1) reviewed with wandering/exit-seeking behaviors, which resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-610 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020 - 2/10/2020 through review of assessments, policies related to exit-seeking behavior, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, showed, .neglect .thoroughly investigated by facility management .witness reports will be obtained in writing . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses' Notes showed that Resident #1 exited the facility through a door on the 700 Hall on 11/1/2019 and 11/14/2019 and was redirected back into the facility by staff. During an interview conducted on 2/4/2020 at 10:50 AM, the Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine possible causes of the exit-seeking behaviors. She stated that she did not think these needed to be investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. Review of the facility's investigation showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed that Resident #1 was returned to the facility by a police officer (after being found 1.3 miles from the facility). Resident #1 had no memory of the incident when she was questioned by Social Services. Review of the facility investigation showed there were no statements written by the staff who were responsible for Resident #1's care on 1/16/2020. During an interview on 2/3/2020 at 1:30 PM, the DON stated, .yes, this is the complete investigation of the elopement .did I need statements from staff for the investigation? . During an interview on 2/7/2020 at 4:00 PM, the Administrator confirmed there were no staff or witness statements and the investigation for the incident on 1/16/2020 was not thorough and complete. The Administrator confirmed that staff should have known Resident #1 was gone. The facility failed to ensure a thorough and complete investigation was conducted when Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors, exited the facility and was found 1.3 miles from the facility. The facility failed to ensure Resident #1's elopement attempts were investigated and failed to ensure witness statements were obtained related to Resident #1's location in the facility and the last time staff had observed the resident in the facility, which resulted in IJ for Resident #1. Refer to F-600, F-656, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Written statements have been requested and obtained from staff regarding incident with Resident #1, including location prior to exiting the facility. The surveyors interviewed the Corporate Operations Officer, Administrator, DON and direct care staff on all shifts. 2. Statements will be obtained from staff dating back 3 days prior to any incident that occurs. The surveyors interviewed the Chief Operations Officer, Administrator, DON and direct care staff on all shifts. 3. The facility developed an Elopement/exit-seeking procedure and initiated inservice/education to all employees as follows: All nursing staff, Certified Nursing Assistants, Social Services, Dietary, Physical Therapy, Business office, Respiratory Therapy, Admissions, Marketing, Activities, Minimum Data Set, Administration, and contracted Housekeeping services. No staff will be able to work until inservice is completed. Inservices will be ongoing to include new hires. The surveyors reviewed inservice records and interviewed staff on all shifts. 4. When any resident opens exit doors, statements will be obtained from all staff involved in redirecting resident from exit doors. If the elopement/exit seeking behaviors continue, the elopement/exit-seeking procedure protocols will be reinstated. The surveyors reviewed procedures and protocols and interviewed staff on all shifts. 5. All residents who are exit-seeking will be interviewed to attempt to determine reasons for exit-seeking behaviors to address the residents' needs at the time. The surveyors interviewed administrative staff and staff on all shifts. 6. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. All staff will be educated on the proper protocol to complete a thorough investigation. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation The surveyors reviewed inservice records and interviewed staff on all shifts. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 4 sampled residents (Resident #1) reviewed with wandering/exit-seeking behaviors, which resulted in Immediate Jeopardy (IJ) for Resident #1. The facility neglected to ensure a safe environment and neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors. Resident #1 had exited the facility on 11/1/2019 and 11/14/2019. Resident #1 exited the facility on 1/16/2020 through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. The facility did not know Resident #1 was missing until a police officer returned the resident to the building 2 hours and 45 minutes after she was last seen by facility staff. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020 - 2/10/2020 through review of assessments, policies related to exit-seeking behavior, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised 3/2018, showed, .Neglect .failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .physician and staff will help identify risk factors for abuse within the facility .issues related to staff knowledge and skill: performance that might affect resident care .identify situations that might constitute or could be construed as neglect . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed with [REDACTED]. Resident #1 required staff supervision and 1 person physical assistance for all activities of daily living (ADLs), including ambulation and locomotion in a wheelchair. Review of the Care Plan revised 11/1/2019, showed Resident #1 was .at risk for elopement r/t (related to) poor safety awareness .will remain safely on facility property until safe discharge is possible .Interventions .assess skin under/near wander guard placement for irritation, breakdown and proper fit. Check wander guard placement every shift. Encourage participation and interactions that decreases anxiety and exit seeking Review of the Nurses' Notes dated 11/1/2019 and 11/14/2019, showed that Resident #1 held the exit door on the 700 Hall until it opened and exited the building. Resident #1 was redirected back into the building each time by staff. Review of the facility's investigation dated 1/16/2020 showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed that Resident #1 was returned to the facility by a police officer responding to a call. Resident #1 had no memory of the incident when she was questioned by Social Services. Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During a telephone interview on 2/3/2020 at 3:12 PM, the police officer stated, .not a police report because there was no crime committed .the 911 call came in at approximately 3:00 PM. The report was of a suspicious person, a female, knocking on doors near the (Named Apartment Complex) .when I arrived I asked her (Resident #1) where she lived and she gave me an address on (Named Street) so I took her to the address .The gentleman living there knew her and said she resided at (Named Nursing Home) so I took her back to the nursing home .It was approximately 4:15 PM when I arrived at the facility . During an interview on 2/3/2020 at 3:00 PM, Certified Nursing Assistant (CNA) #1, who was assigned to care for Resident #1 on 1/16/2020 for the 7:00 AM to 3:00 PM shift, stated, .I saw her at approximately 1:30 (PM) .did not see her when we changed shifts .I thought she was still in activities . During an interview on 2/4/2020 at 9:00 AM, the DON stated that the facility staff was unaware Resident #1 was missing until the police brought her back. During an interview on 2/4/2020 at 10:50 AM, the Administrator stated, .I saw a police car in the parking lot .they called and asked about a resident .we went out to the car and she (Resident #1) was in the backseat of the police car .that's when I knew she had exited the facility . The Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine possible causes of the exit seeking behaviors. She stated that the incidents were not investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. During an interview on 2/4/2020 at 2:20 PM, Licensed Practical Nurse (LPN) #1, who was the nurse coming on shift at 3:00 PM on 1/16/2020, stated, .I didn't see her (Resident #1) so I asked day shift nurse where she was .I walked by the activity room but didn't see her . LPN #1 was asked when she knew Resident #1 had eloped from the building. LPN #1 stated, .When I got back to the floor .around 4 (PM) .she was sitting at the nurse's station in a wheelchair .since she has come back from (Named Psychiatric hospital on [DATE]) she's had increased exit-seeking behaviors . During an interview on 2/7/2020 at 4:00 PM, the Administrator confirmed that staff should have known Resident #1 was gone. The facility's failure to provide supervision for Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors, and failure to identify that Resident #1 was missing from the facility for approximately 2 hours and 45 minutes on 1/16/2020 resulted in substantiated resident neglect. Resident #1 was found by a police officer, 1.3 miles away from the facility, after a 911 call was made regarding a suspicious female knocking on doors of houses in the area. The facility failed to ensure a resident was free from staff neglect which resulted in Immediate Jeopardy for Resident #1. Refer to F-610, F-656, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Nursing staff involved on 1/16/2020 with incomplete rounds had been disciplined up to and including termination. The surveyors reviewed personnel records and disciplinary forms. 2. A new elopement assessment was completed on Resident #1 on 2/5/2020 at 7:40 PM. The surveyors reviewed the assessment. 3. To meet and maintain compliance, elopement assessments for all at-risk residents for elopement were updated on 2/5/2020 with documentation of new information if applicable. The surveyors reviewed the updated elopement assessments. 4. Facility inserviced CNA staff on proper rounding frequency on residents. Additional inservice was provided on CNA shift change Communication Form for Elopement/Exit-Seeking/Wanderers. On 2/5/2020, a new 30-minute elopement/exit-seeking form was established for charge nurses with 30 minute checks for active exit-seeking residents for a period of daily for 2 weeks, weekly for 4 months, and ongoing until other adjustments are made in order to prevent exit-seeking/elopement. No staff will be able to work until inservice is completed. The surveyors reviewed inservice records, observed 30 min elopement/exit-seeking form being utilized on all 3 shifts, and interviewed staff on all 3 shifts. 5. An inservice on walking rounds at the change of shift with nursing staff was initiated on 2/5/2020. No nursing staff will be able to work until inservice is completed to include new hires. The surveyors reviewed inservice records, observed all shifts conducting walking rounds, and interviewed staff on all shifts. 6. Elopement assessments will be reviewed in daily clinical meetings for accuracy. The surveyors interviewed management staff and reviewed inservices related to elopement assessments in daily clinical meetings. 7. The use of the elopement assessment tool inserviced and educated to all nurses on 2/5/2020. The surveyors reviewed the elopement assessment tool and interviewed nurses on all shifts. 8. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. No licensed nurse will be allowed to work until inservice is completed to include new hires. The surveyors reviewed inservice records and interviewed licensed staff on all shifts. 9. A new elopement risk rounds document has been adopted and will be utilized by unit managers and house supervisors on a daily basis ongoing. The document will identify residents' name, date, time, room number, location and a signature of responsible employee which will safeguard measures to ensure staff supervision of residents assessed to be at risk for elopement and known exit-seeking behaviors. The Director of Nursing, Assistant Director of Nursing, or a designee will conduct daily audits to ensure compliance and report findings to the Quality Assurance Performance Improvement Committee. The surveyors reviewed audit tools and interviewed the Director of Nursing, Assistant Director of Nursing, and the Unit Managers. 10. A sign-in sheet has been added to the existing elopement book on each unit to show time and location of a resident when taken to another location within the facility. The surveyors reviewed the elopement books, observed sign in/out sheets being used, and interviewed staff on all shifts. 11. The facility conducted elopement drills on 1/20/2019, 2/5/2020, and 2/6/2020 as a measure to ensure staff are familiar with their roles in the event of an elopement. The surveyors reviewed documentation and interviewed staff on all shifts. Noncompliance of F-600 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a Comprehensive Care Plan was developed for elopement risk/exit-seeking behaviors for 1 of 4 sampled residents (Resident #1) reviewed for wandering, exit-seeking behaviors, and elopement. The facility failed to ensure the comprehensive Care Plan included interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in Immediate Jeopardy for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-656 on 2/5/2020 at 2:45 PM, in the Conference Room. F-656 was cited at a scope and severity of J. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 to 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policy related to active exit-seeking behavior, assessments, inservice training records, and staff interviews. The findings include: Review of the facility's undated policy titled, Care Planning, showed that the facility should develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident needs and is developed for each resident. The comprehensive care plan is designed to identify problem areas, incorporate risk factors associated with identified problems. Areas of concern are triggered during the resident assessment before interventions are added to the care plan, interventions are designed after careful consideration between resident's problem areas and their causes. The care plan is developed within 7 days of completion of the comprehensive assessment. The nurses on the unit are responsible for all episodic care planning. Assessments of residents are ongoing and care plans are revised as information changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plan. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed to be severely impaired cognitively. Review of the Comprehensive Care Plan dated 8/6/2019, showed there was not a Care Plan developed related to Resident #1's assessed risk of elopement. Review of the Nurses' Notes dated 11/1/2019 and 11/14/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. Review of Resident #1's Social Services note dated 1/16/2020 documented, .exit (exited) the building (Resident #1 was found by a police officer 1.3 miles from the facility) .returned safely .according to officer they received a called (call) resident was picked up . Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview on 2/7/2020 at 2:02 PM, the Director of Nursing (DON) confirmed that Resident #1's Comprehensive Care Plan dated 8/6/2019 should have had interventions in place for Resident #1's elopement risk on admission. The facility failed to ensure a Comprehensive Care Plan was developed to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in IJ for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Refer to F-600, F-610, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Resident #1 was assessed on 1/16/2020 and reassessed on 2/5/2020 to ensure the accuracy of the assessment. The surveyors reviewed the assessments. 2. A Care Plan will be updated with additional interventions related to elopement risks for Resident #1. The surveyors reviewed Resident #1's Care Plan. 3. All residents will have an elopement assessment on admission, quarterly, and as needed. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. No licensed nurse will be allowed to work until inservice is completed to include new hires. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation The surveyors reviewed assessments, inservice records, and interviewed licensed staff on all shifts. 4. All residents with a high risk of elopement were assessed on 2/5/2020 for accuracy. The surveyors reviewed the assessments. 5. All residents will have a care plan that addresses elopement risks with interventions to address residents' needs and will be updated with any incidents that occur and with appropriate interventions. Unit managers/Designees will ensure Care Plans are in place and will be reviewed on the daily clinical report and discussed in clinical meetings daily. Unit Managers/Designees will be educated on the proper protocol to complete a Care Plan and update with appropriate interventions. The surveyors interviewed the administrative staff, staff on all shifts, and Unit Managers. 6. Care Plans for all residents with a high risk of elopement have been audited on 2/5/2020. The surveyors reviewed the Care Plans. Noncompliance of F-656 continued at a scope and severity D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were reported to the physician and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. The failure of the facility to report identified skin condition changes to the physician and obtain treatment orders before deterioration to a Stage 3 pressure ulcer and an Unstageable pressure ulcer resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined . The facility's Changes in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative sponsor of changes in the resident's medical condition and/or status .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition . The facility's Pressure Ulcer Risk Assessment policy dated 2/20/19 documented, .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected . The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy dated (MONTH) (YEAR) documented, Assessment and Recognition .4. The physician will assist the staff to identify the type .and characteristics (presence of necrotic (dead or devitalized) tissue, status of wound bed .) of an ulcer .Treatment/Management .1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and applications of topical agents. 2. The physician will help identify medical interventions related to wound management .3. The physician will help staff characterize the likelihood of wound healing . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] due to gastrointestinal symptoms. Medical record review of the nursing admission assessment and the interim care plan dated 7/26/19 revealed Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was at risk for pressure ulcer development. Medical record review of a Shower Sheet dated 9/26/19 revealed Resident #1 had a dark area to her left hip. The form was signed by Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 indicating the newly identified skin condition had been reported to the nurse by the CN[NAME] Medical record review of the nursing progress notes dated 9/26/19 revealed there was no documentation the physician was notified of the darkened area on the resident's left hip. Medical record review of a Shower Sheet dated 9/28/19 revealed Resident #1 had an open area on her sacral region (bottom of the spine and lies between the lumbar spine and the coccyx (tailbone)). The form was signed by CNA #2 and LPN #1 indicating the newly identified skin condition had been reported to the nurse by the CN[NAME] Medical record review of the nursing progress notes dated 9/28/19 revealed there was no documentation the physician was notified of the open area to the sacral region. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a facility acquired Unstageable pressure ulcer to Resident #1's left hip was first observed by the Treatment Nurse on 9/30/19, slough was present, and the wound bed was 100 percent (%) necrotic tissue. The pressure ulcer measured 1.8 centimeters (cm) in length, 1.4 cm in width, and without measurable depth. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a Stage 3 pressure ulcer present on Resident #1's sacrum was first observed by the Treatment Nurse on 9/30/19, the wound bed was 50% pink tissue and 50% yellow slough. The pressure ulcer measured 1 cm in length, 1 cm in width, and 0.1 cm in depth. The Physician was notified on 10/1/19 of the pressure ulcers and the following physician's orders [REDACTED].> .Cleanse Sacrum with wound cleanser, pat dry, apply [MEDICATION NAME] dressing qod (every other day)/prn (as needed) every day shift .Santyl Ointment 250 UNIT/GM (Grams) ([MEDICATION NAME]) Apply to Left hip topically every day shift . Interview with the Treatment Nurse on 10/31/19 at 11:34 AM, the Treatment Nurse was asked about Resident #1's pressure ulcers to her left hip and sacrum. The Treatment Nurse confirmed that 10/1/19 was the first time the physician had been notified of the pressure ulcers. The Treatment Nurse also confirmed the left hip pressure ulcer was 100 % necrotic and the sacral pressure ulcer was 50% slough when identified on 9/30/19. Interview with LPN #1 on 10/31/19 at 12:20 PM, in the Conference Room, LPN #1 was asked about Resident #1's changes in skin condition reported to her by CNA #1 on 9/26/19 and CNA #2 on 9/28/19. LPN #1 confirmed she had not reported the newly identified areas to the physician for treatment orders. Interview with the Nurse Practitioner (NP) on 10/31/19 at 3:40 PM, in the Conference Room, the NP stated, .I would expect the nurse look at it (pressure ulcer) and report it (to the physician) . The NP confirmed she had not been informed of the pressure ulcers until 10/1/19. The facility's failure to report and obtain a physician's orders [REDACTED].#1.

Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were assessed, reported, and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. This failure of the facility resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined . The facility's Pressure Ulcer Risk Assessment policy dated 2/20/19 documented, .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected .Routinely assess and document the condition of the resident's skin .for signs and symptoms of irritation or breakdown .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated . The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy dated (MONTH) (YEAR) documented, .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and applications of topical agents . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the nursing admission assessment and interim care plan dated 7/26/19 revealed Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the comprehensive care plan dated 7/29/19 revealed the Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact, required extensive assistance for bed mobility, transfer, ambulation, dressing, eating, toileting, and personal hygiene, and was at risk for pressure ulcer development. Medical record review of a Shower Sheet dated 9/26/19 revealed Resident #1 had a dark area to her left hip. The form was signed by Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 indicating the newly identified skin condition had been reported to the nurse by CNA #1. Medical record review of the nursing progress notes and assessments dated 9/26/19 revealed no documented assessment of Resident #1's left hip by LPN #1. Medical record review of a Shower Sheet dated 9/28/19 revealed Resident #1 had an open area on her sacral region. The form was signed by CNA #2 and LPN #1 indicating the newly identified skin condition had been reported to the nurse by CNA #2. Medical record review of the nursing progress notes and assessments dated 9/28/19 revealed no documented assessment of Resident #1's sacrum by LPN #1. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a facility acquired Unstageable pressure ulcer to Resident #1's left hip was first observed by the Treatment Nurse on 9/30/19, slough was present, and the wound bed was 100 percent (%) necrotic (dead or devitalized) tissue. The pressure ulcer measured 1.8 centimeters (cm) in length, 1.4 cm in width, and without measurable depth. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a Stage 3 pressure ulcer present on Resident #1's sacrum was first observed by the Treatment Nurse on 9/30/19, the wound bed was 50% pink tissue and 50% yellow slough. The pressure ulcer measured 1 cm in length, 1 cm in width, and 0.1 cm in depth. Interview with the Treatment Nurse on 10/31/19 at 11:34 AM, the Treatment Nurse was asked about Resident #1's pressure ulcers to her left hip and sacrum. The Treatment Nurse revealed she had worked 11:00 PM - 7:00 AM on 9/30/19 on Resident #1's hall and the resident's CNA had called her into Resident #1's room to look at her skin due to the skin breakdown. The Treatment Nurse confirmed that 9/30/19 was the first time either pressure ulcer had been assessed. The Treatment Nurse also confirmed the left hip pressure ulcer was 100% necrotic and the sacral pressure ulcer was 50% slough when identified on 9/30/19. The Treatment Nurse was asked if the pressure ulcers should have been identified and treated before they had become necrotic. The Treatment Nurse stated, Yes. Interview with CNA #1 on 10/31/19 at 11:55 AM, in the Conference Room, CNA #1 was asked about the dark area on Resident #1's left hip she had identified on 9/26/19. CNA #1 revealed the area was in the crease between the resident's left lower hip and upper thigh, the area was not open, and confirmed she had reported it to LPN #1 both verbally and had documented it on the shower form. Interview with LPN #1 on 10/31/19 at 12:20 PM, in the Conference Room, LPN #1 was asked if she had assessed Resident #1's changes in skin condition reported to her by CNA #1 on 9/26/19 and CNA #2 on 9/28/19. LPN #1 confirmed she had not assessed or reported the newly identified skin condition changes to the oncoming shift or the physician for treatment orders. Interview with the Nurse Practitioner (NP) on 10/31/19 at 3:40 PM, in the Conference Room, the NP was asked if LPN #1 should have assessed the pressure ulcers when they were first identified. The NP stated, .I would expect the nurse to look at it (pressure ulcer) and report it . The NP confirmed she had not been informed of the pressure ulcers until 10/1/19. Telephone interview with CNA #2 on 10/31/19 at 3:52 PM, CNA #2 was asked about the open area on Resident #1's sacrum she had identified on 9/28/19. CNA #2 revealed the area was not dark, had not looked necrotic, there was no odor or drainage and she had reported the area to LPN #1. The facility's failure to assess, report and provide treatment before the newly identified pressure ulcers deteriorated and progressed to a Stage 3 pressure ulcer and an Unstageable pressure ulcer resulted in actual Harm for Resident #1.

