Every finding on record at Guardian Care Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to complete a thorough investigation of an alleged violation of neglect by failing to maintain thorough investigation documentation of the alleged violation, for 1 out of 2 residents reviewed for abuse/neglect, of a total sample of 36 residents, (#26).Findings:Resident #26 was admitted to the facility on [DATE] with diagnoses that included stage 4 pressure ulcer to the sacral region, neuromuscular dysfunction of the bladder and paraplegia.Review of the Minimum Data Set quarterly assessment, with Assessment Reference Date 5/11/26 revealed resident # 26's Brief Mental Status score was 15 out of 15, which indicated his cognition was intact.Review of the medical record also showed resident #26 had a suprapubic catheter (a tube to drain urine that comes out of your abdomen).Review of resident #26's care plan revealed the resident refused care at times with interventions that included When resident refuses, reapproach later and try again. If continues to refuse, try another staff member.On 8/18/26 at 4:22 PM, the Director of Nursing (DON) explained that on 7/15/26 a verbal abuse report was filed. Resident #26 reported to the [NAME] Wing Unit Manager (UM) on 7/16/26, that the 11 PM -7 AM assigned Licensed Practical Nurse (LPN) J did not want to flush his catheter. He said it leaked and was painful, which caused him to be upset. The resident stated the nurse told him she would not return to the room to provide care for the remainder of the shift. The DON stated that LPN J was no longer employed at the facility. The facility's investigation file did not have the statement from LPN J to be reviewed. The Nursing Home Administrator (NHA) said she had it in her office and would provide it. A review of the medical record showed no documentation that another nurse resumed the resident's care. There was no documentation if the resident's catheter was assessed or if his pain was addressed for the remainder of the shift. A review of the Nurse's Behavioral Progress Note by LPN J on 7/15/26 at 5:39 AM, showed resident told Certified Nursing Assistant (CNA) K at 3:45 AM that he needed to speak to the nurse in regard to his stomach hurting. I entered residents room w/prn 9 (with as needed) tums and asked him if he wanted to take medication to help. Resident snatched medication and slammed it down onto the bedside table. Then resident started to yell and curse at this writer. Resident tells this writer to flush his catheter; this writer explained to resident that I would need to check if there is an order in emar (electronic medication administration record) first and will be right back. After this writer checked emar for orders and returned to explain that this writer was able to replace the foley as needed per order, additionally a call to the doctor would need to be made for an order to flush. Resident cursed, yelled at this writer and did not wish this writer to be his nurse. Resident also stated that this writer was not to come back into his room for the rest of shift.On 8/19/26 at 4:00 PM, LPN J's statement was provided and was the same as documented in her behavioral progress note. Her statement included an assessment of the catheter and the resident's refusal to have her assess the catheter site. The facility's report of the investigation read, The Executive Director initiated a thorough investigation, which included interviews with the resident, the resident's responsible party (son), the agency nurse (LPN J), CNA K, and other staff with knowledge of the incident. The resident's medical record, nursing documentation, physician orders, and treatment records were reviewed. The assigned CNA K reported hearing the resident yelling and using profanity toward the nurse from the hallway. Although she did not witness the conversation inside the room, she stated that after the nurse exited the room, she reported the resident did not want her to return to the room. The CNA K also reported that the resident refused assistance from nursing staff until his catheter issue was addressed.A review of the facility's investigation showed the senior nurse on the unit refused to write a statement. The NHA provided documentation showing communication with the senior nurse stating that she would not write a statement because the resident is known to be verbally abusive toward staff. The assigned CNA K's statement was reviewed, and it showed that CNA K entered the room to answer the call light. At the resident's request for his nurse, CNA K told his nurse LPN J who responded with he told me do not enter my room, I don't want anything from you. The next morning, after the night of the incident, the [NAME] Wing Unit Manager (UM) assessed the resident and obtained an order from the physician to flush the catheter. The UM was the first to receive the complaint by the resident of the incident. The UM did not write a statement on the resident's behalf nor a statement of her own. There was also no statement provided by the resident's son in the investigation.The NHA said she spoke to the Evening Supervisor on duty at the time but there were no statements provided in the investigation.On 8/18/26 at 5:30 PM, the Administrator said the team always did a thorough investigation even though the only statements provided were from LPN J and CNA K. They also acknowledged CNA K's statement was not reflective of what was in their report. The Administrator reiterated their investigation was thorough and their conclusion was the verbal abuse allegation was not substantiated. The NHA could not explain why this incident was not investigated as allegation of neglect as the resident did not receive the care he needed. Review of the facility's undated policy on Prevention and Reporting of Suspected/Alleged Resident Abuse and Neglect revealed, Our facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse and neglect. The Administrator and the Director of Nursing are responsible for the implementation and ongoing monitoring of abuse standards and procedures. One of the standards implemented and monitored is Investigation. For Investigation, it called for a list of possible or known witnesses, interview and obtain signed statement from each staff separately, residents, .interview staff on other shifts who might have seen or heard anything prior to the incident .interview residents in the vicinity where the incident occurred.