Based on policy review, review of the daily staff sheets, review of 24 hour nursing log, review of an incident report, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent neglect for 3 of 6 (Residents #22, 218 and 220) residents reviewed for abuse and neglect of the 52 residents included on the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of the swelling of the right arm resulted in a delay in treatment for [REDACTED].#218 reported being fearful and not resting at night due to Resident #220 entering her room and failure to address Resident #220's behaviors of wandering, exit seeking and elopement from the facility all resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F224 K constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on 5/22/14, removed the Immediate Jeopardy. Noncompliance for F224 continues at a "E" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY... A. physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "...some [MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, Certified Nursing Assistant (CNA) #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater. I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 3. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:25 PM, Resident #218 was asked if the staff treat her with dignity and respect. Resident #218 stated, "No." Resident #218 was then asked how the staff treated her that wasn't with dignity and respect. Resident #218 stated, "(Nurse #18) Slow about changing [MEDICAL CONDITION] bag like they don't want to do it..." Resident #218 was asked if anyone said anything to her about changing her [MEDICAL CONDITION]. Resident #218 stated, "Nobody said anything but you can tell by their attitude and body language..." During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, CNA #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 4. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wanderguard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. A nurse heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign in sheets for all nursing staff on when and how to complete a SBAR, how to document on the 24 hour report, the abuse policy, when and what to care plan, how to complete a head-to-toe assessment and how to document the findings, what type of intervention to put in place based upon the residents condition, updating care plans in the morning clinicals, how to initiate an investigation on elopement and abuse, how to complete an incident report and checking placement of the Wanderguard. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and that RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. There have been no allegations of abuse, neglect, misappropriation or injury of unknown cause since the exit date of 5/5/14. Interview with licensed staff: Licensed Practical Nurses, RN's, Unit Managers, conducted May 23, 2014, at the facility the nursing staff verbalized how to complete a SBAR, how to document on the 24 hour report, what constitutes abuse, how to complete an investigation and how to report an allegation of abuse, when and what to care plan, how to complete a head-to-toe assessment and how to document the findings, what type of interventions to put into place based on the resident's condition, what happens in the morning clinical meetings with care plans, how to complete an incident report, how to check placement of the Wanderguard and what to do when a resident is missing. Interviews with Direct Care Staff: CNA's, Housekeeping and Dietary Staff, conducted May 23, 2014, at the facility the CNA's, housekeeping and dietary staff verbalized what constitutes abuse, whom to report the incident to and how to document the incident. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for resident #218 documented the care plan had been revised to address the use of a "STOP" sign, her concerns and her inability to sleep. There was documentation by the Nurse Practitioner and the DON that addressed her concerns and her inability to sleep. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left." The facility will remain out of compliance at a Scope and Severity level "E", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, review of shift assignment sheet, review of 24 hour nursing log, medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F520 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death) for Residents #22, 218 and 220. 2. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." During an interview in the activity room on 5/5/14 at 4:40 PM, the Administrator was asked if the QA Committee had looked at abuse. The Administrator stated, "Nothing specific..." The Administrator was asked if the QA Committee had looked at elopements, the Administrator stated, "No." 3. The facility's QA committee failed to address identified issues such as abuse, neglect and elopement. 4. The facility's QA committee failed to ensure the plans of action to correct identified quality deficiencies cited on the abbreviated survey completed on 3/28/14, with a compliance date of 4/30/14, were effective. The following plan of actions were not followed: a. F225 - the facility will ensure all incidents will be thoroughly investigated. b. F314 - 9 of 103 licensed staff failed to attend inservice on performing head to toe assessments. c. F323 - the facility failed to ensure the resident's environment was free of accident hazards. d. F514 - 9 of 103 licensed staff failed to attend inservice for documentation. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level, F314 was cited at a D level, F323 was cited at a G level and F514 was cited at a D level. The citation F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continue in substantial non compliance. Refer to F157, F166, F223, F224, F225, F226, F282, F309, F319, F323, F514 and F518. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service with sign in sheets for all staff on the abuse and elopement/missing person policy, resident-to-resident altercation and responding to the activated door alarm. After the in-service training, a POST test was given on the abuse policy. The DON stated that a passing score on the Abuse In-service Post Test was 80 percent (%). Any staff that scored below 80% had to take the test again. There were 13 staff members that initially scored below 80%. All 13 were retested and scored above 80% on the retest. The facility provided evidence of in-service training with sign in sheets for all charge nurses on how to complete an investigation on abuse and elopement. The facility provided evidence of in-service training with sign in sheets for the Unit Managers, DON, and Administrator on how to initiate an investigation on abuse and elopement. The facility provided evidence of in-service with sign in sheets for Social Services and the MDS Nurses on regulatory compliance and timeliness of updating and implementing care plans to reflect changes in the residents condition. The facility provided evidence of in-service training with sign in sheets for all staff on Abuse Policy, Elopement/Missing Person Policy, how to complete an investigation, how to handle wandering residents and when to complete a grievance form. There have been no new admissions. A review was completed of policies and the Management Rounds Checklist. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, review of shift assignment sheet, review of 24 hour nursing log, medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F520 continues at a "E" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death) for Residents #22, 218 and 220. 2. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." During an interview in the activity room on 5/5/14 at 4:40 PM, the Administrator was asked if the QA Committee had looked at abuse. The Administrator stated, "Nothing specific..." The Administrator was asked if the QA Committee had looked at elopements, the Administrator stated, "No." 3. The facility's QA committee failed to address identified issues such as abuse, neglect and elopement. 4. The facility's QA committee failed to ensure the plans of action to correct identified quality deficiencies cited on the abbreviated survey completed on 3/28/14, with a compliance date of 4/30/14, were effective. The following plan of actions were not followed: a. F225 - the facility will ensure all incidents will be thoroughly investigated. b. F314 - 9 of 103 licensed staff failed to attend inservice on performing head to toe assessments. c. F323 - the facility failed to ensure the resident's environment was free of accident hazards. d. F514 - 9 of 103 licensed staff failed to attend inservice for documentation. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level, F314 was cited at a D level, F323 was cited at a D level and F514 was cited at a D level. The citation F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continue in substantial non compliance. Refer to F157, F166, F223, F224, F225, F226, F282, F309, F319, F323, F514 and F518. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service with sign in sheets for all staff on the abuse and elopement/missing person policy, resident-to-resident altercation and responding to the activated door alarm. After the in-service training, a POST test was given on the abuse policy. The DON stated that a passing score on the Abuse In-service Post Test was 80 percent (%). Any staff that scored below 80% had to take the test again. There were 13 staff members that initially scored below 80%. All 13 were retested and scored above 80% on the retest. The facility provided evidence of in-service training with sign in sheets for all charge nurses on how to complete an investigation on abuse and elopement. The facility provided evidence of in-service training with sign in sheets for the Unit Managers, DON, and Administrator on how to initiate an investigation on abuse and elopement. The facility provided evidence of in-service with sign in sheets for Social Services and the MDS Nurses on regulatory compliance and timeliness of updating and implementing care plans to reflect changes in the residents condition. The facility provided evidence of in-service training with sign in sheets for all staff on Abuse Policy, Elopement/Missing Person Policy, how to complete an investigation, how to handle wandering residents and when to complete a grievance form. There have been no new admissions. A review was completed of policies and the Management Rounds Checklist. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "E", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of the daily staff sheets, review of 24 hour nursing log, review of an incident report, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent neglect for 3 of 6 (Residents #22, 218 and 220) residents reviewed for abuse and neglect of the 52 residents included on the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of the swelling of the right arm resulted in a delay in treatment for [REDACTED].#218 reported being fearful and not resting at night due to Resident #220 entering her room and failure to address Resident #220's behaviors of wandering, exit seeking and elopement from the facility all resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F224 K constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY... A. physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "...some [MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, Certified Nursing Assistant (CNA) #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater. I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 3. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:25 PM, Resident #218 was asked if the staff treat her with dignity and respect. Resident #218 stated, "No." Resident #218 was then asked how the staff treated her that wasn't with dignity and respect. Resident #218 stated, "(Nurse #18) Slow about changing [MEDICAL CONDITION] bag like they don't want to do it..." Resident #218 was asked if anyone said anything to her about changing her [MEDICAL CONDITION]. Resident #218 stated, "Nobody said anything but you can tell by their attitude and body language..." During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, CNA #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 4. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wanderguard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. A nurse heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

Based on policy review, review of incident reports, review of shift assignment sheet, review of 24 hour nursing log, medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death) for Residents #22, 218 and 220. 2. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." During an interview in the activity room on 5/5/14 at 4:40 PM, the Administrator was asked if the QA Committee had looked at abuse. The Administrator stated, "Nothing specific..." The Administrator was asked if the QA Committee had looked at elopements, the Administrator stated, "No." 3. The facility's QA committee failed to address identified issues such as abuse, neglect and elopement. 4. The facility's QA committee failed to ensure the plans of action to correct identified quality deficiencies cited on the abbreviated survey completed on 3/28/14, with a compliance date of 4/30/14, were effective. The following plan of actions were not followed: a. F225 - the facility will ensure all incidents will be thoroughly investigated. b. F314 - 9 of 103 licensed staff failed to attend inservice on performing head to toe assessments. c. F323 - the facility failed to ensure the resident's environment was free of accident hazards. d. F514 - 9 of 103 licensed staff failed to attend inservice for documentation. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level, F314 was cited at a D level, F323 was cited at a G level and F514 was cited at a D level. The citation F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continue in substantial non compliance. Refer to F157, F166, F223, F224, F225, F226, F282, F309, F319, F323, F514 and F518.

Based on policy review, review of an incident report and staff interviews, it was determined the facility failed to ensure staff were competent in emergency preparedness for when residents are discovered missing and were not aware of the elopement code for 4 of 8 (Certified Nursing Assistants (CNA) #20 and 21 and Nurses #15 and 16) staff interviewed. The failure of the facility to respond to a sounding alarm and follow a resident observed leaving the facility resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #220 who elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F518 continues at a "E" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "Missing Resident" policy documented, "...When a resident is suspected of missing... 2. The nursing supervisor will announce overhead "Code Green" to alert facility employees of the missing resident..." 2. During an interview on the 300 hall on 5/5/14 at 3:10 PM, CNA #20 was asked what the code for elopement was. CNA #20 stated, "I don't know the code to announce elopement." 3. During an interview on the 400 hall, on 5/5/14 at 3:30 PM, CNA #21 was asked what the code for elopement was. CNA #21 answered, "I don't remember what the code is for elopement. I'm new and don't remember codes for any of the emergencies." 4. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what would she do if she heard a wanderguard alarm going off. Nurse #15 answered, "...call the AWOL (Absent Without Leave) code..." Nurse #15 was then asked, "...Would you not stop what you were doing to look? Nurse #15 stated, "It depends on what I was doing... I'm an agency nurse and really don't know what the policy is... no... I guess I should stop what I am doing, check the facility and then outside... call the AWOL code..." During an interview in the activities room [ROOM NUMBER]/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." 5. During an interview on the 100 hall on 5/3/14 at 1:40 PM, Nurse #16 was asked what do you do when you find you have a missing resident. Nurse #16 stated, "...(call) AWOL code..." The facility failed to ensure each employee was knowledgeable of each of the components in the missing resident policy. Not all of the staff were aware of "Code Green" which is used when a resident is missing. Refer to the findings of elopement in regard to Resident #220 in citation F323. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents, observation and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all staff on responding to exit door alarms and that the Unit Managers, Minimum Data Set Coordinator and the Restorative Nurse had been in-serviced on the "Elopement Wandering Form". Evidence was provided that all licensed nursing staff had been in-serviced on incidents and accidents, how to complete incident and accident forms, and how to complete an investigation. Evidence was also provided that the facility had conducted elopement drills 5 days a week on different shifts, that required staff to canvas the neighborhood surrounding the facility to look for a missing "Resident". Emergency codes have been placed at each nurses station and in the employee break room. Evidence provided that the Maintenance Director checked each exit door daily to ensure they are functioning properly. The agency staff book placed at each nursing station was reviewed. The book contained emergency numbers and codes, examples of a completed Situation, Behavioral, Assessment, Response (SBAR), samples of documentation, fall documentation, antibiotic documentation, Intravenous therapy, Peripherally Inserted Central Catheter lines, how to do a head-to-toe assessment, how to handle telephone orders, weekly skin assessments, how to document on weekly summary, 24 hour report policy on abuse, abuse training policy, safe transfer policy, how to retrieve medications from the emergency kit box, how to do an admission, wanderguard policy, the skin and wound care policy. During an interview with an agency Licensed Practical Nurse #19 verbalized understanding of the above information in the book. He had a laminated card with information as noted above. Interviews with Licensed Nursing Staff (including Agency): Licensed Practical Nurses and Registered Nurses conducted on May 23, 2014, in the facility, the staff verbalized how to complete incident and accidents forms and how to complete an investigation. Interviews with facility staff: Certified Nursing Assistants and Housekeeping staff, conducted on May 23, 2014, in the facility, the staff verbalized how to respond to the exit door alarms. Interview with the Restorative Nurse revealed he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. During an interview the Administrator stated that Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for Resident #108 revealed "Elopement/Wandering Form" documentation is current and a elopement assessment was completed. During an interview, the DON stated that the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "E", a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on policy review, review of an incident report and staff interviews, it was determined the facility failed to ensure staff were competent in emergency preparedness for when residents are discovered missing and were not aware of the elopement code for 4 of 8 (Certified Nursing Assistants (CNA) #20 and 21 and Nurses #15 and 16) staff interviewed. The failure of the facility to respond to a sounding alarm and follow a resident observed leaving the facility resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #220 who elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's "Missing Resident" policy documented, "...When a resident is suspected of missing... 2. The nursing supervisor will announce overhead "Code Green" to alert facility employees of the missing resident..." 2. During an interview on the 300 hall on 5/5/14 at 3:10 PM, CNA #20 was asked what the code for elopement was. CNA #20 stated, "I don't know the code to announce elopement." 3. During an interview on the 400 hall, on 5/5/14 at 3:30 PM, CNA #21 was asked what the code for elopement was. CNA #21 answered, "I don't remember what the code is for elopement. I'm new and don't remember codes for any of the emergencies." 4. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what would she do if she heard a wanderguard alarm going off. Nurse #15 answered, "...call the AWOL (Absent Without Leave) code..." Nurse #15 was then asked, "...Would you not stop what you were doing to look? Nurse #15 stated, "It depends on what I was doing... I'm an agency nurse and really don't know what the policy is... no... I guess I should stop what I am doing, check the facility and then outside... call the AWOL code..." During an interview in the activities room [ROOM NUMBER]/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." 5. During an interview on the 100 hall on 5/3/14 at 1:40 PM, Nurse #16 was asked what do you do when you find you have a missing resident. Nurse #16 stated, "...(call) AWOL code..." The facility failed to ensure each employee was knowledgeable of each of the components in the missing resident policy. Not all of the staff were aware of "Code Green" which is used when a resident is missing. Refer to the findings of elopement in regard to Resident #220 in citation F323.

Based on policy review, review of an incident report and staff interviews, it was determined the facility failed to ensure staff were competent in emergency preparedness for when residents are discovered missing and were not aware of the elopement code for 4 of 8 (Certified Nursing Assistants (CNA) #20 and 21 and Nurses #15 and 16) staff interviewed. The failure of the facility to respond to a sounding alarm and follow a resident observed leaving the facility resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #220 who elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F518 continues at a "E" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "Missing Resident" policy documented, "...When a resident is suspected of missing... 2. The nursing supervisor will announce overhead "Code Green" to alert facility employees of the missing resident..." 2. During an interview on the 300 hall on 5/5/14 at 3:10 PM, CNA #20 was asked what the code for elopement was. CNA #20 stated, "I don't know the code to announce elopement." 3. During an interview on the 400 hall, on 5/5/14 at 3:30 PM, CNA #21 was asked what the code for elopement was. CNA #21 answered, "I don't remember what the code is for elopement. I'm new and don't remember codes for any of the emergencies." 4. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what would she do if she heard a wanderguard alarm going off. Nurse #15 answered, "...call the AWOL (Absent Without Leave) code..." Nurse #15 was then asked, "...Would you not stop what you were doing to look? Nurse #15 stated, "It depends on what I was doing... I'm an agency nurse and really don't know what the policy is... no... I guess I should stop what I am doing, check the facility and then outside... call the AWOL code..." During an interview in the activities room [ROOM NUMBER]/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." 5. During an interview on the 100 hall on 5/3/14 at 1:40 PM, Nurse #16 was asked what do you do when you find you have a missing resident. Nurse #16 stated, "...(call) AWOL code..." The facility failed to ensure each employee was knowledgeable of each of the components in the missing resident policy. Not all of the staff were aware of "Code Green" which is used when a resident is missing. Refer to the findings of elopement in regard to Resident #220 in citation F323. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all staff on responding to exit door alarms and that the Unit Managers, Minimum Data Set Coordinator and the Restorative Nurse had been in-serviced on the "Elopement Wandering Form". Evidence was provided that all licensed nursing staff had been in-serviced on incidents and accidents, how to complete incident and accident forms, and how to complete an investigation. Evidence was also provided that the facility had conducted elopement drills 5 days a week on different shifts, that required staff to canvas the neighborhood surrounding the facility to look for a missing "Resident". Emergency codes have been placed at each nurses station and in the employee break room. Evidence provided that the Maintenance Director checked each exit door daily to ensure they are functioning properly. The agency staff book placed at each nursing station was reviewed. The book contained emergency numbers and codes, examples of a completed Situation, Behavioral, Assessment, Response (SBAR), samples of documentation, fall documentation, antibiotic documentation, Intravenous therapy, Peripherally Inserted Central Catheter lines, how to do a head-to-toe assessment, how to handle telephone orders, weekly skin assessments, how to document on weekly summary, 24 hour report policy on abuse, abuse training policy, safe transfer policy, how to retrieve medications from the emergency kit box, how to do an admission, wanderguard policy, the skin and wound care policy. During an interview with an agency Licensed Practical Nurse #19 verbalized understanding of the above information in the book. He had a laminated card with information as noted above. Interviews with Licensed Nursing Staff (including Agency): Licensed Practical Nurses and Registered Nurses conducted on May 23, 2014, in the facility, the staff verbalized how to complete incident and accidents forms and how to complete an investigation. Interviews with facility staff: Certified Nursing Assistants and Housekeeping staff, conducted on May 23, 2014, in the facility, the staff verbalized how to respond to the exit door alarms. Interview with the Restorative Nurse revealed he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. During an interview the Administrator stated that Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for Resident #108 revealed "Elopement/Wandering Form" documentation is current and a elopement assessment was completed. During an interview, the DON stated that the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "E", a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on policy review, review of an incident report and staff interviews, it was determined the facility failed to ensure staff were competent in emergency preparedness for when residents are discovered missing and were not aware of the elopement code for 4 of 8 (Certified Nursing Assistants (CNA) #20 and 21 and Nurses #15 and 16) staff interviewed. The failure of the facility to respond to a sounding alarm and follow a resident observed leaving the facility resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #220 who elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's "Missing Resident" policy documented, "...When a resident is suspected of missing... 2. The nursing supervisor will announce overhead "Code Green" to alert facility employees of the missing resident..." 2. During an interview on the 300 hall on 5/5/14 at 3:10 PM, CNA #20 was asked what the code for elopement was. CNA #20 stated, "I don't know the code to announce elopement." 3. During an interview on the 400 hall, on 5/5/14 at 3:30 PM, CNA #21 was asked what the code for elopement was. CNA #21 answered, "I don't remember what the code is for elopement. I'm new and don't remember codes for any of the emergencies." 4. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what would she do if she heard a wanderguard alarm going off. Nurse #15 answered, "...call the AWOL (Absent Without Leave) code..." Nurse #15 was then asked, "...Would you not stop what you were doing to look? Nurse #15 stated, "It depends on what I was doing... I'm an agency nurse and really don't know what the policy is... no... I guess I should stop what I am doing, check the facility and then outside... call the AWOL code..." During an interview in the activities room [ROOM NUMBER]/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." 5. During an interview on the 100 hall on 5/3/14 at 1:40 PM, Nurse #16 was asked what do you do when you find you have a missing resident. Nurse #16 stated, "...(call) AWOL code..." The facility failed to ensure each employee was knowledgeable of each of the components in the missing resident policy. Not all of the staff were aware of "Code Green" which is used when a resident is missing. Refer to the findings of elopement in regard to Resident #220 in citation F323.

Based on policy review, review of incident reports, review of 24 hour nursing log, review of daily staffing sheets, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured residents were protected from psychological harm and potential resident to resident altercation; administration failed to ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for behaviors of wandering and/or exiting seeking residents were effective; administration failed to fully investigate grievances; administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each staff member was knowledgeable of the facility missing resident policy; administration failed to ensure staff completed wanderguard checks and ensure a bed alarm and mat were in place for 6 of 52 (Residents #7, 22, 108, 218, 220 and 247) residents reviewed of the 52 residents included in the stage 2 sample. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F490 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Administration failed to ensure staff assessed and timely notified the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION] which resulted in delay of care and placed Resident #22 in immediate jeopardy. Refer to F157. 2. Administration failed to ensure residents were protected from psychological harm and potential resident to resident altercation; ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for wandering and/or exiting seeking behaviors were effective and administration failed to fully investigate grievances for Residents 7, 22, 218 and 220. Refer to F166, F223, F224, F225, F226 and F319. 3. Administration failed to ensure necessary care and services were provided to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right arm for Resident #22. Refer to F309. 4. Administration failed to ensure staff provided supervision when staff failed to respond to an alarm when a resident was leaving the facility or ensure a wanderguard was checked as ordered by the physician for Residents #108 and 220. Administration also failed to ensure handrails did not have nails sticking to cause potential injuries. Refer to F323. 5. The administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each employee was knowledgeable of the facility's missing resident policy. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Refer to F518. 6. Administration failed to ensure the Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The administrator gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit on 5/1/14 validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited in the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continues in substantial non compliance. Refer to F520. Validation of the Credible Allegation of Compliance was accomplished on-site on May 23, 2014, through record review, review of facility documents and interviews with nursing, administration and corporate staff. The facility provided evidence of in-service training with sign in sheets for the Administrator and the DON by the Managing Director of Senior Living Services, on abuse, elopement, missing residents, Wandering Policy and how to start and complete an investigation. Evidence of in-service training with sign in sheets was provided for other facility staff on abuse, elopement, missing residents, timely notification of physician and family, how to complete a head-to toe assessment and how to document the findings, how to investigate a resident grievance or complaint and how to implement interventions based on the residents condition. Evidence was provided for unannounced elopement drills that were conducted 5 times a week on different shifts. These drills required staff to canvas the neighborhood in a grid formation to look for the missing "Resident". Forms and processes developed by the facility were reviewed such as documenting on the 24 hour report, the morning clinical meetings (HART (Health Assessment Review Team) Team Meeting), the Management Rounds Checklist, the Nursing Supervisor Report, SBAR's, Wanderguard Daily Checklist, Behavior Monitoring Checklist, and the Elopement / Wandering Form. There were no concerns identified with these forms or processes. Interviews were conducted with Certified Nursing Assitants, Licensded Practical Nurses, Registered Nurses, Unit Managers and Housekeeping Staff. All staff interviewed were knowledgeable of the abuse policy, what to do for wandering and missing residents, how to report abuse or a grievance and what to document. Licensed nursing staff were knowledgeable of when to notify the physician and family, how to complete a Situation, Background, Assessment, Reguest (SBAR), what to document on the 24 hour report, how to do a head-to-toe assessment and document their findings, how to complete an investigation for abuse or elopement and how to implement interventions based on the residents condition. The agency staff book placed at each nursing station was reviewed. The book contained emergency numbers and codes, examples of a completed SBAR, samples of documentation, fall documentation, antibiotic documentation, Intravenous therapy, Peripherally Inserted Central Catheter lines, how to do a head-to-toe assessment, how to handle telephone orders, weekly skin assessments, how to document on weekly summary, 24 hour report policy on abuse, abuse training policy, safe transfer policy, how to retrieve medications from the emergency kit box, how to do an admission, wanderguard policy, the skin and wound care policy. During an interview with an agency Licensed Practical Nurse #19 verbalized understanding of the above information in the book. He had a laminated card with information as noted above. Resident #218 stated she was no longer afraid and that she felt safe. She stated that she she was resting well. Resident #218's daughter stated that she had noticed an improvement since the state agency had exited on 5/5/14. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "E", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, review of 24 hour nursing log, review of daily staffing sheets, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured residents were protected from psychological harm and potential resident to resident altercation; administration failed to ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for behaviors of wandering and/or exiting seeking residents were effective; administration failed to fully investigate grievances; administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each staff member was knowledgeable of the facility missing resident policy; administration failed to ensure staff completed wanderguard checks and ensure a bed alarm and mat were in place for 6 of 52 (Residents #7, 22, 108, 218, 220 and 247) residents reviewed of the 52 residents included in the stage 2 sample. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Administration failed to ensure staff assessed and timely notified the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION] which resulted in delay of care and placed Resident #22 in immediate jeopardy. Refer to F157. 2. Administration failed to ensure residents were protected from psychological harm and potential resident to resident altercation; ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for wandering and/or exiting seeking behaviors were effective and administration failed to fully investigate grievances for Residents 7, 22, 218 and 220. Refer to F166, F223, F224, F225, F226 and F319. 3. Administration failed to ensure necessary care and services were provided to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right arm for Resident #22. Refer to F309. 4. Administration failed to ensure staff provided supervision when staff failed to respond to an alarm when a resident was leaving the facility or ensure a wanderguard was checked as ordered by the physician for Residents #108 and 220. Administration also failed to ensure handrails did not have nails sticking to cause potential injuries. Refer to F323. 5. The administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each employee was knowledgeable of the facility's missing resident policy. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Refer to F518. 6. Administration failed to ensure the Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The administrator gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit on 5/1/14 validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited in the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continues in substantial non compliance. Refer to F520.

Based on policy review, review of incident reports, review of 24 hour nursing log, review of daily staffing sheets, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured residents were protected from psychological harm and potential resident to resident altercation; administration failed to ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for behaviors of wandering and/or exiting seeking residents were effective; administration failed to fully investigate grievances; administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each staff member was knowledgeable of the facility missing resident policy; administration failed to ensure staff completed wanderguard checks and ensure a bed alarm and mat were in place for 6 of 52 (Residents #7, 22, 108, 218, 220 and 247) residents reviewed of the 52 residents included in the stage 2 sample. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F490 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Administration failed to ensure staff assessed and timely notified the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION] which resulted in delay of care and placed Resident #22 in immediate jeopardy. Refer to F157. 2. Administration failed to ensure residents were protected from psychological harm and potential resident to resident altercation; ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for wandering and/or exiting seeking behaviors were effective and administration failed to fully investigate grievances for Residents 7, 22, 218 and 220. Refer to F166, F223, F224, F225, F226 and F319. 3. Administration failed to ensure necessary care and services were provided to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right arm for Resident #22. Refer to F309. 4. Administration failed to ensure staff provided supervision when staff failed to respond to an alarm when a resident was leaving the facility or ensure a wanderguard was checked as ordered by the physician for Residents #108 and 220. Administration also failed to ensure handrails did not have nails sticking to cause potential injuries. Refer to F323. 5. The administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each employee was knowledgeable of the facility's missing resident policy. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Refer to F518. 6. Administration failed to ensure the Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The administrator gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit on 5/1/14 validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited in the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continues in substantial non compliance. Refer to F520. Validation of the Credible Allegation of Compliance was accomplished on-site on May 23, 2014, through record review, review of facility documents and interviews with nursing, administration and corporate staff. The facility provided evidence of in-service training with sign in sheets for the Administrator and the DON by the Managing Director of Senior Living Services, on abuse, elopement, missing residents, Wandering Policy and how to start and complete an investigation. Evidence of in-service training with sign in sheets was provided for other facility staff on abuse, elopement, missing residents, timely notification of physician and family, how to complete a head-to toe assessment and how to document the findings, how to investigate a resident grievance or complaint and how to implement interventions based on the residents condition. Evidence was provided for unannounced elopement drills that were conducted 5 times a week on different shifts. These drills required staff to canvas the neighborhood in a grid formation to look for the missing "Resident". Forms and processes developed by the facility were reviewed such as documenting on the 24 hour report, the morning clinical meetings (HART (Health Assessment Review Team) Team Meeting), the Management Rounds Checklist, the Nursing Supervisor Report, SBAR's, Wanderguard Daily Checklist, Behavior Monitoring Checklist, and the Elopement / Wandering Form. There were no concerns identified with these forms or processes. Interviews were conducted with Certified Nursing Assitants, Licensded Practical Nurses, Registered Nurses, Unit Managers and Housekeeping Staff. All staff interviewed were knowledgeable of the abuse policy, what to do for wandering and missing residents, how to report abuse or a grievance and what to document. Licensed nursing staff were knowledgeable of when to notify the physician and family, how to complete a Situation, Background, Assessment, Reguest (SBAR), what to document on the 24 hour report, how to do a head-to-toe assessment and document their findings, how to complete an investigation for abuse or elopement and how to implement interventions based on the residents condition. The agency staff book placed at each nursing station was reviewed. The book contained emergency numbers and codes, examples of a completed SBAR, samples of documentation, fall documentation, antibiotic documentation, Intravenous therapy, Peripherally Inserted Central Catheter lines, how to do a head-to-toe assessment, how to handle telephone orders, weekly skin assessments, how to document on weekly summary, 24 hour report policy on abuse, abuse training policy, safe transfer policy, how to retrieve medications from the emergency kit box, how to do an admission, wanderguard policy, the skin and wound care policy. During an interview with an agency Licensed Practical Nurse #19 verbalized understanding of the above information in the book. He had a laminated card with information as noted above. Resident #218 stated she was no longer afraid and that she felt safe. She stated that she she was resting well. Resident #218's daughter stated that she had noticed an improvement since the state agency had exited on 5/5/14. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, review of 24 hour nursing log, review of daily staffing sheets, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured residents were protected from psychological harm and potential resident to resident altercation; administration failed to ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for behaviors of wandering and/or exiting seeking residents were effective; administration failed to fully investigate grievances; administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each staff member was knowledgeable of the facility missing resident policy; administration failed to ensure staff completed wanderguard checks and ensure a bed alarm and mat were in place for 6 of 52 (Residents #7, 22, 108, 218, 220 and 247) residents reviewed of the 52 residents included in the stage 2 sample. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Administration failed to ensure staff assessed and timely notified the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION] which resulted in delay of care and placed Resident #22 in immediate jeopardy. Refer to F157. 2. Administration failed to ensure residents were protected from psychological harm and potential resident to resident altercation; ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for wandering and/or exiting seeking behaviors were effective and administration failed to fully investigate grievances for Residents 7, 22, 218 and 220. Refer to F166, F223, F224, F225, F226 and F319. 3. Administration failed to ensure necessary care and services were provided to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right arm for Resident #22. Refer to F309. 4. Administration failed to ensure staff provided supervision when staff failed to respond to an alarm when a resident was leaving the facility or ensure a wanderguard was checked as ordered by the physician for Residents #108 and 220. Administration also failed to ensure handrails did not have nails sticking to cause potential injuries. Refer to F323. 5. The administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each employee was knowledgeable of the facility's missing resident policy. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Refer to F518. 6. Administration failed to ensure the Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The administrator gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit on 5/1/14 validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited in the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continues in substantial non compliance. Refer to F520.

Based on policy review, review of the daily staff sheets, review of 24 hour nursing log, review of an incident report, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent neglect for 3 of 6 (Residents #22, 218 and 220) residents reviewed for abuse and neglect of the 52 residents included on the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of the swelling of the right arm resulted in a delay in treatment for [REDACTED].#218 reported being fearful and not resting at night due to Resident #220 entering her room and failure to address Resident #220's behaviors of wandering, exit seeking and elopement from the facility all resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F224 K constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY... A. physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "...some [MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, Certified Nursing Assistant (CNA) #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater. I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 3. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:25 PM, Resident #218 was asked if the staff treat her with dignity and respect. Resident #218 stated, "No." Resident #218 was then asked how the staff treated her that wasn't with dignity and respect. Resident #218 stated, "(Nurse #18) Slow about changing [MEDICAL CONDITION] bag like they don't want to do it..." Resident #218 was asked if anyone said anything to her about changing her [MEDICAL CONDITION]. Resident #218 stated, "Nobody said anything but you can tell by their attitude and body language..." During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, CNA #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 4. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wanderguard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. A nurse heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

Based on policy review, review of the daily staff sheets, review of 24 hour nursing log, review of an incident report, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent neglect for 3 of 6 (Residents #22, 218 and 220) residents reviewed for abuse and neglect of the 52 residents included on the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of the swelling of the right arm resulted in a delay in treatment for [REDACTED].#218 reported being fearful and not resting at night due to Resident #220 entering her room and failure to address Resident #220's behaviors of wandering, exit seeking and elopement from the facility all resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F224 K constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on 5/22/14, removed the Immediate Jeopardy. Noncompliance for F224 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY... A. physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "...some [MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, Certified Nursing Assistant (CNA) #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater. I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 3. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:25 PM, Resident #218 was asked if the staff treat her with dignity and respect. Resident #218 stated, "No." Resident #218 was then asked how the staff treated her that wasn't with dignity and respect. Resident #218 stated, "(Nurse #18) Slow about changing [MEDICAL CONDITION] bag like they don't want to do it..." Resident #218 was asked if anyone said anything to her about changing her [MEDICAL CONDITION]. Resident #218 stated, "Nobody said anything but you can tell by their attitude and body language..." During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, CNA #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 4. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wanderguard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. A nurse heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign in sheets for all nursing staff on when and how to complete a SBAR, how to document on the 24 hour report, the abuse policy, when and what to care plan, how to complete a head-to-toe assessment and how to document the findings, what type of intervention to put in place based upon the residents condition, updating care plans in the morning clinicals, how to initiate an investigation on elopement and abuse, how to complete an incident report and checking placement of the Wanderguard. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and that RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. There have been no allegations of abuse, neglect, misappropriation or injury of unknown cause since the exit date of 5/5/14. Interview with licensed staff: Licensed Practical Nurses, RN's, Unit Managers, conducted May 23, 2014, at the facility the nursing staff verbalized how to complete a SBAR, how to document on the 24 hour report, what constitutes abuse, how to complete an investigation and how to report an allegation of abuse, when and what to care plan, how to complete a head-to-toe assessment and how to document the findings, what type of interventions to put into place based on the resident's condition, what happens in the morning clinical meetings with care plans, how to complete an incident report, how to check placement of the Wanderguard and what to do when a resident is missing. Interviews with Direct Care Staff: CNA's, Housekeeping and Dietary Staff, conducted May 23, 2014, at the facility the CNA's, housekeeping and dietary staff verbalized what constitutes abuse, whom to report the incident to and how to document the incident. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for resident #218 documented the care plan had been revised to address the use of a "STOP" sign, her concerns and her inability to sleep. There was documentation by the Nurse Practitioner and the DON that addressed her concerns and her inability to sleep. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left." The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, review of shift assignment sheet, review of 24 hour nursing log, medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death) for Residents #22, 218 and 220. 2. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." During an interview in the activity room on 5/5/14 at 4:40 PM, the Administrator was asked if the QA Committee had looked at abuse. The Administrator stated, "Nothing specific..." The Administrator was asked if the QA Committee had looked at elopements, the Administrator stated, "No." 3. The facility's QA committee failed to address identified issues such as abuse, neglect and elopement. 4. The facility's QA committee failed to ensure the plans of action to correct identified quality deficiencies cited on the abbreviated survey completed on 3/28/14, with a compliance date of 4/30/14, were effective. The following plan of actions were not followed: a. F225 - the facility will ensure all incidents will be thoroughly investigated. b. F314 - 9 of 103 licensed staff failed to attend inservice on performing head to toe assessments. c. F323 - the facility failed to ensure the resident's environment was free of accident hazards. d. F514 - 9 of 103 licensed staff failed to attend inservice for documentation. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level, F314 was cited at a D level, F323 was cited at a G level and F514 was cited at a D level. The citation F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continue in substantial non compliance. Refer to F157, F166, F223, F224, F225, F226, F282, F309, F319, F323, F514 and F518.

Based on policy review, review of a shift assignment sheet, medical record review and interview, it was determined the facility failed to fully investigate grievances voiced by 2 of 52 (Residents #218 and 7) residents included in the stage 2 sample. The failure of the facility to thoroughly investigate grievances; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218 who stated she was afraid of Resident #220 and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F166 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "Investigating a Resident Grievance or Complaint" policy documented, "...all grievances and /or complaints be investigated by the appropriate facility staff and recorded on the grievance/complaint log... the Social Services Director... will begin an investigation into the allegations..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resides in a private room that is next door to Resident#220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man (Resident #220) next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the social worker's office on 5/1/14 at 10:21 AM, the Social Worker was asked if anyone had reported any issues or concerns about Resident #220. The Social worker stated, "I just heard about it a few minutes ago." Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. Resident #220 had wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to follow up on grievances voiced by Resident #218, who is unable to sleep at night for fear of Resident #220 entering her room at night. The facility failed to implement new, appropriate and measurable interventions to keep Resident #218 safe resulted in immediate jeopardy. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented a BIMS score of 15 indicating the resident had no cognitive impairments, required set up help with eating, and had bilateral upper extremity impairment on both sides. The care plan dated 10/16/13 and updated on 4/9/14 documented, "Problem-Impaired mobility w (with) / self-care deficit r/t/ (related to) h/o (history of)[MEDICAL CONDITION]/ Rt. (right) hemi (stroke with right paralysis), h/o GSW (gunshot wound) to head... Approach-Frequency 1. Provide full staff assistance w/bathing, dressing, personal hygiene, grooming, oral, and incontinent care... 3. Set-up all equipment for personal care... 4. Assist resident w/oral care..." During an interview in Resident #7's room on 4/28/14 at 3:20 PM, Resident #7 stated, "(Named CNA #22) left trays without opening items, happens all the time, have told (Named Nurse #5)." During an interview at the 100/200 nurses' station on 4/30/14 at 4:00 PM, Nurse #5 (unit manager) was asked about any complaints regarding care reported by Resident #7. Nurse #5 stated, "Yes, she did complain to me right after I started here (empolyed 2/2014) about (named CNA #22). She complained she (CNA #22) did not put her to bed when she wanted to and did not open her items on her trays for her. I talked to both of them (Resident #7 and CNA #22). I removed (named CNA #22) from caring for (named Resident #7)." Nurse #5 was asked if there were any investigations of these complaints. Nurse #5 stated, "No, I did not write this up anywhere. No, do not have a grievance log. No, I did not document this anywhere. I just talked to them." Nurse #5 was asked about how charge nurses were informed of her removing CNA #22 of caring for Resident #7. Nurse #5 stated, "They (nurses) know, they do not assign (named CNA #22) to (named Resident #7)." The surveyor asked to review the 4/30/14 3-11 shift assignment sheet. The assignment sheet documented Resident #7 was assigned on paper to CNA #22. Nurse #5 stated, "She (named CNA #22) knows not to go in her (Resident #7's) room. She (CNA #22) will get one of the other CNA's to do (named Resident #7) for her." Nurse #5 was asked how staff know this. Nurse #5 stated, "They know." During an interview in the activity room on 5/2/14 at 9:30 AM, the Administrator (the Abuse Coordinator) was asked what was expected if an allegation of abuse was reported to a unit manager. The Administrator stated, "I would expect the unit manager to investigate the situation and report it to me. I was not aware of the situation with (Named Resident #7 and CNA #22) until yesterday." The facility failed to thoroughly investigate and follow up on Resident #7's voiced grievances of not providing preference and needed care for dining and personal hygiene. 4. The facility failed to resolve grievances voiced by Residents #7 and 218. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets, for all licensed nursing staff and the Social Services Department on the policy for investigating grievances and concerns, how to complete and how to document on a grievance form. The facility provided evidence the Social Services Department had interviewed residents to ensure that grievances were reported, investigated and addressed timely. Medical record review for Resident #7, #108 and #220 were reviewed for grievances. There was evidence the Social Worker addressed Resident #7's desire to change rooms in a timely manner and to the resident's satisfaction. Interviews with Direct Care Staff: CNA's, Licensed Practical Nurses, Registered Nurses, conducted on May 23, 2014, in the facility, nursing staff verbalized how to investigate a grievance or concerns reported by the resident or family, how to complete the grievance form and who to report to. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The Social Worker did attend the QA meeting on May 19, 2014. The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of a shift assignment sheet, medical record review and interview, it was determined the facility failed to fully investigate grievances voiced by 2 of 52 (Residents #218 and 7) residents included in the stage 2 sample. The failure of the facility to thoroughly investigate grievances; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218 who stated she was afraid of Resident #220 and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's "Investigating a Resident Grievance or Complaint" policy documented, "...all grievances and /or complaints be investigated by the appropriate facility staff and recorded on the grievance/complaint log... the Social Services Director... will begin an investigation into the allegations..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resides in a private room that is next door to Resident#220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man (Resident #220) next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the social worker's office on 5/1/14 at 10:21 AM, the Social Worker was asked if anyone had reported any issues or concerns about Resident #220. The Social worker stated, "I just heard about it a few minutes ago." Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. Resident #220 had wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to follow up on grievances voiced by Resident #218, who is unable to sleep at night for fear of Resident #220 entering her room at night. The facility failed to implement new, appropriate and measurable interventions to keep Resident #218 safe resulted in immediate jeopardy. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented a BIMS score of 15 indicating the resident had no cognitive impairments, required set up help with eating, and had bilateral upper extremity impairment on both sides. The care plan dated 10/16/13 and updated on 4/9/14 documented, "Problem-Impaired mobility w (with) / self-care deficit r/t/ (related to) h/o (history of)[MEDICAL CONDITION]/ Rt. (right) hemi (stroke with right paralysis), h/o GSW (gunshot wound) to head... Approach-Frequency 1. Provide full staff assistance w/bathing, dressing, personal hygiene, grooming, oral, and incontinent care... 3. Set-up all equipment for personal care... 4. Assist resident w/oral care..." During an interview in Resident #7's room on 4/28/14 at 3:20 PM, Resident #7 stated, "(Named CNA #22) left trays without opening items, happens all the time, have told (Named Nurse #5)." During an interview at the 100/200 nurses' station on 4/30/14 at 4:00 PM, Nurse #5 (unit manager) was asked about any complaints regarding care reported by Resident #7. Nurse #5 stated, "Yes, she did complain to me right after I started here (empolyed 2/2014) about (named CNA #22). She complained she (CNA #22) did not put her to bed when she wanted to and did not open her items on her trays for her. I talked to both of them (Resident #7 and CNA #22). I removed (named CNA #22) from caring for (named Resident #7)." Nurse #5 was asked if there were any investigations of these complaints. Nurse #5 stated, "No, I did not write this up anywhere. No, do not have a grievance log. No, I did not document this anywhere. I just talked to them." Nurse #5 was asked about how charge nurses were informed of her removing CNA #22 of caring for Resident #7. Nurse #5 stated, "They (nurses) know, they do not assign (named CNA #22) to (named Resident #7)." The surveyor asked to review the 4/30/14 3-11 shift assignment sheet. The assignment sheet documented Resident #7 was assigned on paper to CNA #22. Nurse #5 stated, "She (named CNA #22) knows not to go in her (Resident #7's) room. She (CNA #22) will get one of the other CNA's to do (named Resident #7) for her." Nurse #5 was asked how staff know this. Nurse #5 stated, "They know." During an interview in the activity room on 5/2/14 at 9:30 AM, the Administrator (the Abuse Coordinator) was asked what was expected if an allegation of abuse was reported to a unit manager. The Administrator stated, "I would expect the unit manager to investigate the situation and report it to me. I was not aware of the situation with (Named Resident #7 and CNA #22) until yesterday." The facility failed to thoroughly investigate and follow up on Resident #7's voiced grievances of not providing preference and needed care for dining and personal hygiene. 4. The facility failed to resolve grievances voiced by Residents #7 and 218.

Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility staff failed to implement their abuse/neglect policy for investigating and/or reporting allegations of abuse and neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents reviewed included in the stage 2 sample. The facility staff failed to ensure allegations of fear and elopement from the facility were thoroughly investigated and/or reported to administration when Resident #218 reported the inability to sleep at night for fear of Resident #220 entering her room; Resident #220's behaviors of wandering, exit seeking and elopement from the facility which resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F226 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F226 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse... are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that the resident (#220) had come into her mother's room. Resident #218's daughter stated, "About a month ago he (Resident #220) came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 was discharged to the hospital on [DATE]. Resident #218 was scared and unable to sleep due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. The facility was unable to provide an incident report or an investigation related to Resident #218's reported fear of Resident #220 wandering into her room. The facility failed to implement the abuse policy related to documenting incidents; failed to thoroughly investigate and follow up on voiced grievances; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 3. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement the abuse policy to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for the nursing staff on when and how to complete an SBAR, how to document information on the SBAR, the abuse policy, when and what to care plan, how to complete a head to toe assessment and how to document findings, what type of interventions to put in place depending on the residents condition, how to complete an investigation on elopement and abuse, how to complete an incident report and how to check the placement of wanderguards. An addendum to the abuse policy was written that prohibits retaliation against any resident or employee that reports abuse. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and that RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. There have been no allegations of abuse, neglect, misappropriation, or injury of unknown cause since the exit date of 5/5/14. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Interviews with Licensed Nursing Staff: Licensed Practical Nurses, RN's and Unit Managers, conducted on May 23, 2014, in the facility, revealed staff verbalized when and how to complete an SBAR, how to document information on the 24 hour report, how to update/revise care plans based on the needs of the resident, how to complete a head-to-toe assessment and document the findings, how to complete an investigation on abuse or elopement, how to complete an incident report, and how to check wanderguard placement. The facility provided evidence that daily incident and accident reports, the 24-hour report, the Wanderguard Daily Checklist and SBAR's are reviewed in the morning clinical meetings. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. Medical record review for Resident #218 documented the DON was making weekly visits and no further issues had been reported. There was documentation by the Nurse Practitioner and the DON that addressed her concerns and her inability to sleep. Resident #218's care plan has been updated to reflect the use of the "STOP" sign and her concerns. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left" The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility staff failed to implement their abuse/neglect policy for investigating and/or reporting allegations of abuse and neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents reviewed included in the stage 2 sample. The facility staff failed to ensure allegations of fear and elopement from the facility were thoroughly investigated and/or reported to administration when Resident #218 reported the inability to sleep at night for fear of Resident #220 entering her room; Resident #220's behaviors of wandering, exit seeking and elopement from the facility which resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F226 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse... are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that the resident (#220) had come into her mother's room. Resident #218's daughter stated, "About a month ago he (Resident #220) came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 was discharged to the hospital on [DATE]. Resident #218 was scared and unable to sleep due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. The facility was unable to provide an incident report or an investigation related to Resident #218's reported fear of Resident #220 wandering into her room. The facility failed to implement the abuse policy related to documenting incidents; failed to thoroughly investigate and follow up on voiced grievances; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 3. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement the abuse policy to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level. The deficiency level for F225 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J) and continues in substantial non compliance. Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility failed to thoroughly investigate and report allegations of abuse and/or neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and/or neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #218 and 220. The facility staff failed to investigate and/or report to administration the following: a reported incident of fear and inability of Resident #218 to rest at night for fear of Resident #220 entering her room and incidents of Resident #220's behaviors of wandering, exit seeking and elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F225 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A. ...physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (named Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 voiced that she was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in Immediate Jeopardy. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while making rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

Based on policy review, review of the 24 hour nursing log, medical record review, observation and interview, it was determined the facility failed to prevent psychological harm and potential resident to resident altercation for 1 of 6 (Resident #218) residents reviewed for abuse of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate incidents; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218, who stated she was afraid of another resident (Resident #220) and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F223 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's "ABUSE, NEGLECT AND MISAPPROPRIATION" policy documented, "...POLICY... Verbal, sexual, physical, and mental abuse... of the resident... are prohibited... V. Protection of the Resident... A. All allegations of abuse are to be reported immediately to charge nurse... D. The charge nurse will immediately notify the Administrator, DON... VI. Resident to Resident... A. If a resident is observed exhibiting any form of abuse towards another resident, staff will intervene immediately... C. Administrator and/or DON will be notified immediately... D. Residents will be closely supervised... VII... All allegations of abuse will be investigated and reported to the appropriate agencies..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway of Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him (Resident #220) coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of Resident #220's care plan with a start date of 2/24/14 addressed wandering and elopement risk. The care plan was revised on 4/23/14 to include refusing/rejecting care and on 4/24/14 to include combative/verbally abusive. There is no documentation in Resident #220's medical record related to him wandering into Resident #218's room. Review of a daily skilled nurses note dated 4/22/14 on the 3-11 shift for Resident #220 documented, "...requires constant attention by staff... When the new admission arrived this resident went in the tx (treatment) nurse office urinated and had a bowel movement. The other nurse said she tried to stop him from going in tx nurse office stated he had a chart and he hit her..." 4. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy.

Based on policy review, review of the 24 hour nursing log, medical record review, observation and interview, it was determined the facility failed to prevent psychological harm and potential resident to resident altercation for 1 of 6 (Resident #218) residents reviewed for abuse of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate incidents; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218, who stated she was afraid of another resident (Resident #220) and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F223 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F223 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "ABUSE, NEGLECT AND MISAPPROPRIATION" policy documented, "...POLICY... Verbal, sexual, physical, and mental abuse... of the resident... are prohibited... V. Protection of the Resident... A. All allegations of abuse are to be reported immediately to charge nurse... D. The charge nurse will immediately notify the Administrator, DON... VI. Resident to Resident... A. If a resident is observed exhibiting any form of abuse towards another resident, staff will intervene immediately... C. Administrator and/or DON will be notified immediately... D. Residents will be closely supervised... VII... All allegations of abuse will be investigated and reported to the appropriate agencies..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway of Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him (Resident #220) coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of Resident #220's care plan with a start date of 2/24/14 addressed wandering and elopement risk. The care plan was revised on 4/23/14 to include refusing/rejecting care and on 4/24/14 to include combative/verbally abusive. There is no documentation in Resident #220's medical record related to him wandering into Resident #218's room. Review of a daily skilled nurses note dated 4/22/14 on the 3-11 shift for Resident #220 documented, "...requires constant attention by staff... When the new admission arrived this resident went in the tx (treatment) nurse office urinated and had a bowel movement. The other nurse said she tried to stop him from going in tx nurse office stated he had a chart and he hit her..." 4. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for the Administrator and DON on abuse, for all staff on the facility abuse policy and for all licensed nursing staff on the investigation of incidents and the implementation of measurable goals. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and that RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. An addendum to the abuse policy was written that prohibits retaliation against any resident or employee that reports abuse. Incident reports since the exit date of 5/5/14 were reviewed. There was evidence the reports were reviewed by the Supervisors, DON and / or the Unit Managers to ensure intervention, investigation and that measurable goals were implemented and a investigation was started. The incidents were recorded on the "Nursing Supervisor Report" form and on the 24 hour report. There was evidence the incidents were discussed during the clinical morning meeting. The care plans were revised as indicated. There have been no allegations of abuse, neglect, misappropriation or injury of unknown cause since the exit date of 5/5/14. Interviews with Direct Care Staff: CNA's, Licensed Practical Nurses and RN's, conducted on May 23, 2014, in the facility, staff verbalized what constitutes abuse, whom to report the alleged abuse to, and what to document. Licensed nursing staff verbalized how to initiate an investigation and how to develop and initiate measurable goals. The Unit Managers verbalized how to complete an investigation and how to ensure that measurable goals were implemented, how to document on the Nursing Supervisors Report and the 24 hour report. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for Resident #218 documented the DON was making weekly visits and no further issues had been reported. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left." The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to ensure care and treatment for [REDACTED].#220) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to effectively treat behaviors and implement new interventions for wandering and exit seeking behavior resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) when Resident #220 eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F319 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's "ELOPEMENT / WANDERING RESIDENTS" policy documented, "...Care plans and individual behavior plans will address wandering as a specific problems. Approaches will be formulated, patterns identified and the causes determined will be addressed ..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building... Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There is no evidence that the care plan was revised after the elopement on 4/1514. Review of the behavior intervention monthly flow record for "4/15 (2014)" documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros are documented on the day shift on 4/26/14; the evening shift on 4/14/14 - 4/18/14 and 4/21/14 - 4/26/14 and 4/28/14 - 4/30/14; and on the night shift on 4/15/14 - 4/20/14, and 4/22/14 - 4/30/14. All other dates are blank. There is no evidence the facility was tracking wandering. There is no evidence that Resident #220 was seen by Psychology services until 4/25/14. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here... I don't want that man coming into my room scaring me and making me have a set-back..." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to implement new, appropriate and measurable interventions to address wandering and exit seeking behavior which placed Resident #220 in immediate jeopardy when he eloped.