Based on record review, and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) for the 4th quarter in the fiscal year (FY) 2024. Findings: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed no facility staffing data was submitted for the period of July 1,2024 to September 30, 2024 (FY Quarter 4 2024). On 3/12/25 at 5:08 PM, the Administrator acknowledged the facility was supposed to submit the PBJ staffing data and stated she was aware it had not been submitted for Quarter 4 of 2024. She explained that at that time there was a glitch in the system, and due to turnover in their Human Resources department it had not been submitted.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the QAPI plan effective 5/27/24 revealed the facility would use a thorough and highly organized/structured root-cause analysis approach to determine if and how identified problems may be caused or exacerbated by the way care and services were organized or delivered. The systemic actions would look comprehensively across all involved systems to prevent future events and promote sustained improvement. The facility would monitor the effectiveness of performance improvement activities to ensure that improvements were sustained. The facility had a deficiency cited at F689 during the previous recertification survey conducted 7/24/23 through 7/29/23. The facility was cited due to failure to prevent a cognitively impaired resident from exiting the facility unsupervised, and failing to provide adequate supervision and a secure environment. During the current recertification survey, the facility was again found to be in noncompliance with F689 for failing to provide a secure environment and adequate supervision when a cognitively impaired resident exited the facility through an unsecured/unalarmed door. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the repeat citation. On 3/12/25 at 5:11 PM, the Executive Director reported the QAPI committee met monthly as well as held Ad HOC meetings when issues arose. She stated the committee used monthly reports and audits submitted by each department to identify areas of concern. She explained areas of concern were prioritized with areas affecting patient care with safety taking precedence. The Executive Director stated the committee always looked to identify a root cause to prevent the event from recurring. She stated that some type of auditing had to be put in place and documentation would be placed on the Performance Improvement Plan (PIP). The Executive Director explained she felt the previous situation was a result of a door malfunction and the current situation was different as resident #87 exited the building in an attempt to locate his wife. She did not explain how resident #87 was able to open the door without knowledge of staff if the door had been alarmed. The Executive Director acknowledged all exit doors were not alarmed after the previous elopement to ensure other residents could not exit through exterior doors that were designated as emergency exit only.

Based on interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for pneumococcal vaccine for 3 of 5 residents reviewed for immunizations, of a total sample of 34 residents, (#20, #9, and #59). Findings: 1. Resident #20 was admitted to the facility on [DATE]. Review of her medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine. 2. Resident #9 was admitted to the facility on [DATE]. Review of her medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine. 3. Resident #59 was admitted to the facility on [DATE]. Review of his medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine. On 3/12/25 at approximately 6:00 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they were unable to provide a record of documentation of consent, refusal, or contraindication for administration of the pneumococcal vaccine for residents #20, #9, and #59. The DON acknowledged they could not find documentation to show if the residents had previously received the vaccination, refused it or if the vaccination was even offered. The DON explained that the previous ADON was responsible for obtaining consents from the residents or their representatives and it seemed she only documented for the Influenza vaccinations. The facility's policy titled Pneumococcal Polysaccharide Vaccine (PPV) states that all residents will be offered a Pneumococcal Polysaccharide Vaccine (PPV) upon admission and every five years thereafter or according to local health department guidelines.

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect all residents who ate meals prepared in the facility's kitchen. Findings: On 3/09/25 at 9:50 AM, during the initial kitchen tour with the morning (AM) cook M, it was noted the walk-in refrigerator temperature was not written on the temperature log for today or yesterday. [NAME] M acknowledged the temperatures were not on the log and explained she was about to enter the temperature for today. In the walk-in there was a half-full bag of shredded cheese that did not have the date it was opened. There was also an unsealed, open to air, 3/4 full plastic package of sliced meat and a resealed half full plastic package of sliced deli meat which contained approximately 15 slices. Both packages were unlabeled and did not have a date to indicate what date the package was opened. There was also a previously opened package of Parmesan cheese with a manufacturer's use-by date of 2/11/25 (26 days prior). A plastic container of sour cream with an imprint of 2025-0016 on it was noted. AM cook M was unsure as to what that imprint meant and the container was not marked as to when it had been opened at the facility. The AM [NAME] M, stated she used a magic marker to date food items she opened, but acknowledged this package had none. She threw the sour cream away. The Certified Dietary Manager (CDM) arrived and took over the tour. A one-third steam table pan of leftover applesauce was dated 3/5 (four days ago) and the CDM acknowledged it should have been thrown away. There was a one-third steamtable pan of leftover corn and one of leftover gravy dated 3/4 which the CDM stated should have been thrown away previously. Two containers of beef base, and one of chicken base, were opened but undated as to when they were opened. These items were discarded. A half-filled plastic container of an unknown food item that appeared to be leftover coleslaw did not have a label to indicate the date of when it was opened or what the item was. A half used squeeze tube of whipping cream was not sealed and undated as to when it was initially opened. A previously opened box of potato salad in its original packaging, along with eight covered plates of cake slices and eight small bowls of covered fruit were noted as undated to show when they were opened or how long they had been in the cooler. 2. A few minutes later in the dry food storeroom, there were two previously opened but unsealed plastic bags of dry pasta and three pieces of unwrapped graham crackers in the box of individually-packaged graham crackers, which the CDM acknowledged. The CDM stated each person who used the food items were responsible to seal, label, and date the items to ensure they did not attract bugs or other pests and to ensure the items were fresh and safe to serve to residents. The facility's undated policy entitled Food Receiving and Storage indicated foods shall be received and stored in a manner that complied with safe food handling practices. It detailed all food stored in the refrigerator or freezer will be covered, labeled, and dated with a use by date. There was no indication in the policy as to how long different food items could be kept and utilized after they were opened.

Based on observation, interview, and record review, the facility failed to complete a Pre Admission Screening And Resident Review (PASARR) Level I Screen for 5 of 6 residents reviewed for PASARR that were later identified with a possible Serious Mental Illness (SMI), of a total sample of 34 residents, (#20, #42, #72, #28, and #75). Findings: 1. Review of the medical record revealed resident #20, a [AGE] year old female was admitted to the facility from an acute care hospital with diagnoses that included lack of coordination, ulcer of esophagus, hypertension, cerebral infarction (stroke), hemiplegia/hemiparesis (paralysis), major depressive disorder, unspecified psychosis, and anxiety disorder. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 12/29/24 noted during the look-back periods, resident #20 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was severely cognitively impaired. The assessment documented the resident sometimes felt lonely or isolated, for 4 to 6 days had verbal behavioral symptoms directed towards others, requires substantial/maximum staff assistance to complete Activities of Daily Living (ADL) and mobility, did not walk, was always incontinent of bladder and bowel functions, received seven insulin injections and high-risk anti-psychotic, anti-depressant, anti-platelet, and hypo-glycemic medications. No psychological therapy or discharge planning to return to the community occurred. On 3/10/25 at 10:42 AM, resident #20 was observed in the Memory Care common area sitting in a wheelchair amongst approximately 10 other residents. The resident was observed to be distressed for no obvious reason while she yelled out, Hey, hey, hey. On 3/10/25 at 1:59 PM, the resident was observed in her room sitting in a wheelchair. The resident was observed yelling out in the same manner. Review of the Admission Record noted on 12/18/16, after resident #20 was admitted , additional diagnoses were added that included: delusional disorders and pseudobulbar effect (sudden uncontrollable crying or laughing). The State Agency (MedServ Form 004 Part A, October 2015) PASARR (Pre-Admission Screen and Resident Review) Level I Screen completed by the acute care hospital on 11/19/15 documented resident #20 did not have any Suspected Mental Illness (SMI) or difficulty in interpersonal functioning. On 3/11/25 at 1:42 PM, the Social Services Director said she was responsible for completing PASARR forms for the facility. She explained, their process was that the clinical team checked and reviewed records when residents were admitted . She said if a form was missing, for example if a resident was admitted from home, she completed and submitted them electronically. She checked resident #20's medical record and confirmed there were no possible SMI diagnoses listed on the Level I Screen and stated, I don't have to do a new one; I haven't been told it has to be redone if they're not correct. 2. Review of the medical record revealed resident #42, a [AGE] year old male was admitted to the facility from a Veteran's acute care hospital on 5/10/24 with diagnoses that included moderate dementia with anxiety, affective mood disorder, major depressive disorder, cognitive communication deficit, anxiety disorder, and Chronic Post Traumatic Stress Disorder (PTSD). The most recent MDS Quarterly Assessment with an ARD of 2/11/25 noted during the look-back periods, resident #42 scored 11 out of 15 on the BIMS that indicated he was moderately cognitively impaired. The Mood Interview showed for several days, the resident felt down, depressed, or hopeless, had little energy, trouble concentrating, and sometimes felt lonely or socially isolated with no rejections of evaluation or care. The assessment noted the resident required set-up to substantial/maximum assistance to complete ADLs and functional mobility. The resident did not walk, was always incontinent of bladder and bowel functions, received high-risk anti-depressant, anti-coagulant (blood thinner), opioid, and anti-platelet (blood clot prevention) medications. There was no psychological therapy or active discharge planning to return to the community. On 3/10/25 at 9:22 AM, resident #42 was observed in his room alone, lying in bed. The resident was irritable, reluctant to answer questions and stated, they don't help me. Review of the State Agency (MedServ Form 004 Part A, March, 2017) PASARR Level I Screen completed by the acute care hospital on 5/10/24 revealed it did not list resident #42's PTSD diagnosis. On 3/11/25 at 1:45 PM, the Social Services Director checked resident #42's medical record acknowledged the PASARR did not include the PTSD diagnosis and stated, it should have PTSD on there, therefore the previous screening was incorrect. 3. Review of the medical record revealed resident #72, a [AGE] year old male was admitted to the facility from an Veteran's acute care hospital on 3/30/23 with diagnoses that included gait and mobility abnormalities, unspecified dementia with psychotic, mood, and anxiety disturbance, adjustment disorder with depressed mood, and PTSD. The most recent MDS Quarterly Assessment with an ARD of 12/31/24 noted during the look-back periods, resident #72 scored 7 out of 15 on the BIMS that indicated he was severely cognitively impaired. The assessment noted the resident required supervision to moderate assistance to complete ADLs and supervision for functional mobility and walking. The resident was occasionally incontinent of bladder and bowel functions, and received high-risk anti-depressant medications. There was no psychological therapy or active discharge planning to return to the community. The State Agency(MedServ Form 004 Part A, March, 2017) PASARR Level I Screen completed by the acute care hospital on 3/30/23 documented resident #72 did not have any SMI. On 3/09/25 at 4:30 PM, the Social Services Director checked resident #72's medical record acknowledged the PASARR was incorrect and did not include any possible mental illness diagnoses. In a joint interview with the Director of Nursing (DON) and Assistant DON on 3/12/25 at 3:36 PM, the DON said there were weekly meetings with psychiatric services, the pharmacy, social services, and nursing to discuss residents' plan of care. The DON explained any new diagnoses and treatment revisions were discussed and updated. On 3/12/25 at 8:43 AM, Social Services Director said she called the State Agency (SA) PASARR vendor to clarify when a new Level I Screen was required. She said she learned that a new screening was required for incorrect forms or later if possible SMI's, including PTSD were identified to determine if further evaluations were necessary to ensure residents received proper services and placement for their psychiatric diagnoses. She confirmed the facility needed to submit corrected forms for the residents. 