Based on policy review, review of a shift assignment sheet, medical record review and interview, it was determined the facility failed to fully investigate grievances voiced by 2 of 52 (Residents #218 and 7) residents included in the stage 2 sample. The failure of the facility to thoroughly investigate grievances; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218 who stated she was afraid of Resident #220 and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F166 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "Investigating a Resident Grievance or Complaint" policy documented, "...all grievances and /or complaints be investigated by the appropriate facility staff and recorded on the grievance/complaint log... the Social Services Director... will begin an investigation into the allegations..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resides in a private room that is next door to Resident#220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man (Resident #220) next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the social worker's office on 5/1/14 at 10:21 AM, the Social Worker was asked if anyone had reported any issues or concerns about Resident #220. The Social worker stated, "I just heard about it a few minutes ago." Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. Resident #220 had wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to follow up on grievances voiced by Resident #218, who is unable to sleep at night for fear of Resident #220 entering her room at night. The facility failed to implement new, appropriate and measurable interventions to keep Resident #218 safe resulted in immediate jeopardy. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented a BIMS score of 15 indicating the resident had no cognitive impairments, required set up help with eating, and had bilateral upper extremity impairment on both sides. The care plan dated 10/16/13 and updated on 4/9/14 documented, "Problem-Impaired mobility w (with) / self-care deficit r/t/ (related to) h/o (history of)[MEDICAL CONDITION]/ Rt. (right) hemi (stroke with right paralysis), h/o GSW (gunshot wound) to head... Approach-Frequency 1. Provide full staff assistance w/bathing, dressing, personal hygiene, grooming, oral, and incontinent care... 3. Set-up all equipment for personal care... 4. Assist resident w/oral care..." During an interview in Resident #7's room on 4/28/14 at 3:20 PM, Resident #7 stated, "(Named CNA #22) left trays without opening items, happens all the time, have told (Named Nurse #5)." During an interview at the 100/200 nurses' station on 4/30/14 at 4:00 PM, Nurse #5 (unit manager) was asked about any complaints regarding care reported by Resident #7. Nurse #5 stated, "Yes, she did complain to me right after I started here (empolyed 2/2014) about (named CNA #22). She complained she (CNA #22) did not put her to bed when she wanted to and did not open her items on her trays for her. I talked to both of them (Resident #7 and CNA #22). I removed (named CNA #22) from caring for (named Resident #7)." Nurse #5 was asked if there were any investigations of these complaints. Nurse #5 stated, "No, I did not write this up anywhere. No, do not have a grievance log. No, I did not document this anywhere. I just talked to them." Nurse #5 was asked about how charge nurses were informed of her removing CNA #22 of caring for Resident #7. Nurse #5 stated, "They (nurses) know, they do not assign (named CNA #22) to (named Resident #7)." The surveyor asked to review the 4/30/14 3-11 shift assignment sheet. The assignment sheet documented Resident #7 was assigned on paper to CNA #22. Nurse #5 stated, "She (named CNA #22) knows not to go in her (Resident #7's) room. She (CNA #22) will get one of the other CNA's to do (named Resident #7) for her." Nurse #5 was asked how staff know this. Nurse #5 stated, "They know." During an interview in the activity room on 5/2/14 at 9:30 AM, the Administrator (the Abuse Coordinator) was asked what was expected if an allegation of abuse was reported to a unit manager. The Administrator stated, "I would expect the unit manager to investigate the situation and report it to me. I was not aware of the situation with (Named Resident #7 and CNA #22) until yesterday." The facility failed to thoroughly investigate and follow up on Resident #7's voiced grievances of not providing preference and needed care for dining and personal hygiene. 4. The facility failed to resolve grievances voiced by Residents #7 and 218. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets, for all licensed nursing staff and the Social Services Department on the policy for investigating grievances and concerns, how to complete and how to document on a grievance form. The facility provided evidence the Social Services Department had interviewed residents to ensure that grievances were reported, investigated and addressed timely. Medical record review for Resident #7, #108 and #220 were reviewed for grievances. There was evidence the Social Worker addressed Resident #7's desire to change rooms in a timely manner and to the resident's satisfaction. Interviews with Direct Care Staff: CNA's, Licensed Practical Nurses, Registered Nurses, conducted on May 23, 2014, in the facility, nursing staff verbalized how to investigate a grievance or concerns reported by the resident or family, how to complete the grievance form and who to report to. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The Social Worker did attend the QA meeting on May 19, 2014. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of a shift assignment sheet, medical record review and interview, it was determined the facility failed to fully investigate grievances voiced by 2 of 52 (Residents #218 and 7) residents included in the stage 2 sample. The failure of the facility to thoroughly investigate grievances; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218 who stated she was afraid of Resident #220 and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's "Investigating a Resident Grievance or Complaint" policy documented, "...all grievances and /or complaints be investigated by the appropriate facility staff and recorded on the grievance/complaint log... the Social Services Director... will begin an investigation into the allegations..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resides in a private room that is next door to Resident#220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man (Resident #220) next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the social worker's office on 5/1/14 at 10:21 AM, the Social Worker was asked if anyone had reported any issues or concerns about Resident #220. The Social worker stated, "I just heard about it a few minutes ago." Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. Resident #220 had wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to follow up on grievances voiced by Resident #218, who is unable to sleep at night for fear of Resident #220 entering her room at night. The facility failed to implement new, appropriate and measurable interventions to keep Resident #218 safe resulted in immediate jeopardy. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented a BIMS score of 15 indicating the resident had no cognitive impairments, required set up help with eating, and had bilateral upper extremity impairment on both sides. The care plan dated 10/16/13 and updated on 4/9/14 documented, "Problem-Impaired mobility w (with) / self-care deficit r/t/ (related to) h/o (history of)[MEDICAL CONDITION]/ Rt. (right) hemi (stroke with right paralysis), h/o GSW (gunshot wound) to head... Approach-Frequency 1. Provide full staff assistance w/bathing, dressing, personal hygiene, grooming, oral, and incontinent care... 3. Set-up all equipment for personal care... 4. Assist resident w/oral care..." During an interview in Resident #7's room on 4/28/14 at 3:20 PM, Resident #7 stated, "(Named CNA #22) left trays without opening items, happens all the time, have told (Named Nurse #5)." During an interview at the 100/200 nurses' station on 4/30/14 at 4:00 PM, Nurse #5 (unit manager) was asked about any complaints regarding care reported by Resident #7. Nurse #5 stated, "Yes, she did complain to me right after I started here (empolyed 2/2014) about (named CNA #22). She complained she (CNA #22) did not put her to bed when she wanted to and did not open her items on her trays for her. I talked to both of them (Resident #7 and CNA #22). I removed (named CNA #22) from caring for (named Resident #7)." Nurse #5 was asked if there were any investigations of these complaints. Nurse #5 stated, "No, I did not write this up anywhere. No, do not have a grievance log. No, I did not document this anywhere. I just talked to them." Nurse #5 was asked about how charge nurses were informed of her removing CNA #22 of caring for Resident #7. Nurse #5 stated, "They (nurses) know, they do not assign (named CNA #22) to (named Resident #7)." The surveyor asked to review the 4/30/14 3-11 shift assignment sheet. The assignment sheet documented Resident #7 was assigned on paper to CNA #22. Nurse #5 stated, "She (named CNA #22) knows not to go in her (Resident #7's) room. She (CNA #22) will get one of the other CNA's to do (named Resident #7) for her." Nurse #5 was asked how staff know this. Nurse #5 stated, "They know." During an interview in the activity room on 5/2/14 at 9:30 AM, the Administrator (the Abuse Coordinator) was asked what was expected if an allegation of abuse was reported to a unit manager. The Administrator stated, "I would expect the unit manager to investigate the situation and report it to me. I was not aware of the situation with (Named Resident #7 and CNA #22) until yesterday." The facility failed to thoroughly investigate and follow up on Resident #7's voiced grievances of not providing preference and needed care for dining and personal hygiene. 4. The facility failed to resolve grievances voiced by Residents #7 and 218.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely notify the attending physician of a significant change of condition of 1 of 6 (Resident #22) residents reviewed for abuse/neglect of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITIONS], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F157 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." 2. Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity until 4/24/14. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed a family member at the bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all Charge Nurses and Unit Managers on resident assessment, notifying the Physician and Responsible Party timely of a change in the resident status and for all licensed nursing staff regarding physician and family notifications. The facility provided evidence of auditing logs to ensure all significant resident's changes were communicated to the physician and family and that the 24 hour report was reviewed in morning clinicals. Review of the auditing logs and the 24 hour report revealed the facility was utilizing and monitoring the logs and reports timely. Medical Record Review for Resident #7 and #108 documented no changes since 5/22/14. There was evidence in both records that changes since the exit date of 5/5/14 had been reported to the physician and family and had been documented on the 24 hour report. Interviews with Charge Nurses and Unit Managers, conducted on 5/23/14, in the facility, nursing staff verbalized when and how to do a resident assessment, and timely notification of the physician and responsible party when there is a change in the resident's condition. Licensed Practical Nurses and Registered Nurses were able to verbalize when to notify the physician and the responsible party. The 24 hour reports will continue to be reviewed in the morning clinical meetings by the Director of Nursing and the Unit Managers. The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely notify the attending physician of a significant change of condition of 1 of 6 (Resident #22) residents reviewed for abuse/neglect of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITIONS], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." 2. Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity until 4/24/14. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed a family member at the bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

Based on policy review, review of the daily staff sheets, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right for 1 of 52 (Resident #22) resident reviewed of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F309 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. Except in a medical emergency or when a resident is deemed incompetent, the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor vital signs (temperature, pulse respiration, blood pressure, oxygen saturation, pain level) at the onset of the change and as ordered by the physician... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record all physician contacts and notifications. The Change of Condition Evaluation Tool will serve as the official nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 for Resident #22 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test used to determine therapuetic levels for a blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 (was the first time nurses documented swelling) documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows, she has a poor appetite, the last 2 days has had no to little po (my mouth) intake and no medications taken." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request... she was there 2 to (-) 3 days and returned still not eating..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, CNA #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater, I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

Based on policy review, review of a facility report, medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for monitoring a resident's skin and reporting change of conditions to the physician, to protect from wandering and exit seeking behavior, complete wander guard checks and ensure a bed alarm and mat was in place for 4 of 34 (Residents #22, 220, 108 and 247) sampled residents of the 52 residents reviewed on the stage 2 sample. The failure of the facility to follow the care plan intervention for monitoring a resident's arm and timely notification of condition changes to the physician resulted in a delay of treatment for [REDACTED].#220 from elopement and entering another resident's room resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death when Resident #22 who was at high risk for [MEDICAL CONDITIONS] developed a [MEDICAL CONDITION] and Resident #220 wandered into another resident's room and eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health... in an efficient and effective manner; to relay assessment information to physician and to document actions... facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... " Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE (right upper extremity) for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22)... can't remember exact dates March/April 2014, when... her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot..." During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to follow the care plan intervention for monitoring the right arm by failing to complete timely assessments and notification of [MEDICAL CONDITION] to the physician which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing a [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations as needed..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to Kroger. Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no evidence the care plan was effective to protect Resident #220 from eloping from the facility. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." There is no evidence Resident #220's care plan was implemented to keep him from wandering into Resident #218's room which caused psychological harm to Resident #218 when she voiced her inability to rest due to fear of Resident #220 entering her room. The facility failed to implement interventions to address wandering and exit seeking behavior to keep the resident's safe and free from psychological harm and elopement which placed Resident #218 and Resident #220 in immediate jeopardy. Refer to F223. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift..." Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the alarm being checked. During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurses #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard..." During an interview in the Restorative Nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. Nurse #2 stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." The facility failed to follow the care plan intervention to check Resident #108's wanderguard for proper functioning at beginning of shift and end of shift. 4. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of [MEDICAL CONDITION] Approach... Frequency... Bed alarm..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place as care planned. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm in place as care planned.

Based on policy review, review of a facility report, medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for monitoring a resident's skin and reporting change of conditions to the physician, to protect from wandering and exit seeking behavior, complete wander guard checks and ensure a bed alarm and mat was in place for 4 of 34 (Residents #22, 220, 108 and 247) sampled residents of the 52 residents reviewed on the stage 2 sample. The failure of the facility to follow the care plan intervention for monitoring a resident's arm and timely notification of condition changes to the physician resulted in a delay of treatment for [REDACTED].#220 from elopement and entering another resident's room resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death when Resident #22 who was at high risk for [MEDICAL CONDITIONS] developed a [MEDICAL CONDITION] and Resident #220 wandered into another resident's room and eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F282 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health... in an efficient and effective manner; to relay assessment information to physician and to document actions... facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... " Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE (right upper extremity) for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22)... can't remember exact dates March/April 2014, when... her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot..." During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to follow the care plan intervention for monitoring the right arm by failing to complete timely assessments and notification of [MEDICAL CONDITION] to the physician which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing a [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations as needed..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to grocery store. Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no evidence the care plan was effective to protect Resident #220 from eloping from the facility. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." There is no evidence Resident #220's care plan was implemented to keep him from wandering into Resident #218's room which caused psychological harm to Resident #218 when she voiced her inability to rest due to fear of Resident #220 entering her room. The facility failed to implement interventions to address wandering and exit seeking behavior to keep the resident's safe and free from psychological harm and elopement which placed Resident #218 and Resident #220 in immediate jeopardy. Refer to F223. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift..." Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the alarm being checked. During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurses #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard..." During an interview in the Restorative Nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. Nurse #2 stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." The facility failed to follow the care plan intervention to check Resident #108's wanderguard for proper functioning at beginning of shift and end of shift. 4. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of [MEDICAL CONDITION] Approach... Frequency... Bed alarm..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place as care planned. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm in place as care planned. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all licensed staff on how to complete a head-to-toe assessment and document findings, notifying the physician and family, documenting on the 24 hour report, how to complete an SBAR, how to complete an investigation and how to put necessary interventions in place. Evidence was provided that the Restorative Nurse and the Restorative Aide were in-serviced on how to properly use the tester to check Wanderguard functioning and how to document findings on the Wanderguard Daily Checklist. Interviews with Licensed Nursing Staff: Licensed Practical Nurses and RN's conducted on May 23, 2014, in the facility, staff verbalized how to complete a head -to-toe assessment and document the findings, what to document on the 24 hour report, when to notify the physician and the resident's family, what to document on the 24 hour report, when and how to complete an SBAR, how to complete an investigation, and how to implement interventions based on the residents condition. Interview with the Restorative Nurse revealed that he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed that she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. Resident #22 passed away during the annual recertification survey. Resident #220 remains in the hospital. Medical record review for Resident #218 documented that the care plan has been updated to reflect the use of the "STOP" sign and her concerns. Medical record review for Resident #108 has been updated to reflect her risk of elopement. Elopement / Wandering Monitoring Form documentation is present. During an interview the DON was asked about the process in place for implementing interventions based on the needs of the resident. The DON stated, "Review the 24 hour report in the morning meeting, if resident has a change or problem then the resident is added to the HART (Health Assessment Review Team) Team Review Checklist. The medical record is reviewed, the nurses notes are reviewed to make sure that every shift charts and the MD (Medical Doctor) and family are notified, new orders are reviewed, accident and injury reports are reviewed if applicable, check care plans for interventions, then we fix it. We meet on this daily." During an interview, the DON stated that the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of the daily staff sheets, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right for 1 of 52 (Resident #22) resident reviewed of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F309 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. Except in a medical emergency or when a resident is deemed incompetent, the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor vital signs (temperature, pulse respiration, blood pressure, oxygen saturation, pain level) at the onset of the change and as ordered by the physician... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record all physician contacts and notifications. The Change of Condition Evaluation Tool will serve as the official nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 for Resident #22 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test used to determine therapuetic levels for a blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 (was the first time nurses documented swelling) documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows, she has a poor appetite, the last 2 days has had no to little po (my mouth) intake and no medications taken." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request... she was there 2 to (-) 3 days and returned still not eating..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, CNA #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater, I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

Based on policy review, review of the daily staff sheets, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right for 1 of 52 (Resident #22) resident reviewed of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F309 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F309 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. Except in a medical emergency or when a resident is deemed incompetent, the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor vital signs (temperature, pulse respiration, blood pressure, oxygen saturation, pain level) at the onset of the change and as ordered by the physician... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record all physician contacts and notifications. The Change of Condition Evaluation Tool will serve as the official nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 for Resident #22 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test used to determine therapuetic levels for a blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 (was the first time nurses documented swelling) documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." An acute visit dated 4/29/14 completed by the NP documented, "...History of complex mass arm may cause flow issues... d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows, she has a poor appetite, the last 2 days has had no to little po (my mouth) intake and no medications taken." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, "(Named Resident #22) was sent out to hospital due to decreased intake at her daughters request... she was there 2 to (-) 3 days and returned still not eating..." Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, CNA #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, "I am a floater, I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all licensed nursing staff on how to perform a head-to-toe assessment and how to put the necessary interventions into place. During an interview the DON was asked about the process in place for implementing interventions based on the needs of the resident. The DON stated, "Review the 24 hour report in the morning meeting, if resident has a change or problem then the resident is added to the HART (Health Assessment Review Team) Team Review Checklist. The medical record is reviewed, the nurses notes are reviewed to make sure that every shift charts and the MD (Medical Doctor) and family are notified, new orders are reviewed, accident and injury reports are reviewed if applicable, check care plans for interventions, then we fix it. We meet on this daily." During an interview, the DON stated that the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. Resident #22 passed away during the annual recertification survey. The 24 hour report and the HART Team Review Checklist were reviewed with no concerns identified. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to ensure care and treatment for [REDACTED].#220) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to effectively treat behaviors and implement new interventions for wandering and exit seeking behavior resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) when Resident #220 eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F319 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's "ELOPEMENT / WANDERING RESIDENTS" policy documented, "...Care plans and individual behavior plans will address wandering as a specific problems. Approaches will be formulated, patterns identified and the causes determined will be addressed ..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building... Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There is no evidence that the care plan was revised after the elopement on 4/1514. Review of the behavior intervention monthly flow record for "4/15 (2014)" documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros are documented on the day shift on 4/26/14; the evening shift on 4/14/14 - 4/18/14 and 4/21/14 - 4/26/14 and 4/28/14 - 4/30/14; and on the night shift on 4/15/14 - 4/20/14, and 4/22/14 - 4/30/14. All other dates are blank. There is no evidence the facility was tracking wandering. There is no evidence that Resident #220 was seen by Psychology services until 4/25/14. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here... I don't want that man coming into my room scaring me and making me have a set-back..." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to implement new, appropriate and measurable interventions to address wandering and exit seeking behavior which placed Resident #220 in immediate jeopardy when he eloped.

Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility staff failed to implement their abuse/neglect policy for investigating and/or reporting allegations of abuse and neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents reviewed included in the stage 2 sample. The facility staff failed to ensure allegations of fear and elopement from the facility were thoroughly investigated and/or reported to administration when Resident #218 reported the inability to sleep at night for fear of Resident #220 entering her room; Resident #220's behaviors of wandering, exit seeking and elopement from the facility which resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F226 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F226 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse... are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that the resident (#220) had come into her mother's room. Resident #218's daughter stated, "About a month ago he (Resident #220) came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 was discharged to the hospital on [DATE]. Resident #218 was scared and unable to sleep due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. The facility was unable to provide an incident report or an investigation related to Resident #218's reported fear of Resident #220 wandering into her room. The facility failed to implement the abuse policy related to documenting incidents; failed to thoroughly investigate and follow up on voiced grievances; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 3. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement the abuse policy to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for the nursing staff on when and how to complete an SBAR, how to document information on the SBAR, the abuse policy, when and what to care plan, how to complete a head to toe assessment and how to document findings, what type of interventions to put in place depending on the residents condition, how to complete an investigation on elopement and abuse, how to complete an incident report and how to check the placement of wanderguards. An addendum to the abuse policy was written that prohibits retaliation against any resident or employee that reports abuse. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and that RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. There have been no allegations of abuse, neglect, misappropriation, or injury of unknown cause since the exit date of 5/5/14. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Interviews with Licensed Nursing Staff: Licensed Practical Nurses, RN's and Unit Managers, conducted on May 23, 2014, in the facility, revealed staff verbalized when and how to complete an SBAR, how to document information on the 24 hour report, how to update/revise care plans based on the needs of the resident, how to complete a head-to-toe assessment and document the findings, how to complete an investigation on abuse or elopement, how to complete an incident report, and how to check wanderguard placement. The facility provided evidence that daily incident and accident reports, the 24-hour report, the Wanderguard Daily Checklist and SBAR's are reviewed in the morning clinical meetings. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. Medical record review for Resident #218 documented the DON was making weekly visits and no further issues had been reported. There was documentation by the Nurse Practitioner and the DON that addressed her concerns and her inability to sleep. Resident #218's care plan has been updated to reflect the use of the "STOP" sign and her concerns. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left" The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of the 24 hour nursing log, medical record review, observation and interview, it was determined the facility failed to prevent psychological harm and potential resident to resident altercation for 1 of 6 (Resident #218) residents reviewed for abuse of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate incidents; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218, who stated she was afraid of another resident (Resident #220) and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F223 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's "ABUSE, NEGLECT AND MISAPPROPRIATION" policy documented, "...POLICY... Verbal, sexual, physical, and mental abuse... of the resident... are prohibited... V. Protection of the Resident... A. All allegations of abuse are to be reported immediately to charge nurse... D. The charge nurse will immediately notify the Administrator, DON... VI. Resident to Resident... A. If a resident is observed exhibiting any form of abuse towards another resident, staff will intervene immediately... C. Administrator and/or DON will be notified immediately... D. Residents will be closely supervised... VII... All allegations of abuse will be investigated and reported to the appropriate agencies..." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway of Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him (Resident #220) coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of Resident #220's care plan with a start date of 2/24/14 addressed wandering and elopement risk. The care plan was revised on 4/23/14 to include refusing/rejecting care and on 4/24/14 to include combative/verbally abusive. There is no documentation in Resident #220's medical record related to him wandering into Resident #218's room. Review of a daily skilled nurses note dated 4/22/14 on the 3-11 shift for Resident #220 documented, "...requires constant attention by staff... When the new admission arrived this resident went in the tx (treatment) nurse office urinated and had a bowel movement. The other nurse said she tried to stop him from going in tx nurse office stated he had a chart and he hit her..." 4. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy.

Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to ensure care and treatment for [REDACTED].#220) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to effectively treat behaviors and implement new interventions for wandering and exit seeking behavior resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) when Resident #220 eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F319 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F319 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "ELOPEMENT / WANDERING RESIDENTS" policy documented, "...Care plans and individual behavior plans will address wandering as a specific problems. Approaches will be formulated, patterns identified and the causes determined will be addressed ..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building... Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There is no evidence that the care plan was revised after the elopement on 4/1514. Review of the behavior intervention monthly flow record for "4/15 (2014)" documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros are documented on the day shift on 4/26/14; the evening shift on 4/14/14 - 4/18/14 and 4/21/14 - 4/26/14 and 4/28/14 - 4/30/14; and on the night shift on 4/15/14 - 4/20/14, and 4/22/14 - 4/30/14. All other dates are blank. There is no evidence the facility was tracking wandering. There is no evidence that Resident #220 was seen by Psychology services until 4/25/14. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here... I don't want that man coming into my room scaring me and making me have a set-back..." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to implement new, appropriate and measurable interventions to address wandering and exit seeking behavior which placed Resident #220 in immediate jeopardy when he eloped. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all licensed nursing staff on how to handle wandering residents, the "Elopement/Missing Person" and the "Behavior Monitoring Sheet" policy, and documenting on the 24 hour report. Evidence that all facility staff were trained on how to handle wandering residents and whom to report the behavior. The facility provided evidence that elopement drills had been conducted on every shift. Interviews with Licensed Nursing Staff: Licensed Practical Nurses, RN's and Unit Managers, conducted on May 23, 2014, in the facility, staff verbalized how to handle a wandering resident, elements of the "Elopement/Missing Person" policy, use of the behavior monitoring sheets and how to document on the 24 hour report. Licensed staff also verbalized what to do if a resident is reported missing and stated they have been involved in elopement drills where they canvas the area around the facility. Interviews with facility staff: CNA's and Housekeeping staff, conducted on May 23, 2014 in the facility, the staff verbalized how to handle a wandering resident and whom to report the behavior. Staff also verbalized what to do if a resident is reported missing and stated they have been involved in elopement drills where they canvas the area around the facility. There have been no incidents of elopement or exit-seeking behavior since the exit date of 5/5/14. A list of Resident's currently in the building that wander was requested. The Wanderguard Checklist, Elopement/Wandering Monitoring Form, Risk of Elopement Evaluation and Elopement Risk Assessment Forms, Care Plans, Behavior Monitoring Sheets and the 24 Hour Report were reviewed with no concerns identified. The facility will remain out of compliance at a Scope and Severity level "D", an isolated deficient practice that constitutes no actual harm with potential for minimal harm that is not immediate jeopardy.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F323 was cited at a G level. The deficiency level for F323 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F323 J) and continues in substantial non compliance. Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to investigate and implement interventions for wandering, exit seeking behavior and failed to ensure supervision was provided when staff failed to respond to an alarm or failed to check a wanderguard each shift as ordered by the physician for 2 of 5 (Residents #220 and 108) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to respond to a sounding alarm; thoroughly investigate and implement new interventions for wandering and exit seeking behavior allowed Resident #220 to elopement from the facility which resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F323 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or edema..." A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." The facility was unable to provide documentation that the facility checked the functioning of Resident #220's wanderguard or the facility alarm system after he returned to the facility nor were there any interventions put in place to prevent further elopement. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. The failure of the facility to respond to a sounding alarm and failure to follow a resident observed leaving the facility resulted in immediate jeopardy when Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement new, appropriate and measurable interventions to prevent elopement. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the MDS dated [DATE] and updated 2/1/14 documented Resident #108 as being severely impaired in decision making skills and requiring extensive assist and one person physical assist with ambulation. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the wanderguard being checked. Review of an elopement risk assessment dated [DATE] was coded with a score of 18 with a score of 8 or greater indicating at risk for elopement. Review of nurses' note dated 8/29/13 documented "...At 1:15 AM nurse (and) CNA (Certified Nursing Assistant) made rounds to check on resi (resident)... noted she was not in room... (C station CNA) noted D-Station exit door and opened it finding resident resting on ground near the door..." Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift. Keep resident close to supervised areas. Staff to intervene when wandering is observed..." During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurse #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard." During an interview in the restorative nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. The Restorative Nurse (#2) stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." During an interview on the 600 hall on 5/5/14 at 3:50 PM, the Certified Nursing Assistant (CNA) #11 was asked what were her responsibility for wanderguards on her assigned residents. CNA #11 stated, "We don't check them, just make sure they have it on..." B. Based on policy review, review of an incident report, medical record review, observation and interview, it was determined the facility failed to ensure fall interventions of a bed alarm and mat were in place for 1 of 3 (Resident #247) residents of the 3 residents with falls of the 52 residents included in the stage 2 sample. The facility failed to ensure the residents environment remained free of accident hazards as is possible when nails were sticking out from the handrails for 1 of 8 (100 hall) halls. The findings included: 1. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of CVA... Approach... Frequency... Bed alarm..." Review of an incident report dated 4/24/14 documented, "...Resident found in floor laying on her right arm assisted by staff back to bed. this nurse assessed resident. Skin appeared without discoloration-skin tear, r (right) eyelid appeared with edema... Intervention Mat to Floor..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place nor was there a mat on the floor. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm or mat in place as care planned. 2. Observations on the 100 hall on 5/2/14 at 8:45 PM, revealed 2 nails sticking out of handrail next to the fire door between the 600 and 100 hall.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F514 was cited at a D level. The deficiency level for F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F514 J) and continues in substantial non compliance. Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure medical records contained complete and accurate documentation of a residents' conditions of [MEDICAL CONDITION] and wandering, wanderguard checks and/or a prescribed diet for 4 of 52 (Residents #22, 220, 108 and 130) residents reviewed included in the stage 2 sample. The failure of the facility to maintain a complete and accurate medical record resulted in a delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity on this date. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14..." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler... The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to document the [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change minimum data set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of the behavior intervention monthly flow record for 4/15/14 documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros were documented on the day shift on 4/26/14; the evening shift on 4/14/14 through (-) 4/18/14 and 4/21/14-4/26/14 and 4/28/14-4/30/14; and on the night shift on 4/15/14-4/20/14 and 4/22/14-4/30/14. All other dates are blank. There is no documentation the facility was tracking wandering. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if (named Resident #218's family) had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." The facility was unable to provide documentation of Resident #220 entering Resident #218's room. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the wanderguard being checked. Review of an elopement risk assessment dated [DATE] was coded with a score of 18 with a score of 8 or greater indicating at risk for elopement. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Check resident wanderguard for proper functioning at beginning of shift and end of shift..." During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurse #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard." During an interview in the restorative nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. The Restorative Nurse (#2) stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." During an interview on the 600 hall on 5/5/14 at 3:50 PM, the Certified Nursing Assistant (CNA) #11 was asked what were her responsibility for wanderguards on her assigned residents. CNA #11 stated, "We don't check them, just make sure they have it on..." 4. Based on medical record review and interview, it was determined the facility failed to ensure a resident was provided with the diet prescribed by the physician for 1 of 35 (Resident #130) residents of the 52 residents included in the stage 2 sample. The findings included: Medical record review for Resident #130 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Physician telephone orders documented the following: a. 10/22/13 - "...Change diet to mechanical soft for 7 days due to dental extraction..." b. 11/1/13 through 11/30/13 - "...Diet... Regular... No Added Salt..." c. 12/1/13 through 12/31/13 - "...Diet... Regular... No Added Salt..." d. 1/1/14 through 1/30/14 - "...Diet... Regular... No Added Salt..." e. 2/1/14 through 2/30/14 - "...Diet... Regular... No Added Salt..." f. 3/1/14 through 3/30/14 - "...Diet... Regular... No Added Salt..." g. 4/1/14 through 4/30/14 - "...Diet... Regular... No Added Salt..." Review of the "NUTRITION PROGRESS REPORT" documented the following: a. 8/8/13 - "...CURRENT DIET...Reg (Regular) NAS (no added salt)..." b. 11/14/13 - "...CURRENT DIET...mech (mechanical soft) NAS..." c. 1/31/14 - "...CURRENT DIET...MS (mechanical soft) NAS..." Observations in Resident #130's room on 4/28/14 at 7:58 AM, Resident #130's breakfast was a hard boiled egg and some type of unrecognizable chopped up meat. Resident #130 did not know what the food item was on this mechanical soft diet. The resident was not served a regular diet as ordered. During an interview in Resident #130's room on 4/29/14 at 9:28 AM, Resident #130 was asked does the food look good and appetizing. Resident #130 stated, "Doesn't look right and I've never seen it before." During an interview at the C hall nurses' station on 4/30/14 at 11:41 AM, Nurse #3 was asked why Resident #130 was on a mechanical soft diet. Nurse #3 stated, "Because of teeth... she had a tooth extraction..." Nurse #3 was asked if resident had an order for [REDACTED]. During an interview in the Resident's room on 5/2/14 at 12:35 PM, Resident#130 was served a regular texture lunch meal. Resident #130 lifted the top off of her plate and stated, "WOW! Chicken." 5. During an interview in the DON's office 4/30/14 at 2:10 PM, the DON was asked what she was doing to increase the communication between departments and improve documentation. The DON stated, "I realize there was a problem with documentation and transcribing orders." The facility failed to ensure medical records were complete and accurately documented.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F514 was cited at a D level. The deficiency level for F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F514 J) and continues in substantial non compliance. Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure medical records contained complete and accurate documentation of a residents' conditions of [MEDICAL CONDITION] and wandering, wanderguard checks and/or a prescribed diet for 4 of 52 (Residents #22, 220, 108 and 130) residents reviewed included in the stage 2 sample. The failure of the facility to maintain a complete and accurate medical record resulted in a delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2104, removed the Immediate Jeopardy. Noncompliance for F514 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity on this date. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14..." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler... The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to document the [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change minimum data set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of the behavior intervention monthly flow record for 4/15/14 documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros were documented on the day shift on 4/26/14; the evening shift on 4/14/14 through (-) 4/18/14 and 4/21/14-4/26/14 and 4/28/14-4/30/14; and on the night shift on 4/15/14-4/20/14 and 4/22/14-4/30/14. All other dates are blank. There is no documentation the facility was tracking wandering. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if (named Resident #218's family) had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." The facility was unable to provide documentation of Resident #220 entering Resident #218's room. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the wanderguard being checked. Review of an elopement risk assessment dated [DATE] was coded with a score of 18 with a score of 8 or greater indicating at risk for elopement. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Check resident wanderguard for proper functioning at beginning of shift and end of shift..." During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurse #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard." During an interview in the restorative nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. The Restorative Nurse (#2) stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." During an interview on the 600 hall on 5/5/14 at 3:50 PM, the Certified Nursing Assistant (CNA) #11 was asked what were her responsibility for wanderguards on her assigned residents. CNA #11 stated, "We don't check them, just make sure they have it on..." Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all staff on how to handle a wandering resident; for all licensed staff on the Elopement/Missing Person policy, how to perform a head-to-toe assessment and document any findings, how to complete an investigation, completing an incident/accident report, documented physician and family notifications regarding any significant change in the residents status, reviewing and properly transcribing telephone orders, checking monthly Physicians orders for accuracy, checking wanderguard placement, initiating the new "Elopement/Daily Wanderguard Checklist" and "Elopement Risk Assessment Quarterly Form", and updating care plans as warranted. The facility provided auditing logs for residents with wanderguards, and for the review of telephone orders. Interview with the Restorative Nurse revealed he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. Interviews with facility staff: CNA's and Housekeeping staff, conducted on May 23, 2014, in the facility, the facility staff verbalized how to handle a wandering resident. Interviews with licensed nursing staff: Licensed Practical Nurses, Registered Nurses, conducted on May 23, 2014, in the facility the staff verbalized elements of the Elopement / Missing Persons policy, how to perform a head-to-toe assessment and how to document findings, how to complete an investigation, how to complete an accident/incident report, when to notify the physician and the family and how to document the notifications, how to handle physician telephone orders and check the monthly orders for accuracy, how to check wanderguards, how to initiate the Elopement/Daily Wanderguard Checklist, and how to update care plans when needed. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. Medical record review for Resident #108 documented that staff are documenting her whereabouts every 2 hours on the "Elopement/Wandering Form". The Elopement/Quarterly Assessment has been completed. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy. 4. Based on medical record review and interview, it was determined the facility failed to ensure a resident was provided with the diet prescribed by the physician for 1 of 35 (Resident #130) residents of the 52 residents included in the stage 2 sample. The findings included: Medical record review for Resident #130 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Physician telephone orders documented the following: a. 10/22/13 - "...Change diet to mechanical soft for 7 days due to dental extraction..." b. 11/1/13 through 11/30/13 - "...Diet... Regular... No Added Salt..." c. 12/1/13 through 12/31/13 - "...Diet... Regular... No Added Salt..." d. 1/1/14 through 1/30/14 - "...Diet... Regular... No Added Salt..." e. 2/1/14 through 2/30/14 - "...Diet... Regular... No Added Salt..." f. 3/1/14 through 3/30/14 - "...Diet... Regular... No Added Salt..." g. 4/1/14 through 4/30/14 - "...Diet... Regular... No Added Salt..." Review of the "NUTRITION PROGRESS REPORT" documented the following: a. 8/8/13 - "...CURRENT DIET...Reg (Regular) NAS (no added salt)..." b. 11/14/13 - "...CURRENT DIET...mech (mechanical soft) NAS..." c. 1/31/14 - "...CURRENT DIET...MS (mechanical soft) NAS..." Observations in Resident #130's room on 4/28/14 at 7:58 AM, Resident #130's breakfast was a hard boiled egg and some type of unrecognizable chopped up meat. Resident #130 did not know what the food item was on this mechanical soft diet. The resident was not served a regular diet as ordered. During an interview in Resident #130's room on 4/29/14 at 9:28 AM, Resident #130 was asked does the food look good and appetizing. Resident #130 stated, "Doesn't look right and I've never seen it before." During an interview at the C hall nurses' station on 4/30/14 at 11:41 AM, Nurse #3 was asked why Resident #130 was on a mechanical soft diet. Nurse #3 stated, "Because of teeth... she had a tooth extraction..." Nurse #3 was asked if resident had an order for [REDACTED]. During an interview in the Resident's room on 5/2/14 at 12:35 PM, Resident#130 was served a regular texture lunch meal. Resident #130 lifted the top off of her plate and stated, "WOW! Chicken." 5. During an interview in the DON's office 4/30/14 at 2:10 PM, the DON was asked what she was doing to increase the communication between departments and improve documentation. The DON stated, "I realize there was a problem with documentation and transcribing orders." The facility failed to ensure medical records were complete and accurately documented.

Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility staff failed to implement their abuse/neglect policy for investigating and/or reporting allegations of abuse and neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents reviewed included in the stage 2 sample. The facility staff failed to ensure allegations of fear and elopement from the facility were thoroughly investigated and/or reported to administration when Resident #218 reported the inability to sleep at night for fear of Resident #220 entering her room; Resident #220's behaviors of wandering, exit seeking and elopement from the facility which resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F226 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A... physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse... are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that the resident (#220) had come into her mother's room. Resident #218's daughter stated, "About a month ago he (Resident #220) came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 was discharged to the hospital on [DATE]. Resident #218 was scared and unable to sleep due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. The facility was unable to provide an incident report or an investigation related to Resident #218's reported fear of Resident #220 wandering into her room. The facility failed to implement the abuse policy related to documenting incidents; failed to thoroughly investigate and follow up on voiced grievances; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 3. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement the abuse policy to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely notify the attending physician of a significant change of condition of 1 of 6 (Resident #22) residents reviewed for abuse/neglect of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITIONS], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." 2. Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity until 4/24/14. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed a family member at the bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

Based on policy review, review of a facility report, medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for monitoring a resident's skin and reporting change of conditions to the physician, to protect from wandering and exit seeking behavior, complete wander guard checks and ensure a bed alarm and mat was in place for 4 of 34 (Residents #22, 220, 108 and 247) sampled residents of the 52 residents reviewed on the stage 2 sample. The failure of the facility to follow the care plan intervention for monitoring a resident's arm and timely notification of condition changes to the physician resulted in a delay of treatment for [REDACTED].#220 from elopement and entering another resident's room resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death when Resident #22 who was at high risk for [MEDICAL CONDITIONS] developed a [MEDICAL CONDITION] and Resident #220 wandered into another resident's room and eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health... in an efficient and effective manner; to relay assessment information to physician and to document actions... facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... " Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE (right upper extremity) for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22)... can't remember exact dates March/April 2014, when... her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot..." During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to follow the care plan intervention for monitoring the right arm by failing to complete timely assessments and notification of [MEDICAL CONDITION] to the physician which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing a [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations as needed..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to Kroger. Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no evidence the care plan was effective to protect Resident #220 from eloping from the facility. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." There is no evidence Resident #220's care plan was implemented to keep him from wandering into Resident #218's room which caused psychological harm to Resident #218 when she voiced her inability to rest due to fear of Resident #220 entering her room. The facility failed to implement interventions to address wandering and exit seeking behavior to keep the resident's safe and free from psychological harm and elopement which placed Resident #218 and Resident #220 in immediate jeopardy. Refer to F223. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift..." Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the alarm being checked. During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurses #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard..." During an interview in the Restorative Nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. Nurse #2 stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." The facility failed to follow the care plan intervention to check Resident #108's wanderguard for proper functioning at beginning of shift and end of shift. 4. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of [MEDICAL CONDITION] Approach... Frequency... Bed alarm..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place as care planned. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm in place as care planned.

Based on policy review, review of a facility report, medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for monitoring a resident's skin and reporting change of conditions to the physician, to protect from wandering and exit seeking behavior, complete wander guard checks and ensure a bed alarm and mat was in place for 4 of 34 (Residents #22, 220, 108 and 247) sampled residents of the 52 residents reviewed on the stage 2 sample. The failure of the facility to follow the care plan intervention for monitoring a resident's arm and timely notification of condition changes to the physician resulted in a delay of treatment for [REDACTED].#220 from elopement and entering another resident's room resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death when Resident #22 who was at high risk for [MEDICAL CONDITIONS] developed a [MEDICAL CONDITION] and Resident #220 wandered into another resident's room and eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F282 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health... in an efficient and effective manner; to relay assessment information to physician and to document actions... facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... " Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE (right upper extremity) for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22)... can't remember exact dates March/April 2014, when... her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot..." During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." The facility failed to follow the care plan intervention for monitoring the right arm by failing to complete timely assessments and notification of [MEDICAL CONDITION] to the physician which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing a [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations as needed..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to grocery store. Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no evidence the care plan was effective to protect Resident #220 from eloping from the facility. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." There is no evidence Resident #220's care plan was implemented to keep him from wandering into Resident #218's room which caused psychological harm to Resident #218 when she voiced her inability to rest due to fear of Resident #220 entering her room. The facility failed to implement interventions to address wandering and exit seeking behavior to keep the resident's safe and free from psychological harm and elopement which placed Resident #218 and Resident #220 in immediate jeopardy. Refer to F223. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift..." Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the alarm being checked. During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurses #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard..." During an interview in the Restorative Nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. Nurse #2 stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." The facility failed to follow the care plan intervention to check Resident #108's wanderguard for proper functioning at beginning of shift and end of shift. 4. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of [MEDICAL CONDITION] Approach... Frequency... Bed alarm..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place as care planned. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm in place as care planned. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all licensed staff on how to complete a head-to-toe assessment and document findings, notifying the physician and family, documenting on the 24 hour report, how to complete an SBAR, how to complete an investigation and how to put necessary interventions in place. Evidence was provided that the Restorative Nurse and the Restorative Aide were in-serviced on how to properly use the tester to check Wanderguard functioning and how to document findings on the Wanderguard Daily Checklist. Interviews with Licensed Nursing Staff: Licensed Practical Nurses and RN's conducted on May 23, 2014, in the facility, staff verbalized how to complete a head -to-toe assessment and document the findings, what to document on the 24 hour report, when to notify the physician and the resident's family, what to document on the 24 hour report, when and how to complete an SBAR, how to complete an investigation, and how to implement interventions based on the residents condition. Interview with the Restorative Nurse revealed that he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed that she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. Resident #22 passed away during the annual recertification survey. Resident #220 remains in the hospital. Medical record review for Resident #218 documented that the care plan has been updated to reflect the use of the "STOP" sign and her concerns. Medical record review for Resident #108 has been updated to reflect her risk of elopement. Elopement / Wandering Monitoring Form documentation is present. During an interview the DON was asked about the process in place for implementing interventions based on the needs of the resident. The DON stated, "Review the 24 hour report in the morning meeting, if resident has a change or problem then the resident is added to the HART (Health Assessment Review Team) Team Review Checklist. The medical record is reviewed, the nurses notes are reviewed to make sure that every shift charts and the MD (Medical Doctor) and family are notified, new orders are reviewed, accident and injury reports are reviewed if applicable, check care plans for interventions, then we fix it. We meet on this daily." During an interview, the DON stated that the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely notify the attending physician of a significant change of condition of 1 of 6 (Resident #22) residents reviewed for abuse/neglect of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITIONS], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F157 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions... the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical... status, A need to alter treatment significantly... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor... at the onset of the change... 4. Review all findings with the physician and non-physician practitioner... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." 2. Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity until 4/24/14. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed a family member at the bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, "If there was a change in condition, I would evaluate resident and notify the doctor." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14." During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, "I expect nurse to evaluate, notify doctor, and keep hand and arm elevated." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all Charge Nurses and Unit Managers on resident assessment, notifying the Physician and Responsible Party timely of a change in the resident status and for all licensed nursing staff regarding physician and family notifications. The facility provided evidence of auditing logs to ensure all significant resident's changes were communicated to the physician and family and that the 24 hour report was reviewed in morning clinicals. Review of the auditing logs and the 24 hour report revealed the facility was utilizing and monitoring the logs and reports timely. Medical Record Review for Resident #7 and #108 documented no changes since 5/22/14. There was evidence in both records that changes since the exit date of 5/5/14 had been reported to the physician and family and had been documented on the 24 hour report. Interviews with Charge Nurses and Unit Managers, conducted on 5/23/14, in the facility, nursing staff verbalized when and how to do a resident assessment, and timely notification of the physician and responsible party when there is a change in the resident's condition. Licensed Practical Nurses and Registered Nurses were able to verbalize when to notify the physician and the responsible party. The 24 hour reports will continue to be reviewed in the morning clinical meetings by the Director of Nursing and the Unit Managers. The facility will remain out of compliance at a Scope and Severity level "D", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to ensure care and treatment for [REDACTED].#220) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to effectively treat behaviors and implement new interventions for wandering and exit seeking behavior resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) when Resident #220 eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F319 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F319 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "ELOPEMENT / WANDERING RESIDENTS" policy documented, "...Care plans and individual behavior plans will address wandering as a specific problems. Approaches will be formulated, patterns identified and the causes determined will be addressed ..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly... when resident begins to wander, provide comfort measures... remove resident from other's room and unsafe situations..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building... Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There is no evidence that the care plan was revised after the elopement on 4/1514. Review of the behavior intervention monthly flow record for "4/15 (2014)" documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros are documented on the day shift on 4/26/14; the evening shift on 4/14/14 - 4/18/14 and 4/21/14 - 4/26/14 and 4/28/14 - 4/30/14; and on the night shift on 4/15/14 - 4/20/14, and 4/22/14 - 4/30/14. All other dates are blank. There is no evidence the facility was tracking wandering. There is no evidence that Resident #220 was seen by Psychology services until 4/25/14. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here... I don't want that man coming into my room scaring me and making me have a set-back..." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to implement new, appropriate and measurable interventions to address wandering and exit seeking behavior which placed Resident #220 in immediate jeopardy when he eloped. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all licensed nursing staff on how to handle wandering residents, the "Elopement/Missing Person" and the "Behavior Monitoring Sheet" policy, and documenting on the 24 hour report. Evidence that all facility staff were trained on how to handle wandering residents and whom to report the behavior. The facility provided evidence that elopement drills had been conducted on every shift. Interviews with Licensed Nursing Staff: Licensed Practical Nurses, RN's and Unit Managers, conducted on May 23, 2014, in the facility, staff verbalized how to handle a wandering resident, elements of the "Elopement/Missing Person" policy, use of the behavior monitoring sheets and how to document on the 24 hour report. Licensed staff also verbalized what to do if a resident is reported missing and stated they have been involved in elopement drills where they canvas the area around the facility. Interviews with facility staff: CNA's and Housekeeping staff, conducted on May 23, 2014 in the facility, the staff verbalized how to handle a wandering resident and whom to report the behavior. Staff also verbalized what to do if a resident is reported missing and stated they have been involved in elopement drills where they canvas the area around the facility. There have been no incidents of elopement or exit-seeking behavior since the exit date of 5/5/14. A list of Resident's currently in the building that wander was requested. The Wanderguard Checklist, Elopement/Wandering Monitoring Form, Risk of Elopement Evaluation and Elopement Risk Assessment Forms, Care Plans, Behavior Monitoring Sheets and the 24 Hour Report were reviewed with no concerns identified. The facility will remain out of compliance at a Scope and Severity level "D", an isolated deficient practice that constitutes no actual harm with potential for minimal harm that is not immediate jeopardy.