50875 4. Review of the medical record revealed resident #28 was admitted to the facility on [DATE]. Her diagnosis included hypertension, hemiplegia, major depressive disorder, cerebral infarction (stroke), auditory hallucinations and bipolar disorder. Resident #28's Annual MDS with an ARD of 1/18/25 revealed the resident scored 15 out of 15 on the BIMS assessment which indicated she had no cognitive impairment. The assessment also indicated the resident felt depressed, had no behaviors nor rejection of care and listed diagnoses of depression, bipolar disorder and auditory hallucinations. Resident #28's Order Summary Report showed the resident had an order for Quetiapine Fumarate Tablet 75 milligrams (mg) by mouth at bedtime for bipolar disorder and Bupropion HCl tablet 150 mg by mouth two times a day major depressive disorder. On 3/10/25 at 10:50 AM, a review of resident #28's PASARR Level I Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 1/15/21 incorrectly indicated no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 5. Review of the medical record revealed resident #75 was initially admitted on [DATE] and readmitted on [DATE]. His diagnosis included dementia, delusional disorders, dysphagia (difficulty swallowing), psychotic disorders with delusions and Parkinson's disease. Resident #75's Quarterly MDS with an ARD of 12/24/24 revealed the resident scored 3 out of 15 on the BIMS which indicated he had severe cognitive impairment, displayed no behaviors and listed psychotic disorder as a diagnosis. The Plan of Care for resident #75 indicated he was at risk for adverse effects related to the use of antipsychotic medications. Review of resident #75's Order Summary Report revealed the resident had orders for Quetiapine Fumarate tablet 25 mg by mouth daily and 50 mg by mouth at bedtime for hallucinations. On 3/09/25 at 4:30 PM, a review of resident #75's PASARR Level I Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 3/22/23 revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. On 3/11/25 at 11:55 AM, the Social Service Director explained she was the one who reviewed the PASARR forms. She explained the process was that nurses would review the admission packet from the hospital, the clinical team would review it, then it was reviewed by medical records and finally, it was scanned into the electronic medical record. A copy was left in the hard chart as well. If a resident was admitted from home, she would complete the form. The Social Service Director would only update it if there were new behaviors which required a reassessment of a resident. The Social Service Director said she had always assumed that PASARRs from the hospital were correct. On 3/12/25 at 10:36 AM, the Social Services Director verified there were no diagnoses listed on the PASARR form for both resident #28 or #75. She confirmed the forms needed to be corrected. On 3/12/25 at 9:20 AM, the Director of Nursing (DON) said her expectation would be that the residents' diagnoses should have been listed in Section A and the PASARRs should have been updated when new diagnoses or changes occurred. The DON stated they needed to audit the whole facility for PASARR accuracy. The facility's undated policy for preadmission statements and eligibility requirements indicated that prior to admission, if the facility did not receive sufficient information to make an informed decision as to whether adequate care could be provided .the facility would transfer the resident to a more appropriate level of care. In section 1 d. Prior to admission, a screening by an outside agency was done to determine whether the individual's primary diagnosis was mental illness.

Based on observation, and interview, the facility failed to ensure residents were treated with dignity by not referring to them according to their care needs, for example, as feeders. This had the potential to affect 2 of 2 residents who required assistance with dining on the East Wing, of a total sample of 34 residents. Findings: On 3/12/25 at 8:30 AM, Certified Nursing Assistant (CNA) F, was observed training CNA G, and overheard telling her that resident #15 was a feeder, so CNA G was to bring his food to him and go back to feed him when she finished passing trays to other residents. CNA G did as she was instructed by CNA F. CNA F did not explain why she called resident #15 a feeder and only acknowledged with, OK. On 3/12/25 at 4:00 PM, Registered Nurse (RN) H asked, you mean how many feeders? in response to how many residents on the East Unit were dependent on staff for eating their meals. RN H acknowledged he erroneously referred to the residents by the term, feeders and then named the two residents on the unit that needed assistance with dining. On 3/12/25 at 4:30 PM, the Director of Nursing (DON) acknowledged staff should not refer to residents with the term feeders, as it was a dignity issue. She explained the facility had provided a staff in-service on policies and procedures during meal times, including instruction to not use labels such as feeders when referring to residents, about 10 minutes prior to when RN-H had used the term.

Based on observation, interview, and record review, the facility failed to provide ongoing monitoring and mitigate triggers of identified past trauma for 2 of 3 residents reviewed for trauma informed care, of a total sample of 34 residents, (#42, and #72). Findings: 1. Review of the medical record revealed resident #42, a [AGE] year old male was admitted to the facility from a Veteran's acute care hospital on 5/10/24 with diagnoses that included moderate dementia with anxiety, affective mood disorder, major depressive disorder, cognitive communication deficit, anxiety disorder, and Chronic Post Traumatic Stress Disorder (PTSD). The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 2/11/25 noted during the look-back periods, resident #42 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was moderately cognitively impaired. The Mood Interview showed for several days, the resident felt down, depressed, or hopeless, had little energy, had trouble concentrating, and sometimes felt lonely or socially isolated. There were no rejections of evaluation or care. The assessment noted the resident required set-up to substantial/maximum assistance to complete Activities of Daily Living (ADL) and for functional mobility. The resident did not walk, was always incontinent of bladder and bowel functions, received high-risk anti-depressant, anti-coagulant (blood thinner), opioid (narcotic pain), and anti-platelet (blood clot prevention) medications. There was no psychological therapy or active discharge planning to return to the community. The Order Summary Report included active physician's medication orders for Donepezil (chemical inhibitor) 5 Milligrams (MG) daily at bedtime for dementia, Meclizine (antihistamine) 25 MG three times daily for vertigo (dizziness), Mirtazapine (anti-depressant) 15 MG daily at bedtime for depression, and Tramadol (opioid) 50 MG twice daily for pain. The Care Plan Report's focuses included: ADL self-care deficits, resistance to care, prefers to remain in bed most days, incontinence, nurse monitoring of anti-depressant medication adverse effects, easily upset when things don't go his way; becomes accusatory of staff when they try to provide care with an intervention that read, maintain a stable physical environment by decreasing sensory overload . The Comprehensive Care Plan did not include a Focus for PTSD. On 3/10/25 at 9:22 AM, resident #42 was observed in his room. The resident was awake while lying in bed and displayed an irritable mood. He was reluctant to answer questions and stated, they don't help me. Review of the Activities Initial Evaluation completed by the Activities Director on 5/16/24 noted resident #42's former occupation was a Veteran Army Military Police Officer. On 3/11/25 at 10:50 AM, Certified Nursing Assistant (CNA) I said she knew resident #42 well and he was frequently included in her assignment. The CNA stated, he is very agitated, refuses care; he's very jumpy, cusses you and throws things; he is not predictable; doesn't like the noise; he complains it's noisy and says close my door. The CNA said she didn't know anything about the resident's background. On 3/11/25 at 10:58 AM, the North [NAME] Unit Manager said he was in the position for approximately four months. He described resident #42 as alert with a varied mood and unpredictable behavior. The nurse stated, I don't know if he has any special issues; if they have problems they come to me. On 3/11/25 at 11:10 AM, Registered Nurse (RN) L said resident #42 was included in her assignment frequently when she worked the 7:00 AM to 3:00 PM shift. She said the resident was grumpy and didn't ask for much. The RN said she wasn't sure if the resident received any psychiatric services and stated, I'm not sure what his issues are; there's no special instructions; nothing out of the ordinary. On 3/11/25 at 1:42 PM, the Social Services Director said she was responsible for completing Trauma Informed Care assessments which were done on admission. She checked resident #42's medical record and said he triggered for PTSD on admission 10 months earlier, and he received psychiatric services. The Social Services Director explained bells, slamming doors, and overstimulation were common triggers of PTSD with veterans. Review of the PC-PTSD-5 assessment completed by the Social Services Director on 5/20/24 noted resident #42 had a positive response to past trauma events with examples that read, . A war. Seeing someone killed or seriously injured. Having a loved one die through homicide or suicide. The psychiatric provider's progress note dated 12/03/24 read, reports irritability and anger as a response to loud noises and disruptive environment at skilled nursing facility. Reports history of nightmares secondary to traumatic experiences during the Vietnam War. On 3/11/25 from 10:48 AM to 10:51 AM, resident #42's room door was observed open. Loud continuous alarms were heard at the nurses' station located just outside his room. On 3/12/25 at 8:43 AM, the Social Services Director checked resident #42's medical record and said the only PTSD screening/monitoring evaluation she conducted was completed on admission, 10 months prior. Review of the State Agency (PASARR) Level I Screen completed by the acute care hospital on 5/10/24 did not include resident #42's PTSD diagnosis. On 3/11/25 at 1:45 PM, the Social Services Director checked resident #42's medical record and said the PASARR did not include a PTSD diagnosis and confirmed, it should have PTSD on there. 2. Review of the medical record revealed resident #72, a [AGE] year old male was admitted to the facility from an Veteran's acute care hospital on 3/30/23 with diagnoses that included gait and mobility abnormalities, unspecified dementia with psychotic, mood, and anxiety disturbance, adjustment disorder with depressed mood, insomnia, and PTSD. The most recent MDS Quarterly Assessment with an ARD of 12/31/24 noted during the look-back periods, resident #72 scored 7/15 on the BIMS that indicated he was severely cognitively impaired. The assessment noted the resident required supervision to moderate assistance to complete ADLs, and supervision for functional mobility and walking. The resident was occasionally incontinent of bladder and bowel functions and received high-risk anti-depressant medications. There was no psychological therapy or active discharge planning to return to the community. The Care Plan Report's focuses included: nurse monitoring of adverse psychotropic medication effects, risk and history of falls, Long Term Care placement, ADL self-care deficits, incontinence, and at risk for changes in mood and/or behavior related to the diagnosis of PTSD with a goal for freedom from negative abrupt changes in behavior and mood. The Order Summary Report included active physician's medication orders for: Bupropion (anti-depressant) 12 Hour 150 MG once daily for PTSD, and Trazodone (anti-depressant) 100 MG daily at bedtime for insomnia. On 3/11/25 at 11:13 AM, resident #72 was observed in his room, awake, lying in bed. He said he was a [NAME] Veteran and he liked it quiet. He said he wasn't aware of any special services in regard to PTSD at the facility and stated, I would like that. On 3/12/25 at 3:58 PM, resident #72's door was open and he was observed in his room sitting in a wheelchair. The resident said he liked his door closed and stated, all I do is sit in here and watch TV, so I don't get into no kind of trouble. On 3/11/25 at 10:55 AM, CNA I said she knew resident #72 well and he preferred to stay in his room. The CNA said she was not aware of any special needs for the resident. On 3/11/25 from 11:13 AM to 11:16 AM, resident #42's room door was observed open. The resident's room was located across and down the hall approximately 30 feet away from the nurses' station. Loud continuous alarms were heard from inside the room. On 3/11/25 at 11:18 AM, RN L said resident #72 was routinely included in her assignments and she knew him well. The RN explained, she was not aware of anything out of ordinary for the resident's needs and he mostly stayed in his room. Review of resident #72's State Agency PASARR Level I Screen completed by the acute care hospital on 3/30/23 did not include the diagnosis of PTSD. The psychiatric provider's progress note dated 12/16/24 read, . He has a history of combat exposure during the Vietnam War and has been observed by nursing staff with triggers including hypersensitivity to loud noises with some hypervigilance . he reports he usually prefers to avoid triggers by staying in his room most of the day and sleeping during daytime hours.triggered by hearing screams, avoidance of skilled nursing facility environment and preferring to stay in his room, sleep and watch TV. On 3/09/25 at 4:30 PM, the Social Services Director checked resident #72's medical record, confirmed the PASARR was incorrect and stated, it should have PTSD. On 3/12/25 at 8:43 AM, the Social Services Director explained the facility screened for Trauma Informed Care/PTSD for residents once on admission and resident #72 was noted to have PTSD. She explained she had not conducted subsequent assessments/screens to monitor residents' triggers and stated, we should do follow-up for the Long Term Care residents; it's important to recognize PTSD because it affects their well-being. In a joint interview with the Director of Nursing (DON) and Assistant DON on 3/12/25 at 3:36 PM, the DON explained there were weekly meetings with the clinical team and psychiatry providers to discuss residents who received mental/behavioral health services. She said progress, changes in needs or services, and interventions were discussed. The DON conveyed that veterans frequently had a history of traumatic life experiences with special mental health needs, and the facility's census included a higher than average population of veterans. Review of the facility's undated standards and guidelines titled Trauma Informed Care Policy noted the facility aimed to provide an individualized supportive, safe, and healing environment for residents identified with past trauma. The policy included measures which included, . quiet space, minimizing noise . , . staff should be trained to recognize signs of distress and respond with empathy and care. , and ongoing monitoring . identify any potential triggers or trauma reactions and address them early .