2 Based on policy review, review of incident reports, review of 24 hour nursing log, review of daily staffing sheets, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that ensured residents were protected from psychological harm and potential resident to resident altercation; administration failed to ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for behaviors of wandering and/or exiting seeking residents were effective; administration failed to fully investigate grievances; administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each staff member was knowledgeable of the facility missing resident policy; administration failed to ensure staff completed wanderguard checks and ensure a bed alarm and mat were in place for 6 of 52 (Residents #7, 22, 108, 218, 220 and 247) residents reviewed of the 52 residents included in the stage 2 sample. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Administration failed to ensure staff assessed and timely notified the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION] which resulted in delay of care and placed Resident #22 in immediate jeopardy. Refer to F157. 2. Administration failed to ensure residents were protected from psychological harm and potential resident to resident altercation; ensure the abuse policies were implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration; administration failed to ensure staff provided timely care and timely physician notification of condition changes to prevent neglect; administration failed to ensure interventions for wandering and/or exiting seeking behaviors were effective and administration failed to fully investigate grievances for Residents 7, 22, 218 and 220. Refer to F166, F223, F224, F225, F226 and F319. 3. Administration failed to ensure necessary care and services were provided to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right arm for Resident #22. Refer to F309. 4. Administration failed to ensure staff provided supervision when staff failed to respond to an alarm when a resident was leaving the facility or ensure a wanderguard was checked as ordered by the physician for Residents #108 and 220. Administration also failed to ensure handrails did not have nails sticking to cause potential injuries. Refer to F323. 5. The administration failed to ensure the facility had an organized, structural orientation for the agency nurses and failed to ensure each employee was knowledgeable of the facility's missing resident policy. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. Refer to F518. 6. Administration failed to ensure the Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The administrator gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit on 5/1/14 validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited in the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continues in substantial non compliance. Refer to F520.

2 Based on policy review, review of an incident report and staff interviews, it was determined the facility failed to ensure staff were competent in emergency preparedness for when residents are discovered missing and were not aware of the elopement code for 4 of 8 (Certified Nursing Assistants (CNA) #20 and 21 and Nurses #15 and 16) staff interviewed. The failure of the facility to respond to a sounding alarm and follow a resident observed leaving the facility resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #220 who elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Missing Resident policy documented, .When a resident is suspected of missing. 2. The nursing supervisor will announce overhead Code Green to alert facility employees of the missing resident. 2. During an interview on the 300 hall on 5/5/14 at 3:10 PM, CNA #20 was asked what the code for elopement was. CNA #20 stated, I don't know the code to announce elopement. 3. During an interview on the 400 hall, on 5/5/14 at 3:30 PM, CNA #21 was asked what the code for elopement was. CNA #21 answered, I don't remember what the code is for elopement. I'm new and don't remember codes for any of the emergencies. 4. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what would she do if she heard a wanderguard alarm going off. Nurse #15 answered, .call the AWOL (Absent Without Leave) code. Nurse #15 was then asked, .Would you not stop what you were doing to look? Nurse #15 stated, It depends on what I was doing. I'm an agency nurse and really don't know what the policy is. no. I guess I should stop what I am doing, check the facility and then outside. call the AWOL code. During an interview in the activities room [ROOM NUMBER]/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. 5. During an interview on the 100 hall on 5/3/14 at 1:40 PM, Nurse #16 was asked what do you do when you find you have a missing resident. Nurse #16 stated, .(call) AWOL code. The facility failed to ensure each employee was knowledgeable of each of the components in the missing resident policy. Not all of the staff were aware of Code Green which is used when a resident is missing. Refer to the findings of elopement in regard to Resident #220 in citation F323.

Based on policy review, review of incident reports, review of shift assignment sheet, review of 24 hour nursing log, medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and Assurance committee established and implemented a method of identifying concerns identified and implement plans of actions to correct identified concerns of abuse, neglect and an elopement. The failure of the QA committee to identify and address concerns resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #22, 218 and 220. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, POLICY A. physical, and mental abuse. neglect. are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred. VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed. E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death) for Residents #22, 218 and 220. 2. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. During an interview in the activity room on 5/5/14 at 4:40 PM, the Administrator was asked if the QA Committee had looked at abuse. The Administrator stated, Nothing specific. The Administrator was asked if the QA Committee had looked at elopements, the Administrator stated, No. 3. The facility's QA committee failed to address identified issues such as abuse, neglect and elopement. 4. The facility's QA committee failed to ensure the plans of action to correct identified quality deficiencies cited on the abbreviated survey completed on 3/28/14, with a compliance date of 4/30/14, were effective. The following plan of actions were not followed: a. F225 - the facility will ensure all incidents will be thoroughly investigated. b. F314 - 9 of 103 licensed staff failed to attend inservice on performing head to toe assessments. c. F323 - the facility failed to ensure the resident's environment was free of accident hazards. d. F514 - 9 of 103 licensed staff failed to attend inservice for documentation. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level, F314 was cited at a D level, F323 was cited at a G level and F514 was cited at a D level. The citation F314 was cited at a D level and remained at a D level, and continues in substantial non compliance. The deficiency levels for F225, F323 and F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J, F323 J and F514 J) and continue in substantial non compliance. Refer to F157, F166, F223, F224, F225, F226, F282, F309, F319, F323, F514 and F518.

2 Based on policy review, review of the daily staff sheets, review of 24 hour nursing log, review of an incident report, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to prevent neglect for 3 of 6 (Residents #22, 218 and 220) residents reviewed for abuse and neglect of the 52 residents included on the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of the swelling of the right arm resulted in a delay in treatment for [REDACTED].#218 reported being fearful and not resting at night due to Resident #220 entering her room and failure to address Resident #220's behaviors of wandering, exit seeking and elopement from the facility all resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F224 K constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, POLICY. A. physical, and mental abuse. neglect. are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred. VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed. E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities. 2. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical. status, A need to alter treatment significantly. Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor. at the onset of the change. 4. Review all findings with the physician and non-physician practitioner. 5. Document in the medical record. Change of Condition. nursing documentation for change in status. Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented [MEDICAL CONDITION] N (no). The history and physical examination [REDACTED] The care plan dated 4/3/14 documented, Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease). Approach Frequency. 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status. A nutrition services progress note dated 4/11/14 documented, .some [MEDICAL CONDITION] noted to hand. There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, .RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch. The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, .There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present. A nurses note dated 4/21/14 documented, .T (positive) Findings regarding Doppler. N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days. A nurses noted dated 4/24/14 documented, .(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand. There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. An acute visit dated 4/29/14 completed by the NP documented, .History of complex mass arm may cause flow issues. d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit. Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose. She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME] During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed. Nurse #13 was asked about Resident #22. Nurse #13 stated, She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows. Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow. Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, If there was a change in condition, I would evaluate resident and notify the doctor. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, (Named Resident #22) was sent out to hospital due to decreased intake at her daughters request. Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care. During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14. Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, I expect nurse to evaluate, notify doctor, and keep hand and arm elevated. During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, Certified Nursing Assistant (CNA) #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, I am a floater. I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date. During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling. Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, I told a CNA on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots. The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 3. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a STOP banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a STOP banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:25 PM, Resident #218 was asked if the staff treat her with dignity and respect. Resident #218 stated, No. Resident #218 was then asked how the staff treated her that wasn't with dignity and respect. Resident #218 stated, (Nurse #18) Slow about changing [MEDICAL CONDITION] bag like they don't want to do it. Resident #218 was asked if anyone said anything to her about changing her [MEDICAL CONDITION]. Resident #218 stated, Nobody said anything but you can tell by their attitude and body language. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, The man next door comes into my room. I told the nurse and they put the stop banner up. Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, No. He (Resident #220) crawls up under the banner. During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it. Resident #218 was asked when did this happen. Resident #218 stated, Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room. Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1). During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, They (staff) call him (named Resident #220). During an interview on the 300 hall on 5/1/14 at 8:30 AM, CNA #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, A resident (named Resident #220) comes into her room in the evening. CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, She told me about 3 weeks ago. Resident #218 was asked if she reported it to anyone. CNA #17 stated, Yes, my charge nurse (Nurse #18). During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, The CNA reports it to the charge nurse to try and resolve it and then inform me. The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, Haven't heard anything. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here. Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, When I yell he heads for the door. Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back. During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, I've talked to (Resident #218). We need to have him (Resident #220) evaluated. The DON was asked who would do this evaluation. The DON stated, (named hospital with behavioral unit). Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, I try to investigate it and correct it on my shift. Then I pass it along to the next shift. RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift. RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, I put it on the 24 hour log and that goes to (DON). During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014). During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, I slept so good. It was so nice. Resident #220 had been discharged to the hospital on [DATE]. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 4. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, .Wandering / Elopement Risk. Ensure that resident is wearing a wanderguard and that it is working properly. Review of a facility incident report dated 4/15/14 documented, .Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION] There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, .I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there. staff was notified to search the building. He was found at (named grocery store) by staff, and returned to the building. No injury. There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, Go after them. During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, I'd let my charge nurse know that a patient is missing. Nurse #15 was then asked what she would do if she heard a wanderguard alarm. Nurse #15 answered, Notify a supervisor. Call the AWOL (absence without leave) code. Nurse #15 was then asked, Would you not stop what you were doing to go look? Nurse #15 stated, It depends on what I was doing. I'm an agency nurse and really don't know what the policy is. The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. A nurse heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

2 Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility staff failed to implement their abuse/neglect policy for investigating and/or reporting allegations of abuse and neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents reviewed included in the stage 2 sample. The facility staff failed to ensure allegations of fear and elopement from the facility were thoroughly investigated and/or reported to administration when Resident #218 reported the inability to sleep at night for fear of Resident #220 entering her room; Resident #220's behaviors of wandering, exit seeking and elopement from the facility which resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F226 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, POLICY A. physical, and mental abuse. neglect. are prohibited. B. All allegations of abuse involving abuse. are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred. VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed. E. All allegations of abuse are reviewed at QA (Quality Assurance) meetings for any further resolution related to educational opportunities. 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a STOP banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a STOP banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, The man next door comes into my room. I told the nurse and they put the stop banner up. Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, No. He (Resident #220) crawls up under the banner. During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it. Resident #218 was asked when did this happen. Resident #218 stated, Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room. Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, My daughter reported it to the supervisor. During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, They (staff) call him (named Resident #220). During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, A resident (named Resident #220) comes into her room in the evening. CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, She told me about 3 weeks ago. Resident #218 was asked if she reported it to anyone. CNA #17 stated, Yes, my charge nurse (Nurse #18). During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, The CNA reports it to the charge nurse to try and resolve it and then inform me. The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, Haven't heard anything. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, Has been in here 3 times. One time he came in and started pulling on door (points to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here. Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, When I yell he heads for the door. Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back. During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, I've talked to (Resident #218). We need to have him (Resident #220) evaluated. The DON was asked who would do this evaluation. The DON stated, (named hospital with behavioral unit). Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that the resident (#220) had come into her mother's room. Resident #218's daughter stated, About a month ago he (Resident #220) came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, I try to investigate it and correct it on my shift. Then I pass it along to the next shift. RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift. RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, I put it on the 24 hour log and that goes to (DON). During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014). During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, I slept so good. It was so nice. Resident #220 was discharged to the hospital on [DATE]. Resident #218 was scared and unable to sleep due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. The facility was unable to provide an incident report or an investigation related to Resident #218's reported fear of Resident #220 wandering into her room. The facility failed to implement the abuse policy related to documenting incidents; failed to thoroughly investigate and follow up on voiced grievances; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy. 3. Review of the facility's Incident Reporting policy documented, Policy. It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that. each resident shall receive adequate supervision and assistive devices that shall reduce accidents. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, .Wandering / Elopement Risk. Ensure that resident is wearing a wanderguard and that it is working properly. Review of a facility incident report dated 4/15/14 documented, .Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION] There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from Registered Nurse (RN) Supervisor #1 documented, .I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there. staff was notified to search the building. He was found at (named grocery store) by staff, and returned to the building. No injury. There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, Go after them. During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset. During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, I'd let my charge nurse know that a patient is missing. Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, Notify a supervisor. Call the AWOL (absence without leave) code. Nurse #15 was then asked, Would you not stop what you were doing to go look? Nurse #15 stated, It depends on what I was doing. I'm an agency nurse and really don't know what the policy is. The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement the abuse policy to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy.

2 Based on policy review, medical record review, observation and interview, it was determined the facility failed to timely notify the attending physician of a significant change of condition of 1 of 6 (Resident #22) residents reviewed for abuse/neglect of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITIONS], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical. status, A need to alter treatment significantly. Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor. at the onset of the change. 4. Review all findings with the physician and non-physician practitioner. 5. Document in the medical record. Change of Condition. nursing documentation for change in status. 2. Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented [MEDICAL CONDITION] N (no). The history and physical examination [REDACTED] The care plan dated 4/3/14 documented, Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease). Approach Frequency. 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status. A nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity until 4/24/14. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, .RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch. The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, .There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present. A nurses note dated 4/21/14 documented, .T (positive) Findings regarding Doppler. N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days. A nurses noted dated 4/24/14 documented, .(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand. There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note, yet a nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed a family member at the bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose. She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME] During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed. Nurse #13 was asked about Resident #22. Nurse #13 stated, She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows. Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow. Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, If there was a change in condition, I would evaluate resident and notify the doctor. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care. During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, I expect nurse to evaluate, notify doctor, and keep hand and arm elevated. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots. During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling. The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F514 was cited at a D level. The deficiency level for F514 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F514 J) and continues in substantial non compliance. Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure medical records contained complete and accurate documentation of a residents' conditions of [MEDICAL CONDITION] and wandering, wanderguard checks and/or a prescribed diet for 4 of 52 (Residents #22, 220, 108 and 130) residents reviewed included in the stage 2 sample. The failure of the facility to maintain a complete and accurate medical record resulted in a delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2104, removed the Immediate Jeopardy. Noncompliance for F514 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, "Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner... Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination... 5. Document in the medical record... Change of Condition... nursing documentation for change in status..." Medical record review for Resident #22 documented an admitted 9/3/05 with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented "[MEDICAL CONDITION] N (no)..." The history and physical examination [REDACTED]" The care plan dated 4/3/14 documented, "Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease)... Approach Frequency... 4. Observed RUE for swelling and bruising..." A nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity on this date. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, "...RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch..." The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, "...There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present..." A nurses note dated 4/21/14 documented, "...T (positive) Findings regarding Doppler... N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test to determine therapeutic levels of blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days." A nurses noted dated 4/24/14 documented, "...(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand..." There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, "[MEDICAL CONDITION] noted to hand..." Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, "My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose... She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME]" During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, "I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed." Nurse #13 was asked about Resident #22. Nurse #13 stated, "She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows..." Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, "She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow." During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #13 stated, "No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14..." During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, "The daughter found it and told me on 4/21/14 the day of the Doppler... The daughter is a nurse. She is quite involved in her care." During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, "I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots." During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, "I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling." The facility failed to document the [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change minimum data set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of the behavior intervention monthly flow record for 4/15/14 documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros were documented on the day shift on 4/26/14; the evening shift on 4/14/14 through (-) 4/18/14 and 4/21/14-4/26/14 and 4/28/14-4/30/14; and on the night shift on 4/15/14-4/20/14 and 4/22/14-4/30/14. All other dates are blank. There is no documentation the facility was tracking wandering. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if (named Resident #218's family) had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." The facility was unable to provide documentation of Resident #220 entering Resident #218's room. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the wanderguard being checked. Review of an elopement risk assessment dated [DATE] was coded with a score of 18 with a score of 8 or greater indicating at risk for elopement. Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Check resident wanderguard for proper functioning at beginning of shift and end of shift..." During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurse #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard." During an interview in the restorative nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. The Restorative Nurse (#2) stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." During an interview on the 600 hall on 5/5/14 at 3:50 PM, the Certified Nursing Assistant (CNA) #11 was asked what were her responsibility for wanderguards on her assigned residents. CNA #11 stated, "We don't check them, just make sure they have it on..." Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all staff on how to handle a wandering resident; for all licensed staff on the Elopement/Missing Person policy, how to perform a head-to-toe assessment and document any findings, how to complete an investigation, completing an incident/accident report, documented physician and family notifications regarding any significant change in the residents status, reviewing and properly transcribing telephone orders, checking monthly Physicians orders for accuracy, checking wanderguard placement, initiating the new "Elopement/Daily Wanderguard Checklist" and "Elopement Risk Assessment Quarterly Form", and updating care plans as warranted. The facility provided auditing logs for residents with wanderguards, and for the review of telephone orders. Interview with the Restorative Nurse revealed he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. Interviews with facility staff: CNA's and Housekeeping staff, conducted on May 23, 2014, in the facility, the facility staff verbalized how to handle a wandering resident. Interviews with licensed nursing staff: Licensed Practical Nurses, Registered Nurses, conducted on May 23, 2014, in the facility the staff verbalized elements of the Elopement / Missing Persons policy, how to perform a head-to-toe assessment and how to document findings, how to complete an investigation, how to complete an accident/incident report, when to notify the physician and the family and how to document the notifications, how to handle physician telephone orders and check the monthly orders for accuracy, how to check wanderguards, how to initiate the Elopement/Daily Wanderguard Checklist, and how to update care plans when needed. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. Medical record review for Resident #108 documented that staff are documenting her whereabouts every 2 hours on the "Elopement/Wandering Form". The Elopement/Quarterly Assessment has been completed. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy. 4. Based on medical record review and interview, it was determined the facility failed to ensure a resident was provided with the diet prescribed by the physician for 1 of 35 (Resident #130) residents of the 52 residents included in the stage 2 sample. The findings included: Medical record review for Resident #130 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Physician telephone orders documented the following: a. 10/22/13 - "...Change diet to mechanical soft for 7 days due to dental extraction..." b. 11/1/13 through 11/30/13 - "...Diet... Regular... No Added Salt..." c. 12/1/13 through 12/31/13 - "...Diet... Regular... No Added Salt..." d. 1/1/14 through 1/30/14 - "...Diet... Regular... No Added Salt..." e. 2/1/14 through 2/30/14 - "...Diet... Regular... No Added Salt..." f. 3/1/14 through 3/30/14 - "...Diet... Regular... No Added Salt..." g. 4/1/14 through 4/30/14 - "...Diet... Regular... No Added Salt..." Review of the "NUTRITION PROGRESS REPORT" documented the following: a. 8/8/13 - "...CURRENT DIET...Reg (Regular) NAS (no added salt)..." b. 11/14/13 - "...CURRENT DIET...mech (mechanical soft) NAS..." c. 1/31/14 - "...CURRENT DIET...MS (mechanical soft) NAS..." Observations in Resident #130's room on 4/28/14 at 7:58 AM, Resident #130's breakfast was a hard boiled egg and some type of unrecognizable chopped up meat. Resident #130 did not know what the food item was on this mechanical soft diet. The resident was not served a regular diet as ordered. During an interview in Resident #130's room on 4/29/14 at 9:28 AM, Resident #130 was asked does the food look good and appetizing. Resident #130 stated, "Doesn't look right and I've never seen it before." During an interview at the C hall nurses' station on 4/30/14 at 11:41 AM, Nurse #3 was asked why Resident #130 was on a mechanical soft diet. Nurse #3 stated, "Because of teeth... she had a tooth extraction..." Nurse #3 was asked if resident had an order for [REDACTED]. During an interview in the Resident's room on 5/2/14 at 12:35 PM, Resident#130 was served a regular texture lunch meal. Resident #130 lifted the top off of her plate and stated, "WOW! Chicken." 5. During an interview in the DON's office 4/30/14 at 2:10 PM, the DON was asked what she was doing to increase the communication between departments and improve documentation. The DON stated, "I realize there was a problem with documentation and transcribing orders." The facility failed to ensure medical records were complete and accurately documented.

2 Based on policy review, review of a shift assignment sheet, medical record review and interview, it was determined the facility failed to fully investigate grievances voiced by 2 of 52 (Residents #218 and 7) residents included in the stage 2 sample. The failure of the facility to thoroughly investigate grievances; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218 who stated she was afraid of Resident #220 and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Investigating a Resident Grievance or Complaint policy documented, .all grievances and /or complaints be investigated by the appropriate facility staff and recorded on the grievance/complaint log. the Social Services Director. will begin an investigation into the allegations. 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resides in a private room that is next door to Resident#220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, The man (Resident #220) next door comes into my room. I told the nurse and they put the stop banner up. Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, No. He (Resident #220) crawls up under the banner. During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, The CNA reports it to the charge nurse to try and resolve it and then inform me. The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, Haven't heard anything. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here. Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, When I yell he heads for the door. Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back. During an interview in the social worker's office on 5/1/14 at 10:21 AM, the Social Worker was asked if anyone had reported any issues or concerns about Resident #220. The Social worker stated, I just heard about it a few minutes ago. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. Resident #220 had wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to follow up on grievances voiced by Resident #218, who is unable to sleep at night for fear of Resident #220 entering her room at night. The facility failed to implement new, appropriate and measurable interventions to keep Resident #218 safe resulted in immediate jeopardy. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented a BIMS score of 15 indicating the resident had no cognitive impairments, required set up help with eating, and had bilateral upper extremity impairment on both sides. The care plan dated 10/16/13 and updated on 4/9/14 documented, Problem-Impaired mobility w (with) / self-care deficit r/t/ (related to) h/o (history of)[MEDICAL CONDITION]/ Rt. (right) hemi (stroke with right paralysis), h/o GSW (gunshot wound) to head. Approach-Frequency 1. Provide full staff assistance w/bathing, dressing, personal hygiene, grooming, oral, and incontinent care. 3. Set-up all equipment for personal care. 4. Assist resident w/oral care. During an interview in Resident #7's room on 4/28/14 at 3:20 PM, Resident #7 stated, (Named CNA #22) left trays without opening items, happens all the time, have told (Named Nurse #5). During an interview at the 100/200 nurses' station on 4/30/14 at 4:00 PM, Nurse #5 (unit manager) was asked about any complaints regarding care reported by Resident #7. Nurse #5 stated, Yes, she did complain to me right after I started here (empolyed 2/2014) about (named CNA #22). She complained she (CNA #22) did not put her to bed when she wanted to and did not open her items on her trays for her. I talked to both of them (Resident #7 and CNA #22). I removed (named CNA #22) from caring for (named Resident #7). Nurse #5 was asked if there were any investigations of these complaints. Nurse #5 stated, No, I did not write this up anywhere. No, do not have a grievance log. No, I did not document this anywhere. I just talked to them. Nurse #5 was asked about how charge nurses were informed of her removing CNA #22 of caring for Resident #7. Nurse #5 stated, They (nurses) know, they do not assign (named CNA #22) to (named Resident #7). The surveyor asked to review the 4/30/14 3-11 shift assignment sheet. The assignment sheet documented Resident #7 was assigned on paper to CNA #22. Nurse #5 stated, She (named CNA #22) knows not to go in her (Resident #7's) room. She (CNA #22) will get one of the other CNA's to do (named Resident #7) for her. Nurse #5 was asked how staff know this. Nurse #5 stated, They know. During an interview in the activity room on 5/2/14 at 9:30 AM, the Administrator (the Abuse Coordinator) was asked what was expected if an allegation of abuse was reported to a unit manager. The Administrator stated, I would expect the unit manager to investigate the situation and report it to me. I was not aware of the situation with (Named Resident #7 and CNA #22) until yesterday. The facility failed to thoroughly investigate and follow up on Resident #7's voiced grievances of not providing preference and needed care for dining and personal hygiene. 4. The facility failed to resolve grievances voiced by Residents #7 and 218.