Based on interview, and record review, the facility failed to refer a resident with identified mental illness for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 6 residents reviewed for PASARR, of a total sample of 34 residents, (#87). Findings: Resident #87 was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction (stroke), unspecified mood [affective] disorder, cognitive communication deficit, dementia in other diseases classified elsewhere mild with other behavioral disturbance, post-traumatic stress disorder, and bipolar disorder. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of 2/27/25 revealed resident #87 had a Brief Interview for Mental Status score of 10/15 which indicated he had moderate cognitive impairment. The document indicated his active diagnoses included non-Alzheimer's Dementia, Bipolar Disorder, post-traumatic stress disorder, unspecified mood [affective] disorder, and cognitive communication deficit. The MDS revealed resident #87 received antipsychotic medications on a routine basis. Review of resident #87's care plan revealed a behavior care plan initiated 11/07/24 which indicated he displayed agitated behavior with history of refusing care, yelling at staff, hitting, slapping and kicking. The Electronic Medical Record contained a Level I PASARR screening form dated 9/03/24 which indicated resident #87 had anxiety disorder and psychotic disorder. Review of the Level I PASARR screening form revealed resident #87 had exhibited actions or behaviors that may make him a danger to himself or others, received psychiatric treatment more intensive than outpatient care and had experienced an episode of significant disruption to his normal living situation due to the mental illness. The PASARR Screen completion section read, Individual may not be admitted to [a] Nursing Facility. Use this form and required documentation to request a Level II [PASARR] evaluation because there is a diagnosis of or suspicion of: serious mental illness. The medical record did not contain a Level II PASARR Evaluation and Determination form. On 3/12/25 at 11:09 AM, the Social Services Director (SSD) stated she and the Director of Nursing were ultimately responsible for reviewing PASARR screenings upon admission. The SSD explained the admissions department obtained the level I PASARRs and put them in the admissions packet for nursing. The clinical team then reviewed the PASARR for accuracy. The SSD confirmed resident #87's need for a Level II was missed. She acknowledged a PASARR Level II screening was not submitted for resident #87 but should have been. The facility's undated policy and procedure for Pre-Admission Assessments and Eligibility Requirements contained a list of information required prior to admission. The required information included a screening to determine if the individual had a primary diagnosis of mental illness or mental retardation. The policy and procedure indicated that an individual with mental illness or mental retardation who was not a danger to himself/herself may be admitted to the facility.

Based on observation, interview, and record review, the facility failed to provide a secure environment to prevent a vulnerable resident from exiting the facility unsupervised for 1 of 3 residents reviewed for elopement, of a total sample of 34 residents, (#87). Findings: Resident #87 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified sequelae of cerebral infarction (stroke), personal history of pulmonary embolism, muscle weakness, unspecified mood [affective] disorder, unspecified abnormalities of gait and mobility, cognitive communication deficit, urinary tract infections, dementia in other diseases classified elsewhere mild with other behavioral disturbance, post-traumatic stress disorder, bipolar disorder and encephalopathy. Review of the Minimum Data Set quarterly assessment with assessment reference date of 2/27/25 revealed resident #87 had a Brief Interview for Mental Status score of 10/15 which indicated he had moderate cognitive impairment. The document indicated he required substantial/maximal assistance for transfers and used a wheelchair for mobility. The assessment indicated resident #87 did not use a wander/elopement alarm. Review of the medical record revealed an elopement evaluation dated 3/01/25 which indicated resident #87 was at high risk for elopement; an elopement evaluation dated 2/02/25 which indicated he was at low risk for elopement and an elopement evaluation dated 1/26/25 which indicated he was at moderate risk for elopement. A care plan for at risk for elopement due to resident #87's level of dementia was initiated 1/20/25. Interventions included to monitor location and provide supervision as needed. On 3/10/25 at 3:37 PM, Certified Nursing Assistant (CNA) C confirmed she was the assigned CNA for resident #87 on 3/01/25. She recalled seeing resident #87 around 7:00 PM. CNA C reported she observed him in the rotunda just down from the reception area between the units. She stated she believed she was headed to the kitchen and then returned to her unit. CNA C recalled going on break around 8:15 PM after making rounds. When she returned from break, she was informed resident #87 was observed outside the facility. She stated he was brought back in side and she prepared him for bed. Someone placed a wander alert bracelet on him and she was assigned to sit 1:1 with resident #87 for the rest of the shift. CNA C stated she had never worked with resident #87 before and did not know he was a risk for elopement. She recalled there was no indication on the Kardex and no one informed her of his risk for elopement before that day. On 3/09/25 at 3:55 PM, Registered Nurse (RN) A verified she was the assigned nurse for resident #87 on 3/01/25. She recalled she last saw him at approximately 8:00 PM sitting around room [ROOM NUMBER]. RN A explained she attempted to get the resident to return to his unit, but he refused. She stated she returned to her unit after she decided to give him time and would reapproach him. She recalled sometime later, resident #87 was brought back to the unit after he exited the building through the double door off the 200 unit. On 3/09/25 at 4:13 PM, CNA B recalled she worked the night of 3/01/25. She stated she went to the dayroom to get some ice for another resident. She walked over and began filling a glass when she heard a knock on the window. CNA B explained she looked out the window and saw resident #87 in his wheelchair on the sidewalk motioning for her to come to him. She stated she exited through the doors in the dayroom which led to the back courtyard and went around to side of the building to where resident #87 was sitting on his wheelchair waiting for her to let him back inside the building. CNA B reported she did not hear any door alarms prior to or at the time she exited to go outside. She stated she asked resident #87 what he was doing outside and he told her he was looking for his wife. CNA B explained that resident #87 was compliant and returned to the facility with her through the front door at approximately 8:50 PM. On 3/10/25 at 8:57 AM, the Maintenance Director pointed out the doors at the end of the 200 hallway. The doors were marked with a red sticker that read, push until alarm sounds, door will open in 15 seconds. The Maintenance Director pushed on the door and it opened. An alarm sounded. He acknowledged the doors were not locked and would open immediately if pushed. He clarified the alarms were installed after resident #87 exited the building on the night of 3/01/25. The Maintenance Director explained a wander alert system was previously installed at each door which would lock the door if a resident with a wander alert bracelet came near the door. The Maintenance Director stated the doors did not lock or alarm when resident #87 exited the facility because he did not have a wander alert bracelet. In a phone interview on 3/10/25 at 10:26 AM, resident #87's wife confirmed she was informed that her husband exited the facility on the night of 3/01/25. She stated she was unsure which door he exited through and thought it may have been the front door. Resident #87's wife recalled she was at the facility that day, left sometime after 6:00 PM and did not return inside the facility. She explained she left her car parked in front of the facility and went shopping with her daughter, but did not tell her husband she was leaving. She explained when she left and did not tell her husband she was leaving he likely exited the facility to look for her as he could see her car still parked in the parking lot from the lobby. She stated he had never done anything like this at home. Resident #87's wife expressed his mind fluctuated at times and he had good days and bad days with his cognition. She stated she did not think he would do anything to hurt himself. On 3/11/25 at 11:21 AM, the Executive Director and the DON reviewed the facility investigation. The Executive Director expressed the investigation revealed resident #87's wife left the facility without telling her husband she was leaving. She stated resident #87 exited the facility in an attempt to locate his wife. She explained he had not exhibited any exit seeking behavior previously. She acknowledged resident had previously been identified as an elopement risk and a care plan remained active. The Executive Director verified the doors used by resident #87 were not used for entrance to the facility from the outside but were used as emergency exit doors. She acknowledged there were no alarms on the doors to alert staff to the door being breached unless the resident had a wander alert bracelet. She clarified that resident #87 did not have a wander alert bracelet at the time he exited the facility. The Executive Director acknowledged that resident #87 had been out of the facility for approximately 35 minutes without staff being aware he was not in the facility. Review of the facility's policy and procedure Resident Elopement Defined revealed an elopement occurred when a resident left the premises or a safe area without authorization and/or necessary supervision to do so. The document identified the facility would seek to prevent elopement through components which included but were not limited to regular rounds, staff supervision and interventions and environmental modification. The document indicated that only residents at high risk of elopement would be issued a wander alarm bracelet.

Based on interview, and record review, the facility failed to ensure coordination of hospice services for 1 of 1 resident reviewed for hospice care, of a total sample of 34 residents, (#249). Findings: Resident #249 was admitted to the facility on [DATE] following an acute care hospitalization for Congestive Heart Failure exacerbation. His diagnoses include end stage heart failure, prostate cancer, hypertension and paroxysmal atrial fibrillation. He was initially admitted to hospice on 12/03/24. On 2/21/25 the resident was transferred from home hospice to Long Term Care hospice. According to the National Institute of Health, heart failure is characterized by impairment in cardiac structure and function which results in decreased cardiac output and fluid buildup or congestion. Management of advanced heart failure centers around volume status (the amount of fluid in the body) and managing fluid overload or hypervolemia (too much fluid) (retrieved on 3/21/24 from www.nih.gov). Review of resident #249's care plan revealed a focus for receiving hospice services related to end stage heart disease which was initiated 2/28/25. The Skilled Nursing Facility Integrated Plan of Care for resident #249 between the facility and the hospice indicated the facility nurse would notify hospice regarding changes in patient status, comfort level and on new orders. A review of the resident's clinical record revealed a nurse progress note from 3/06/25 at 8:00 PM, IV infusion installed successfully. Started 50 ml [milliliters] per hour during 24 hour for hydration. Review of the resident's Electronic Medical Record (EMR) revealed an order dated 3/05/25 Sodium Chloride Solution 0.9 % use 50 milliliters/hour intravenously for 24 hours for hydration for one day. Review of resident #249's medical record revealed no documentation of hospice notification for the initiation of intravenous fluids on 3/05/25 or 3/06/25. On 3/11/25 at 4:29 PM, in a phone interview the Hospice Supervisor revealed the facility called hospice on 3/06/25 to discuss a wheelchair for the resident but there was no notification of the order for intravenous (IV) fluids being initiated. On 3/12/25 at 9:39 AM, in a phone interview with the Hospice Registered Nurse revealed that the order for IV fluids was initiated by the facility and not by hospice. She explained when she arrived to the facility on [DATE], the IV fluid was already running. Since the fluid was ordered for only one liter and the resident was 'okay' with it, all she did was document that the fluids were running. She stated that typically IV fluids were not in their goals of care when it came to hospice resident's care. On the day she was there, she got report from facility staff that he was eating or drinking without issue. On 3/12/25 at 11:19 AM, in a phone interview with the Medical Director she