2 Based on policy review, review of the 24 hour nursing log, medical record review, observation and interview, it was determined the facility failed to prevent psychological harm and potential resident to resident altercation for 1 of 6 (Resident #218) residents reviewed for abuse of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate incidents; implement new, appropriate and measurable interventions to prevent psychological harm and potential resident to resident altercations resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #218, who stated she was afraid of another resident (Resident #220) and could not rest at night because he might come into her room. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F223 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's ABUSE, NEGLECT AND MISAPPROPRIATION policy documented, .POLICY. Verbal, sexual, physical, and mental abuse. of the resident. are prohibited. V. Protection of the Resident. A. All allegations of abuse are to be reported immediately to charge nurse. D. The charge nurse will immediately notify the Administrator, DON. VI. Resident to Resident. A. If a resident is observed exhibiting any form of abuse towards another resident, staff will intervene immediately. C. Administrator and/or DON will be notified immediately. D. Residents will be closely supervised. VII. All allegations of abuse will be investigated and reported to the appropriate agencies. 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a STOP banner across Resident #218's doorway, fears/concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a STOP banner across the doorway of Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, The man next door comes into my room. I told the nurse and they put the stop banner up. Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, No. He (Resident #220) crawls up under the banner. During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, When I told the nurse (Nurse #12) about him (Resident #220) coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it. Resident #218 was asked when did this happen. Resident #218 stated, Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room. Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, My daughter reported it to the supervisor (Registered Nurse (RN) Supervisor #1). During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, They (staff) call him (named Resident #220). During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, A resident (named Resident #220) comes into her room in the evening. CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, She told me about 3 weeks ago. Resident #218 was asked if she reported it to anyone. CNA #17 stated, Yes, my charge nurse (Nurse #18). During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, The CNA reports it to the charge nurse to try and resolve it and then inform me. The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, Haven't heard anything. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here. Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, When I yell he heads for the door. Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back. During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, I've talked to (Resident #218). We need to have him (Resident #220) evaluated. The DON was asked who would do this evaluation. The DON stated, (named hospital with behavioral unit). Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named Registered Nurse (RN) Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, RN Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, I try to investigate it and correct it on my shift. Then I pass it along to the next shift. RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift. RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, I put it on the 24 hour log and that goes to (DON). During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014). During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, I slept so good. It was so nice. Resident #220 had been discharged to the hospital on [DATE]. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. Review of Resident #220's care plan with a start date of 2/24/14 addressed wandering and elopement risk. The care plan was revised on 4/23/14 to include refusing/rejecting care and on 4/24/14 to include combative/verbally abusive. There is no documentation in Resident #220's medical record related to him wandering into Resident #218's room. Review of a daily skilled nurses note dated 4/22/14 on the 3-11 shift for Resident #220 documented, .requires constant attention by staff. When the new admission arrived this resident went in the tx (treatment) nurse office urinated and had a bowel movement. The other nurse said she tried to stop him from going in tx nurse office stated he had a chart and he hit her. 4. Resident #218 was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in immediate jeopardy.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F323 was cited at a G level. The deficiency level for F323 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F323 J) and continues in substantial non compliance. A. Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to investigate and implement interventions for wandering, exit seeking behavior and failed to ensure supervision was provided when staff failed to respond to an alarm or failed to check a wanderguard each shift as ordered by the physician for 2 of 5 (Residents #220 and 108) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to respond to a sounding alarm; thoroughly investigate and implement new interventions for wandering and exit seeking behavior allowed Resident #220 to elopement from the facility which resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F323 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F323 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's "Incident Reporting" policy documented, "Policy... It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that... each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or edema..." A written statement from Registered Nurse (RN) Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." The facility was unable to provide documentation that the facility checked the functioning of Resident #220's wanderguard or the facility alarm system after he returned to the facility nor were there any interventions put in place to prevent further elopement. During an interview in the DON's office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while make rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." The facility failed to ensure staff were knowledgeable of the facility's policy requirements when a resident is discovered missing by not knowing the facility's elopement code. Refer to F518. The failure of the facility to respond to a sounding alarm and failure to follow a resident observed leaving the facility resulted in immediate jeopardy when Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to implement new, appropriate and measurable interventions to prevent elopement. 3. Review of the "Wanderer Monitoring System" policy documented, "...Policy... To provide a reliable system for protecting residents who have a history of wandering... Daily documentation by nursing staff to ensure wanderguard is intact... MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check..." Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the MDS dated [DATE] and updated 2/1/14 documented Resident #108 as being severely impaired in decision making skills and requiring extensive assist and one person physical assist with ambulation. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the wanderguard being checked. Review of an elopement risk assessment dated [DATE] was coded with a score of 18 with a score of 8 or greater indicating at risk for elopement. Review of nurses' note dated 8/29/13 documented "...At 1:15 AM nurse (and) CNA (Certified Nursing Assistant) made rounds to check on resi (resident)... noted she was not in room... (C station CNA) noted D-Station exit door and opened it finding resident resting on ground near the door..." Review of the care plan dated 5/1/14 documented, "Problem... Resident h/o (history of) wandering as well as an elopement risk... Approach/Frequency... Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift. Keep resident close to supervised areas. Staff to intervene when wandering is observed..." During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurse #3 stated, "The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard." During an interview in the restorative nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. The Restorative Nurse (#2) stated, "I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them..." During an interview on the 600 hall on 5/5/14 at 3:50 PM, the Certified Nursing Assistant (CNA) #11 was asked what were her responsibility for wanderguards on her assigned residents. CNA #11 stated, "We don't check them, just make sure they have it on..." Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing, administrative and corporate staff. The facility provided evidence of in-service training with sign in sheets for all staff on responding to exit door alarms and that the Unit Managers, MDS Coordinator and the Restorative Nurse had been in-serviced on the "Elopement Wandering Form". Evidence was provided that all licensed nursing staff had been in-serviced on incidents and accidents, how to complete incident and accident forms and how to complete an investigation. Evidence was also provided that the facility had conducted elopement drills that required staff to canvas the neighborhood surrounding the facility. Interviews with Licensed Nursing Staff (including Agency): LPN's and RN's conducted on May 23, 2014, in the facility, revealed that staff could verbalize how to complete incident and accidents forms and how tocomplete an investigation. Interviews with facility staff: CNA's and Housekeeping staff, conducted on May 23, 2014, in the facility, revealed that facility staff could verbalize how to respond to the exit door alarms. Interview with the Restorative Nurse revealed that he checks the wanderguards daily and documents the findings on the checklist - date, if the wanderguard is functioning properly and expiration date. If the wanderguard is not working he will replace it. The Restorative Nurse has a tester, when the tester is placed to the wanderguard and the on button is pressed, it will say "OK (okay)" if it is functioning properly. Interview with the Restorative Aide revealed that she takes the tester to each resident, puts it to the wanderguard and it lights up green if it is ok, yellow when not working. She also takes residents to the door to see if the wanderguard is working. The facility provided evidence the Restorative Nurse, Restorative Aide, and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for Resident #108 revealed the "Elopement/Wandering Form" documentation is current and a elopement assessment was completed. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. The facility will remain out of compliance at a Scope and Severity level "D", an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on policy review, review of an incident report, medical record review, observation and interview, it was determined the facility failed to ensure fall interventions of a bed alarm and mat were in place for 1 of 3 (Resident #247) residents of the 3 residents with falls of the 52 residents included in the stage 2 sample. The facility failed to ensure the residents environment remained free of accident hazards as is possible when nails were sticking out from the handrails for 1 of 8 (100 hall) halls. The findings included: 1. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, "...Problem... Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of CVA... Approach... Frequency... Bed alarm..." Review of an incident report dated 4/24/14 documented, "...Resident found in floor laying on her right arm assisted by staff back to bed. this nurse assessed resident. Skin appeared without discoloration-skin tear, r (right) eyelid appeared with edema... Intervention Mat to Floor..." Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place nor was there a mat on the floor. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm or mat in place as care planned. 2. Observations on the 100 hall on 5/2/14 at 8:45 PM, revealed 2 nails sticking out of handrail next to the fire door between the 600 and 100 hall.

Based on policy review, review of a facility's investigation, medical record review, observation and interview, it was determined the facility failed to thoroughly investigate an injury of unknown origin for 1 of 2 (Resident #1) investigations reviewed. The failure of the facility to complete a thorough investigation and the failure of staff to provide two person assistance for Resident #1 resulted in actual harm when the resident sustained [REDACTED]. The findings included: Review of the facility's "Incident Reporting" policy documented, "Policy It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that the resident's environment shall remain as free of accident hazards as possible, and that each resident shall receive adequate supervision and assistive devices that shall reduce accidents... Procedure... Incident/Occurrence Investigation Form initiated by the Charge Nurse with completion by DON (Director of Nursing)/designee..." Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, able to make self understood, understands with clear comprehension, and had adequate vision. The resident's cognitive a summary score was 10 out of a possible 15 indicating moderate cognitive impairment. Functionally the resident was totally dependent for transfers, full staff performance every time, two persons physical assist due to functional limitation in range of motion of the lower extremity, impairment on both sides. Review of the most recent MDS dated [DATE] documented a cognitive summary score of 13 out of a possible 15 indicating the resident was cognitively intact. Functional status remained the same. Review of the care plan dated 7/5/13 documented, "...Laceration to toe next to great toe on right foot... monitor stitches for s/s (signs and symptoms) of infection... Resident has a fracture of L (left) knee with a immobilizer... Immobilizer d/c'd (discontinued) 8/26/13..." The care plan was updated 8/15/13 and documented, "...Total assist with lift with transfers..." Review of the facility's investigation of Resident #1's injury on 7/5/13 did not include an Incident / Occurrence Investigation Form which would include interviews, conclusion, and corrective action. An undated and unsigned hand written note documented, "(Named Certified Nursing Assistant (CNA) #1), states that he reported what he saw to the charge nurse, he noted blood coming from the resident's right foot. Unsure as to what happened." Observations in Resident #1's room on 1/15/14 at 11:15 AM and 3:55 PM and 2/4/14 at 1:00 PM, revealed Resident #1 was lying on a specialty air mattress bed, a trapeze bar was over the head of the bed, unable to move lower extremities, and the resident was noted to have bilateral foot drop. During an interview in Resident #1's room on 1/15/14 at 3:55 PM, Resident #1 was asked if he had ever been treated roughly or injured by the facility staff. Resident #1 stated, "He (CNA #1) was a rookie. Split my toes. He didn't know what he was doing, but it was not done intentionally..." Resident #1 continued and stated that he was paraplegic and had no feeling in his lower extremities. He didn't know what the CNA hit his foot on to split it. He had to go to the emergency room and get stitches but did not recall having had a fracture. During an interview in the conference room on 2/5/14 at 10:30 AM, the Administrator was asked, "How do you decide which injuries of unknown origin should be investigated?" The Administrator stated, "Investigate all occurrences to determine "reasonable outcome", how the injury occurred..." The Administrator, who started working at the facility in December 2013, also confirmed the facility was unable to provide documentation of a thorough investigation related to Resident #1's injuries.

On April 28 through May 5, 2014 a recertification survey and a complaint follow-up survey were completed. The provider gave an acceptable plan of correction (PoC) for the abbreviated survey completed on 3/28/14 with a compliance date of 4/30/14. The abbreviated revisit was conducted on 5/1/14. The revisit validated the facility was not in substantial compliance as specified in the written PoC. During the abbreviated survey of 3/28/14, F225 was cited at a D level. The deficiency level for F225 cited on the abbreviated survey actually increased in scope and severity to immediate jeopardy (F225 J) and continues in substantial non compliance. Based on policy review, review of incident reports, medical record review, observation and interview, it was determined the facility failed to thoroughly investigate and report allegations of abuse and/or neglect for 2 of 6 (Residents #218 and 220) residents reviewed for abuse and neglect of the 52 residents included in the stage 2 sample. The failure of the facility to thoroughly investigate and/or report to administration allegations of abuse and/or neglect resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) for Residents #218 and 220. The facility staff failed to investigate and/or report to administration the following: a reported incident of fear and inability of Resident #218 to rest at night for fear of Resident #220 entering her room and incidents of Resident #220's behaviors of wandering, exit seeking and elopement from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F225 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The facility provided an acceptable Allegation of Compliance on May 22, 2014 and a revisit on May 23, 2014 revealed the corrective actions implemented on May 22, 2014, removed the Immediate Jeopardy. Noncompliance for F225 continues at a "G" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility Abuse, Neglect and Misappropriation protocol documented, "POLICY A. ...physical, and mental abuse... neglect... are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines... VII Investigation All allegations of abuse will be investigated and reported to the appropriate agencies. A. The Administrator / designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes name of resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred... VIII Follow up A. Allegations are to be report within the timeframe allotted by state agency B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. Referral for Psychological/Psychiatric services will be made as needed... E. All allegations of abuse are reviewed at QA (quality assurance) meetings for any further resolution related to educational opportunities." 2. Medical record review for Resident #218 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #218 resided in a private room next door to Resident #220. The physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/29/13 and the quarterly MDS with an ARD of 2/25/14 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #218 was cognitively intact. There are no behaviors documented on the annual or quarterly MDS. Review of the resident care plan with a start date of 8/30/13 does not address the use of a "STOP" banner across Resident #218's doorway, fears / concerns with wandering male resident or issues with sleep. The facility was unable to provide an incident report or other investigation related to Resident #218's fear of Resident #220 wandering into her room. Review of the 24 hour nursing log from 3/25/14 through 4/15/14 did not document any report for Resident #218. Observations on the 300 hall on 4/28/14 at 1:06 PM and 5:00 PM, 4/29/14 at 8:10 AM, 4/30/14 at 8:30 AM, 5/1/14 at 9:30 AM and 2:30 PM, 5/2/14 at 9:45 AM, 5/3/14 at 10:00 AM and 2:30 PM and on 5/5/14 at 9:30 AM and 5:00 PM, revealed a "STOP" banner across the doorway into Resident #218's room. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, "The man next door comes into my room. I told the nurse and they put the stop banner up." Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, "No. He (Resident #220) crawls up under the banner." During an interview in Resident #218's room on 4/28/14 at 5:00 PM, Resident #218 was asked for additional information on the nurses response when it was reported to her that Resident #220 was in her room. Resident #218 stated, "When I told the nurse (Nurse #12) about him coming in the room she got smart with me. She (Nurse #12) said I know it's your room but he doesn't know it." Resident #218 was asked when did this happen. Resident #218 stated, "Happened about a month ago. I don't know for sure but my daughter does. I'm afraid of him (Resident #220) and I don't rest well. I'm scared he might come into my room." Resident #218 was asked if she had reported this to anyone else besides Nurse #12. Resident #218 stated, "My daughter reported it to the supervisor (named Registered Nurse (RN) Supervisor #1)." During an interview in Resident #218's room on 4/30/14 at 8:29 AM, Resident #218 was asked if she knew the name of the resident that comes into her room. Resident #218 stated, "They (staff) call him (named Resident #220)." During an interview on the 300 hall on 5/1/14 at 8:30 AM, Certified Nursing Assistant (CNA) #17 was asked the reason for the 'STOP' banner across Resident #218's doorway. CNA #17 stated, "A resident (named Resident #220) comes into her room in the evening." CNA #17 was asked if Resident #218 had reported this to her. CNA #17 stated, "She told me about 3 weeks ago." Resident #218 was asked if she reported it to anyone. CNA #17 stated, "Yes, my charge nurse (Nurse #18)." During an interview in the DON's office on 5/1/14 at 8:55 AM, the DON was asked what should happen when a resident reports a concern to a CNA. The DON stated, "The CNA reports it to the charge nurse to try and resolve it and then inform me." The DON was asked if she had any reported concerns regarding Resident #218 and Resident #220. The DON stated, "Haven't heard anything." During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, "Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here." Resident #218 was asked what do you do when Resident #220 comes into her room. Resident #218 stated, "When I yell he heads for the door." Resident #218 was asked if she had reported it to anyone else. Resident #218 stated, "I told that nurse (Nurse #12) that was smart with me. Didn't want to report it anymore after that. Didn't think I was supposed to. My daughter reported it to the supervisor. I don't want that man coming into my room scaring me and making me have a set-back." During an interview in the activity room on 5/1/14 at 1:30 PM, the DON stated, "I've talked to (Resident #218). We need to have him (Resident #220) evaluated." The DON was asked who would do this evaluation. The DON stated, "(named hospital with behavioral unit)." Resident #220 was discharged on [DATE]. During an interview in Resident #218's room on 5/1/14 at 5:40 PM, Resident #218's daughter was asked if she had the dates that Resident #220 had come into her mother's room. Resident #218's daughter stated, "About a month ago he came in and she told him this wasn't his room. He's done it when I'm here too. I scribbled the dates on the calendar. The first time it happened in March (2014), the second time was on 4/3 (2014). That's when he (Resident #220) tried to get into the bathroom. I talked to (named RN Supervisor #1). Happened again on 4/9 (4/9/14) and I talked to (named RN Supervisor #1) again. She said she would write up a report." During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked what she does when a resident or family has a concern or complaint. RN Supervisor #1 stated, "I try to investigate it and correct it on my shift. Then I pass it along to the next shift." RN Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, "Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift." RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, "I put it on the 24 hour log and that goes to (DON)." During an interview in the unit managers office on 5/2/14 at 9:15 AM, Nurse #11 (Unit Manager) was asked if there are any reports for Resident #218 on the 24 hour nursing log. Nurse #11 (Unit Manager) stated, "I did not find anything on the 24 hour report. I looked from March 25 through April 14 (2014)." During an interview in Resident #218's room on 5/2/14 at 9:45 AM, Resident #218 was asked how she slept last night. Resident #218 stated, "I slept so good. It was so nice." Resident #220 had been discharged to the hospital on [DATE]. Resident #218 voiced that she was scared and afraid to rest due to Resident #220 wandering into her room. He has wandered into her room on 3 different occasions. Resident #220 had recently hit a staff member while the staff was attempting to redirect him. Resident #218 stated that she yelled at Resident #220 when he wandered into her room. The facility failed to document the incidents; failed to thoroughly investigate the incidents; and failed to implement new, appropriate and measurable interventions to keep the resident safe which placed Resident #218 in Immediate Jeopardy. 3. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the significant change MDS with an ARD date of 2/18/14 documented a BIMS score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, "...Wandering / Elopement Risk... Ensure that resident is wearing a wanderguard and that it is working properly..." Review of a facility incident report dated 4/15/14 documented, "...Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION]" There is no documentation on the incident report that the facility checked the functioning of his wanderguard or the facility alarm system after he returned to the facility. A written statement from RN Supervisor #1 documented, "...I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. I went to check on (named another resident) room he was asleep in bed. Someone checked (named Resident #220) and he wasn't there... staff was notified to search the building... He was found at (named grocery store) by staff, and returned to the building... No injury..." There was no statement from Nurse #17 in the facility's investigation or an investigation of how Resident #220 got out of the facility. During an interview in the DON office on 5/1/14 at 9:00 AM, the DON was asked what she expects a nurse to do if they hear the wanderguard alarm and see someone leave the building. The DON stated, "Go after them." During an interview while making rounds to check the door alarms on 5/2/14 beginning at 4:30 PM, the maintenance man was asked once the alarm is set off by a resident what happens. The maintenance man stated, "When a resident with a wanderguard gets near the door another red light comes on, then when they push on the door it starts sounding and will open after 15 seconds, the alarm will keep sounding until someone resets it. It (alarm) will not stop sounding until it's reset." During an interview on the 100 hall on 5/3/14 at 2:05 PM, Nurse #15 was asked what do you do when you find you have a missing resident. Nurse #15 stated, "I'd let my charge nurse know that a patient is missing." Nurse #15 was then asked what she would do if she heard a wander guard alarm. Nurse #15 answered, "Notify a supervisor. Call the AWOL (absence without leave) code." Nurse #15 was then asked, "Would you not stop what you were doing to go look? Nurse #15 stated, "It depends on what I was doing. I'm an agency nurse and really don't know what the policy is." During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, "From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now..." Resident #220 eloped from the facility on 4/15/14 around 10:33 PM. Nurse #17 heard the alarm and saw a man leave but did not go after him. According to the Maintenance Director the wanderguard alarm will ring until it is reset. Resident #220 had to cross a street and walk approximately 0.4 miles to a named grocery store. The facility failed to thoroughly investigate this incident and failed to implement new, appropriate and measurable interventions which placed Resident #220 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site May 23, 2014, through medical record review, review of facility documents and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign in sheets for the Administrator and the DON on abuse, elopement, Missing Residents, Wandering policy, and how to start and complete an investigation. The facility provided evidence the nursing staff was in-serviced on incident reporting, how to handle wandering residents, resident-to-resident altercations, abuse, completing an investigation, documenting for the 24 hour report and implementing interventions to keep residents safe. There was evidence provided that all staff had been trained on abuse and had taken a post test. The DON stated that a passing score on the Abuse Inservice Post Test was 80 percent (%). Any staff that scored below 80% had to take the test again. There were 13 staff members that initially scored below 80%. All 13 were retested and scored above 80% on the repeat test. There was evidence that Nurse #12 received 1:1 in-service regarding customer service and nursing ethics and RN Supervisor #1 received 1:1 in-service regarding how to handle resident's concerns and when and how to report those concerns. Nurse #12 also received a suspension and RN Supervisor #1 was demoted to a charge nurse. The facility provided evidence the Restorative Nurse, Restorative Aide and the Weekend Supervisor were monitoring the Wanderguards daily since 5/13/14. There have been no malfunctioning wanderguards. Interviews with Nursing Staff: CNA's, Licensed Practical Nurses and RN's, conducted on May 23, 2014, in the facility, revealed that staff verbalized how to complete an investigation, how to handle wandering residents, what to do during a resident-to-resident altercation, what constitutes abuse and how to report it, documenting on the 24 hour report, and how to implement interventions to keep the resident safe. During an interview, the DON stated the Quality Assurance (QA) committee met on May 19, 2014 and the agenda was "...the entire 2567. We gave out new forms, policies and went over each tag and what the department head was suppose to do..." The next weekly QA meeting was scheduled for 5/23/14. During an interview the Administrator stated Resident #220 remained at the hospital and would be going to a locked unit when discharged . This facility does not have a locked unit. Medical record review for Resident #218 documented the care plan had been revised to address the use of a "STOP" sign, her concerns and her inability to sleep. There was documentation by the Nurse Practitioner and the DON that addressed her concerns and her inability to sleep. During an interview, Resident #218 stated, "I'm resting so good. I don't know how much more of that I could take. Thank you. You saved me." During an interview, Resident #218's daughter stated, "I have seen a lot of improvement since you left." The facility will remain out of compliance at a Scope and Severity level "G", isolated deficient practice that constitutes actual harm that is not immediate jeopardy.

Based on medical record review, observation and interview, it was determined the facility failed to ensure 1 of 17 (Resident #9) sampled residents reviewed had complete medical records. The findings included: Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] documented the resident had clear speech, was usually able to make self understood and usually understands conversation, had a cognitive summary score was 6 out of a possible 15 indicating severe cognitive impairment, and had impairment in functional range of motion on the upper and lower extremity on one side. Review of the "DAILY SKILLED NURSE'S NOTES" from 1/11/14 to 1/13/14 documented no skilled note for 1/12/14. Review of a physician's "ACUTE VISIT" progress note completed by the Nurse Practitioner (NP) dated 1/13/14 documented, "...(Named Resident #9) reports sl (slightly) slurred speech onset yesterday after lunch - he says "was stuttering"..." Observations on the 400's hall, in the facility's lobby area, on 1/16/14 at 2:00 PM and on 2/4/14 at 10:15 AM, revealed Resident #9 to be alert and oriented to person and place, had right-sided paralysis, and slightly slurred speech. Resident #9 displayed some hesitation before speaking, but his responses were appropriate. Resident #9 was able to propel himself in the wheelchair throughout the facility independently. During an interview, by request of Resident #9's Responsible Party (RP), in the conference room on 1/15/14 at 4:25 PM, the RP stated she was concerned with the nursing care Resident #9 was receiving because on Saturday 1/11/14 she had noticed the resident was slurring his speech and the "...Temp (temporary) Services didn't know anything about him..." The RP stated the resident's speech was more slurred on Sunday 1/12/14, she spoke with the same nurse again, and didn't get an answer to her concerns until she spoke with the B Station Nurse Manager on Monday 1/13/14. During an interview at the B nurses' station on 1/16/14 at 2:30 PM, Nurse #3 and the B Station Unit Manger were asked if Resident #9 had had a change in condition over the past weekend, 1/11/14 and 1/12/14. Nurse #3 stated, "...He wasn't ever talking clearly. I was here Sunday. He was talking fine, more dragging of his leg than a change in speech, occurring intermittently." The B Station Unit Manager stated that she had worked Sunday from 9:30 PM until Monday at 10:00 AM and didn't notice changes in Resident #9's speech or use of his right side. She had been in Resident #9's room Monday morning early and had held the wheelchair for him while he independently transferred from the bed to the chair. During an interview in the conference room on 1/24/14 at 3:00 PM, the Director of Nursing (DON) confirmed the "DAILY SKILLED NURSE'S NOTES" for 1/12/14 was missing from Resident #9's chart. During an interview on the 400 hall on 2/4/14 at 6:50 PM, an Agency Nurse was asked what kind of orientation she received from facility staff. The Agency Nurse stated, "Been about 2 months since here last. Shown where to get supplies, the residents in my area, who to ask with questions, make walking rounds, given verbal report and review of the 24 hour report..." During an interview in the conference room on 2/5/14 at 11:20 AM, the DON was asked how Agency personnel were oriented to the station they are assigned. The DON stated the nurses leaving and coming in to work make walking rounds. The 24 hour report, documentation by each shift of changes in orders, resident behaviors, and nursing concerns, is reviewed. Also, "hot spots" which are family or patients that have a lot of concerns are reviewed. They are told how often to document and if there is a change in status how to fill out the physician communication sheet. The medication administration records are very detailed. The contracted Agency verifies current license, abuse registry, training on infection control and resident rights. During an interview in the conference room on 2/24/14 at 2:00 PM, the NP was asked about the possible change in Resident #9's status over the weekend of 1/11/14 and 1/12/14. The NP stated that when she saw him of Monday 1/13/14 she could not tell that his speech had worsened, however, the resident "...felt like he was stuttering. That was significant to me..." The NP stated that the brain scan was completed and indicated there had not been a new stroke.

Based on policy review, review of a facility's investigation, medical record review, observation and interview, it was determined the facility failed to provide two person assistance for transfer to ensure resident safety for 1 of 3 (Resident #1) residents reviewed with accidents. The failure to provide two person assistance for Resident #1 resulted in actual harm when the resident sustained [REDACTED]. The findings included: Review of the facility's "Incident Reporting" policy documented, "Policy It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure that the resident's environment shall remain as free of accident hazards as possible, and that each resident shall receive adequate supervision and assistive devices that shall reduce accidents..." Review of the facility's investigation of Resident #1's injury on 7/5/13 did not include an Incident / Occurrence Investigation Form which would include interviews, conclusion, and corrective action. An undated and unsigned hand written note documented, "(Named Certified Nursing Assistant (CNA) #1), states that he reported what he saw to the charge nurse, he noted blood coming from the resident's right foot. Unsure as to what happened." Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, able to make self understood, understands with clear comprehension, and had adequate vision. The resident's cognitive a summary score was 10 out of a possible 15 indicating moderate cognitive impairment. Functionally the resident was totally dependent for transfers, full staff performance every time, two persons physical assist due to functional limitation in range of motion of the lower extremity, impairment on both sides. Review of the most recent MDS dated [DATE] documented a cognitive summary score of 13 out of a possible 15 indicating the resident was cognitively intact. Functionally the resident remained the same. Review of the nurses notes documented the following: a. 7/5/13 at 6:40 AM written by the Night Supervisor - "...Called to room per charge nurse (Nurse #1)... foot with towel wrap around foot bright red blood noted on towel & top sheet R (right) foot with 3+ (plus) pitting edema dried red blood noted to foot area clean with noted splits between each toe No c/o (complaint of) pain or discomfort noted or voiced, when asked resident what happen he (Resident #1) stated "you know how my feet are the CNA (certified nursing assistant) got me up to w/c (wheelchair) & (and) it (foot) started bleeding..." b. 7/5/14 at 7:50 AM written by Nurse #2 - in addition to the laceration to the right foot, bilateral knee swelling, a dime size abrasion to the right knee, and a one and one-half inch scratch to the left knee. The physician was notified and orders received to send Resident #1 to the emergency room for evaluation. c. 7/5/14 at 12:00 PM written by Nurse #2 - the resident had returned to the facility status [REDACTED]. Review of the care plan dated 7/5/13 documented, "...Laceration to toe next to great toe on right foot... monitor stitches for s/s of infection... Resident has a fracture of L (left) knee with a immobilizer... Immobilizer d/c'd (discontinued) 8/26/13..." The care plan was updated 8/15/13 and documented, "...Total assist with lift with transfers..." Observations in Resident #1's room on 1/15/14 at 11:15 AM and 3:55 PM and on 2/4/14 at 1:00 PM, revealed Resident #1 lying on a specialty air mattress bed, a trapeze bar was over the head of the bed, the resident was unable to move lower extremities, and the resident was noted to have bilateral foot drop. During an interview in Resident #1's room on 1/15/14 at 3:55 PM, Resident #1 was asked if he had ever sustained an injury by the facility staff. Resident #1 stated, "He (Certified Nursing Assistant (CNA) #1) was a rookie. Split my toes. He didn't know what he was doing but it was not done intentionally..." Resident #1 continued and stated that he was paraplegic and had no feeling in his lower extremities. He didn't know what the CNA hit his foot on to split it. He had to go to the emergency room an get stitches but did not recall having had a fracture. During a telephone interview on 2/12/14 at 9:45 AM, Nurse #1 was asked If she remembered Resident #1 and could she tell me anything about how he was injured in July of 2013. Nurse #1 stated she had written notes of the incident and would call me back when she got home. At 12:30 PM, Nurse #1 returned the call and stated that CNA #1 worked for an agency. It was the facility's protocol to orient agency staff to the section, where things were and go through the CNA care plan and assignment sheet that has all the activities of daily living (ADL) care needs for the CNAs to follow. CNA #1 had come to her and "...Told me he had had an accident. He had got him (Resident #1) up in the wheelchair and he was bleeding. I went to (Named Resident #1's) room and he was bleeding from his right foot. There was blood on the sheets, towel, even on his gown... I wrapped the foot with a towel and notified the supervisor for night shift... When the bleeding had stopped we were able to see between the toes. It was a deep cut... The CNA had body lifted him by himself. Anytime the CNAs got him up for a shower or anything else they used a lift..." During a telephone interview on 2/18/14 at 3:45 PM, the Night Supervisor was asked could she tell me anything about how Resident #1 was injured in July of 2013. The Night Supervisor stated, "...I was called to the room at 6:15 to 6:30 AM. Appeared as little splits between the toes... Couldn't see the cut. They said they had to move the toes to see it. The agency CNA (#1) said he didn't know how it happened... He (Resident #1) is assessed for lift and 2 person assist." During an interview at the D nurses station on 2/21/14 at 11:15 AM, Nurse #2 was asked could she tell me anything about how Resident #1 was injured in July of 2013. Nurse #2 stated, "...It happened on 11P to (-) 7Ashift. Didn't know the CNA... I came on that morning. Raised to look at his foot and noticed he was going to have to have stitches. A head to toe assessment was done. Pulled the cover back and had abrasions on both knees. Fracture turned out to be just one leg. He denied pain. No body really knew what had happened... (Resident #1) denied falling or dropping. Nurse #2 was asked how agency staff was oriented to their assigned station. Nurse #2 stated the nurse on that shift fills out the assignment sheet and another CNA walks through the unit with the new CNA... The CNA care plan in the ADL book lets them know if the resident can get up and the assistance needed. (Resident #1) uses a lift to get up. His legs are straight..." The failure to provide two person assistance for Resident #1 resulted in actual harm when the resident required stitches to the underside of the right foot and sustained a non-displaced fracture of the left tibial tuberosity.

2 Based on policy review, review of an incident report, medical record review and interview, it was determined the facility failed to ensure care and treatment for [REDACTED].#220) residents with wandering behaviors of the 52 residents included in the stage 2 sample. The failure of the facility to effectively treat behaviors and implement new interventions for wandering and exit seeking behavior resulted in immediate jeopardy (in a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death) when Resident #220 eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F319 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's ELOPEMENT / WANDERING RESIDENTS policy documented, .Care plans and individual behavior plans will address wandering as a specific problems. Approaches will be formulated, patterns identified and the causes determined will be addressed . 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, .Wandering / Elopement Risk. Ensure that resident is wearing a wanderguard and that it is working properly. when resident begins to wander, provide comfort measures. remove resident from other's room and unsafe situations. Review of a facility incident report dated 4/15/14 documented, .Resident (#220) got out of the building by himself wandered over to (named grocery store), Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION] A written statement from Registered Nurse (RN) Supervisor #1 documented, .I was notified by (named Nurse #17) at 10:33 pm, that the alarm had gone off and a man was seen leaving the building. Someone checked (named Resident #220) and he wasn't there. staff was notified to search the building. He was found at (named grocery store) by staff, and returned to the building. No injury. There is no evidence that the care plan was revised after the elopement on 4/1514. Review of the behavior intervention monthly flow record for 4/15 (2014) documented the behavior of agitation. One episode of agitation is documented on 4/1/14 and on 4/15/14 on the day shift. On 4/27/14 seven episodes are documented on the day shift. Zeros are documented on the day shift on 4/26/14; the evening shift on 4/14/14 - 4/18/14 and 4/21/14 - 4/26/14 and 4/28/14 - 4/30/14; and on the night shift on 4/15/14 - 4/20/14, and 4/22/14 - 4/30/14. All other dates are blank. There is no evidence the facility was tracking wandering. There is no evidence that Resident #220 was seen by Psychology services until 4/25/14. During an interview in Resident #218's room on 4/28/14 at 3:33 PM, Resident #218 was asked if there had been any concerns or problems with a roommate or any other resident. Resident #218 stated, The man next door comes into my room. I told the nurse and they put the stop banner up. Resident #218 was asked if the staff addressed this concern to her satisfaction. Resident #218 stated, No. He (Resident #220) crawls up under the banner. During an interview in Resident #218's room on 5/1/14 at 9:00 AM, Resident #218 was asked how many times Resident #220 had come into her room and what did he do when he came in. Resident #218 stated, Has been in here 3 times. One time he came in and started pulling on door (pointed to bathroom door) and started pulling his pants down. The second time he came into room he was standing by the curtain (privacy curtain) looking in the corner. The third time he crawled under the sign (STOP banner). I was in bed resting, around 2 in the afternoon. I always lay down after dinner (lunch). Have to lay down in the evening (after the lunch meal) cause I can't rest at night. I'm afraid he would come in here. I don't want that man coming into my room scaring me and making me have a set-back. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift. RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, I put it on the 24 hour log and that goes to (DON). During an interview in the activities room on 5/5/14 at 8:15 AM, the Administrator, was informed of above nurses response to question of responding to wanderguard alarm and asked if the facility had an orientation for the agency nurses. The Administrator stated, From what I understand, the agency nurses are oriented to the patients they will be taking care of but we don't have an organized, structure orientation for agency nurses, but we will now. The facility failed to implement new, appropriate and measurable interventions to address wandering and exit seeking behavior which placed Resident #220 in immediate jeopardy when he eloped.

2 Based on policy review, review of the daily staff sheets, medical record review, observation and interview, it was determined the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to timely assess and notify the physician of swelling of the right for 1 of 52 (Resident #22) resident reviewed of the 52 residents included in the stage 2 sample. The failure of the facility to appropriately assess and timely notify the physician of swelling of the right arm, of a resident who was at a high risk for [MEDICAL CONDITION], resulted in delay of care and placed Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death). In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The immediate jeopardy for F309 J constitutes substandard quality of care. An extended survey was completed on 5/5/14. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, Policy- It is the intent of this facility to assess and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay assessment information to physician and to document actions. Except in a medical emergency or when a resident is deemed incompetent, the facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly. Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination to monitor vital signs (temperature, pulse respiration, blood pressure, oxygen saturation, pain level) at the onset of the change and as ordered by the physician. 4. Review all findings with the physician and non-physician practitioner. 5. Document in the medical record all physician contacts and notifications. The Change of Condition Evaluation Tool will serve as the official nursing documentation for change in status. Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The nursing admission information assessment completed on 3/19/14 documented Resident #22 was readmitted to the facility from the hospital and documented [MEDICAL CONDITION] N (no). The history and physical examination [REDACTED] The care plan dated 4/3/14 documented, Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] (deep vein thrombus) / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease). Approach Frequency. 4. Observed RUE for swelling and bruising. 5. Notify MD (medical doctor) for changes in status. A nutrition services progress note dated 4/11/14 for Resident #22 documented, [MEDICAL CONDITION] noted to hand. There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, .RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch. The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, .There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present. A nurses note dated 4/21/14 documented, .T (positive) Findings regarding Doppler. N.O. (new order) [MEDICATION NAME] (medication to prevent blood clots) 60 mg (milligrams) subq q (subcutaneous every) 12 (symbol for hours) (start today) 2. [MEDICATION NAME] (medication to prevent blot clots) 5 mg PO (by mouth) daily (start today) 3. INR (International normalized ratio (a laboratory test used to determine therapuetic levels for a blood thinning medication)) daily (start in AM) 4. Continue [MEDICATION NAME] until INR -> (symbol for equal to or greater than) 2 (target INR range) for two consecutive days. A nurses noted dated 4/24/14 (was the first time nurses documented swelling) documented, .(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand. There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. An acute visit dated 4/29/14 completed by the NP documented, .History of complex mass arm may cause flow issues. d/c (discontinue) [MEDICATION NAME], d/c [MEDICATION NAME], risks > (greater than) benefit. Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, My mother is (named Resident #22) has been here 9 years and is in late stages of Alzheimer's, not expecting her to live many more days, is comatose. She was in the hospital, can't remember exact dates March/April 2014, when she came back here her right hand was swollen. It swelled up her arm. I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot, she got started on [MEDICATION NAME] During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 stated, I started working here full time about 2 weeks ago on this hall, prior to that I worked as needed. Nurse #13 was asked about Resident #22. Nurse #13 stated, She has [MEDICAL CONDITION] in her right hand, we elevate it on pillows, she has a poor appetite, the last 2 days has had no to little po (my mouth) intake and no medications taken. Nurse #13 was asked how long resident has had [MEDICAL CONDITION] in the right upper extremity. Nurse #13 stated, She has been in the same condition as she is now since the first day I saw her. Has had [MEDICAL CONDITION]. We kept her hand elevated on a pillow. Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, If there was a change in condition, I would evaluate resident and notify the doctor. During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14. Review of the daily staff sheets for the shifts Nurse #13 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed she had worked on 4/11/14, 4/15/14, 4/16/14 and 4/18/14. During an interview at the 500/600 nurses' station on 5/2/14 at 12:10 PM, Nurse #3 was asked about Resident #22 and stated, (Named Resident #22) was sent out to hospital due to decreased intake at her daughters request. she was there 2 to (-) 3 days and returned still not eating. Nurse #3 was asked about the [MEDICAL CONDITION] in Resident #22's right hand. Nurse #3 stated, The daughter found it and told me on 4/21/14 the day of the Doppler, the NP was in the facility and was notified and ordered the Doppler. The daughter is a nurse. She is quite involved in her care. During an interview in the activity room on 5/2/14 at 5:00 PM, Resident #22's family member was asked what staff had she reported the swelling to. Resident #22's family member stated, I told a CNA (certified nursing assistant) on 3-11 shift, don't know her name. I ask them to keep it (arm) on a pillow, also told a male nurse (named Nurse #14) who works 3-11. My Mother has a history of blood clots. During a telephone interview on 5/5/14 at 4:10 PM, Nurse #14 was asked about Resident #22's hand and arm [MEDICAL CONDITION]. Nurse #14 stated, I do remember caring for (named Resident #22). I do not remember her daughter reporting to me anything about swelling of her right arm, but I do remember being told of that swelling during a shift change report by another nurse but I do not remember the date and can't recall what I did in regards to the arm swelling. Review of the daily staff sheets for the shifts Nurse #14 had worked from 4/11/14 (when [MEDICAL CONDITION] was noted by dietary) through 4/21/14 revealed he had worked on 4/14/14, 4/15/14, 4/16/14, 4/17/14, 4/19/14 and 4/20/14. During an interview at the 500/600 nurses' station on 5/2/14 at 4:10 PM, CNA #16 was asked about Resident #22's arm [MEDICAL CONDITION]. CNA #16 stated, I am a floater, I work with her usually at least once a week. I am not sure when hand and arm swelled. I remember her daughter asking us to put her arm up on a pillow. She thought is was swelled, that was in April but not sure exact date. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, I expect nurse to evaluate, notify doctor, and keep hand and arm elevated. The facility failed to timely assess and notify the physician of [MEDICAL CONDITION] of the right arm which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing [MEDICAL CONDITION], in immediate jeopardy.

2 Based on policy review, review of a facility report, medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for monitoring a resident's skin and reporting change of conditions to the physician, to protect from wandering and exit seeking behavior, complete wander guard checks and ensure a bed alarm and mat was in place for 4 of 34 (Residents #22, 220, 108 and 247) sampled residents of the 52 residents reviewed on the stage 2 sample. The failure of the facility to follow the care plan intervention for monitoring a resident's arm and timely notification of condition changes to the physician resulted in a delay of treatment for [REDACTED].#220 from elopement and entering another resident's room resulted in immediate jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death when Resident #22 who was at high risk for [MEDICAL CONDITIONS] developed a [MEDICAL CONDITION] and Resident #220 wandered into another resident's room and eloped from the facility. In the activity room on 5/2/14 at 3:45 PM, the Administrator and Director of Nursing (DON) were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of the facility's Situation, Background, Assessment, Request (SBAR) Action and Notification protocol documented, Policy- It is the intent of this facility to assess and document changes in a resident's health. in an efficient and effective manner; to relay assessment information to physician and to document actions. facility will consult with the resident and notify the resident's physician, and the legal representative or interested family member of but not limited to the following: A significant change in the resident's physical, mental or psychosocial status, A need to alter treatment significantly. Procedure- 1. Licensed staff will assess any change in condition through observation, physical examination. 4. Review all findings with the physician and non-physician practitioner. 5. Document in the medical record. Change of Condition. Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/3/14 documented, Problem- Resident has potential for discomfort/pain, bruising and swelling r/t (related to) fragile skin, h/o (history of) [MEDICAL CONDITION] / muscle mass RUE (right upper extremity) /PAD (peripheral artery disease). Approach Frequency. 4. Observed RUE (right upper extremity) for swelling and bruising. 5. Notify MD (medical doctor) for changes in status. A nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. There was no documentation by the nursing staff of [MEDICAL CONDITION] to the right hand or upper extremity. An acute visit assessment dated [DATE] completed by the Nurse Practitioner (NP) documented, .RUE hand c (with) 2 t (plus) [MEDICAL CONDITION], R (right) forearm 1 t [MEDICAL CONDITION], R upper arm 2 t [MEDICAL CONDITION] with ^ (increased) heat to touch. The NP ordered a doppler to RUE. The final report of the doppler to RUE dated 4/21/14 documented, .There is incomplete compression, echogenic material and decreased flow in the [MEDICATION NAME], axillary, and brachial veins. Non-occlusive [MEDICAL CONDITION] is demonstrated. Soft tissue [MEDICAL CONDITION] is present. A nurses noted dated 4/24/14 documented, .(symbol for decrease) [MEDICAL CONDITION] to Rt. (right) arm/hand. There was no documentation of the [MEDICAL CONDITION] in the right hand/arm by the nurses until this note dated 4/24/14, yet a nutrition services progress note dated 4/11/14 documented, [MEDICAL CONDITION] noted to hand. Observations in Resident #22's room on 5/2/14 at 12:00 PM, revealed Resident #22 on her left side with wedge pillow present, right hand on pillow and with [MEDICAL CONDITION] noted. Observations in Resident #22's room on 5/2/14 at 6:00 PM, revealed family at bedside and Resident #22 had just been turned back to her left side, oxygen on at 2 liters per nasal cannula, right arm on pillow with [MEDICAL CONDITION] noted, noted facial twitching and mouth breathing. During an interview in the activity room on 5/2/14 at 8:45 AM, Resident #22's family member reported, My mother is (named Resident #22). can't remember exact dates March/April 2014, when. her right hand was swollen. It swelled up her arm, I asked about it, told nurses, and finally just last week (4/21/14) they addressed it and said it was a blood clot. During an interview at the 500/600 nurses' station on 5/2/14 at 11:50 AM, Nurse #13 was asked what was the procedure if there was a change in a resident's condition. Nurse #13 stated, If there was a change in condition, I would evaluate resident and notify the doctor. During another interview in the activity room on 5/2/14 at 12:26 PM, Nurse #13 was asked about documentation of Resident #22's hand and arm [MEDICAL CONDITION] and notifying the doctor. Nurse #13 stated, No, I don't see any documentation about the [MEDICAL CONDITION] until the 4/21/14 Doppler order. No, I don't see any documentation about the doctor being notified about the [MEDICAL CONDITION] prior to 4/21/14. During an interview in the activity room on 5/2/14 at 12:45 PM, the DON was asked what was expected of nurses if a resident developed [MEDICAL CONDITION] in the hand and arm. The DON stated, I expect nurse to evaluate, notify doctor, and keep hand and arm elevated. The facility failed to follow the care plan intervention for monitoring the right arm by failing to complete timely assessments and notification of [MEDICAL CONDITION] to the physician which resulted in a delay of treatment, actual harm, neglect and placed Resident #22, who was at a high risk of developing a [MEDICAL CONDITION], in immediate jeopardy. 2. Medical record review for Resident #220 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) date of 2/18/14 documented a brief interview for mental status (BIMS) score of 3 indicating that his cognitive skills are severely impaired. The preference and frequency of wandering is documented to occur 1 to 3 days during the assessment period. Review of the resident care plan with a start date of 2/24/14 documented, .Wandering / Elopement Risk. when resident begins to wander, provide comfort measures. remove resident from other's room and unsafe situations as needed. Review of a facility incident report dated 4/15/14 documented, .Resident (#220) got out of the building by himself wandered over to Kroger. Wanderguard intact to right ankle. Resident brought back to facility. Appears NAD (no apparent distress) without skin tears, skin discoloration, or [MEDICAL CONDITION] There is no evidence the care plan was effective to protect Resident #220 from eloping from the facility. During an interview at the A hall nurses' station on 5/1/14 at 6:30 PM, Registered Nurse (RN) Supervisor #1 was asked if Resident #218's daughter had reported that a male resident was coming into her mother's room and it scared her mother. RN Supervisor #1 stated, Yes. I told the floor nurse to document (named Resident #220) behavior and keep him out of the room and then to pass it along to the next shift. RN Supervisor #1 was asked how she passed it along to the next shift. RN Supervisor #1 stated, I put it on the 24 hour log and that goes to (DON). There is no evidence Resident #220's care plan was implemented to keep him from wandering into Resident #218's room which caused psychological harm to Resident #218 when she voiced her inability to rest due to fear of Resident #220 entering her room. The facility failed to implement interventions to address wandering and exit seeking behavior to keep the resident's safe and free from psychological harm and elopement which placed Resident #218 and Resident #220 in immediate jeopardy. Refer to F223. 3. Review of the Wanderer Monitoring System policy documented, .Policy. To provide a reliable system for protecting residents who have a history of wandering. Daily documentation by nursing staff to ensure wanderguard is intact. MAR (Medication Administration Record) or ADL (Activities of Daily Living) flow sheet to document the check. Medical record review for Resident #108 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/1/14 documented, Problem. Resident h/o (history of) wandering as well as an elopement risk. Approach/Frequency. Provide resident with wanderguard for safety. Check resident wanderguard for proper functioning at beginning of shift and end of shift. Review of the August 2013 medication record documented, there were 93 opportunities for the wanderguard to be checked and there were 18 times when there was no documentation of the alarm being checked. During an interview in the C hall unit manager's office on 5/5/14 at 11:30 AM, Nurse #3 was asked who checks wanderguards and how often are they checked. Nurses #3 stated, The Restorative Nurse (Named Nurse #2) they are checked weekly and are checked on each resident that has a wanderguard. During an interview in the Restorative Nurses' office on 5/5/14 at 11:35 AM, Nurse #2 was asked when are wanderguards checked. Nurse #2 stated, I check them on Monday, Wednesday and Friday on all residents that have them. We have a machine that we use to check them. The facility failed to follow the care plan intervention to check Resident #108's wanderguard for proper functioning at beginning of shift and end of shift. 4. Medical record review for Resident #247 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/21/14 documented, .Problem. Resident at risk for falls r/t (related to) cognitive loss, functional limitation in ROM (Range of Motion) and dx (diagnosis) of [MEDICAL CONDITION] Approach. Frequency. Bed alarm. Observations in Resident #247's room on 5/3/14 at 2:20 PM, revealed the resident lying in bed, there was no bed alarm in place as care planned. During an interview in Resident #247's room on 5/3/14 at 2:22 PM, Nurse #11 verified there was no bed alarm in place as care planned.