confirmed she ordered the intravenous fluids for resident #249. She explained she ordered the fluids due to the resident's risk for dehydration. She stated this risk was determined by an abnormal lab result, Blood Urea Nitrogen (BUN), and from talking to the certified nursing assistants (CNA) on the resident's fluid intake. She stated his BUN was 32 and confirmed this was from labs drawn on 2/20/25. She stated the reason for the delay in ordering the intravenous fluids was to give the resident a chance to rehydrate on his own. She was asked how she determined the resident's intake was inadequate when the CNA's were documenting the residents intake in the days leading up to the IV was over 1000 milliliters of fluid. She stated that she did not look at the fluid intake in his EMAR, she 'just talked' to the CNAs working. She stated she had also tried to reach out to Resident #249's family in regards to the resident's decreased fluid and food intake and the possibility of inserting a PEG tube, but the family did not answer. When asked what her procedure was for new orders when a resident is on hospice, she stated the facility will typically get the orders cleared by hospice before initiating. She confirmed that she did not notify hospice. She stated she did not even know resident #249 was on hospice and asked when services were started. On 3/12/25 at 1:13 PM, the Director of Nursing (DON) revealed she entered the order for intravenous fluids into the computer that was signed off by the nurse as administered. However, she stated she did not receive the order but rather was modifying the order put into the computer by the Medical Director. She confirmed she did not notify hospice of the IV fluid order and assumed the communication between the facility and hospice had already been done. The Skilled Nursing Facility Services Agreement between hospice and the facility dated 2/24/25 indicated the facility should immediately inform hospice of any changes in condition of a hospice patient. The agreement detailed that the hospice and the facility should communicate with one another regularly and as needed. It described that each party was responsible for documenting such communications in their respective clinical records.

Based on observation, and interview, the facility failed to provide a sanitary environment to help prevent the transmission of communicable diseases by failing to perform hand hygiene between delivering meals to 3 of 15 resident rooms in the East wing. Findings: On 3/12/25 at 8:55 AM, Certified Nursing Assistant (CNA) F, along with trainee CNA G, was observed as they entered a resident's room on the East wing that had a Contact Precautions sign at the door. The sign indicated that anyone who entered must perform hand hygiene. CNA F and CNA G were observed as they brought a breakfast tray without performing hand hygiene before they entered the room or after they left. CNA F was observed as she then entered the next resident room without performing hand hygiene. CNA F without hand hygiene, then went to the food cart, got a tray of food and brought it into a resident in another nearby room. The Director of Nursing (DON) who was in the area and observed CNAs F and G, got up from the unit nursing station and was overheard telling the trainee, CNA G to perform hand hygiene, which she then did. CNA F only nodded and stated, OK, when the observation of her and CNA G not performing hand hygiene between resident rooms was mentioned to her. At 3/12/25 at 9:34 AM, the DON acknowledged CNA G did not perform hand hygiene when she served meals to residents, but should have. She confirmed she reminded the trainee CNA to disinfect her hands between residents when she served meals. The facility's undated policy entitled Hand Hygiene and Resident Cleanliness Policy During Meal Times, indicated staff must wash hands or use hand sanitizer between residents when they delivered meal trays.

Based on interview, and record review, the facility failed to ensure residents who required dialysis received services consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments. A pattern of a lack of assessments was demonstrated for 1 of 4 residents reviewed for dialysis, of a total sample of 34 residents, (# 10). Findings: Resident #10 was admitted to the facility on [DATE] with the diagnoses of end stage renal disease (ESRD) with dependence on renal dialysis, type II diabetes mellitus with hyperglycemia, essential hypertension, unspecified mood disorder, anemia of chronic kidney disease, cognitive communication deficit, dementia, encephalopathy, and abnormalities of gait and mobility. The Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated the resident's Brief Interview for Mental States score was 3/15, which indicated severe cognitive impairment. On 3/11/25 at 10:31 AM, the North [NAME] (NW) Wing Unit Manager (UM) indicated the last nursing report in resident #10's dialysis chart for a dialysis visit was for Thursday 2/20/25 (19 days prior). The most recent one before that was dated 2/08/25 (12 days prior to the 2/20/25 visit). The UM acknowledged the reports were to document the residents' vital signs (vitals) and condition prior to dialysis and after she returned from dialysis treatment. He stated resident #10 was scheduled for dialysis three times per week, on Tuesdays, Thursdays, and Saturdays, so he expected nurses to complete three reports per week. He explained sometimes the resident refused to go to dialysis. For 2025, pre- and post-dialysis reports were found for the dates of 1/02/25, 1/09/25, 1/16/25, 1/31/25, 2/04/25, 2/06/25, and one with no date documented, which totaled eight reports out of a total of 17 dialysis visits during that time period. The NW Wing UM stated he was not able to find any of the missing reports in the residents' paper and electronic medical records. On 3/11/25 at 11:10 AM, the Assistant Director of Nursing (ADON) and the NW Wing UM agreed nurses were expected to chart a progress note anytime when their residents left the facility including for dialysis, and document their condition upon their return. The NW Wing UM searched for nursing progress notes in the electronic medical record for the dialysis dates Tuesday, 1/28/25, Thursday 1/30/25, and Saturday, 2/01/25, which he stated the resident had dialysis treatment. He acknowledged the nursing progress note for 1/28/25 indicated the resident left for dialysis, but did not include documentation that she returned nor her condition upon return. For the dates 1/30/25 and 2/01/25, he confirmed there were no nursing progress notes regarding the resident going to nor returning from dialysis, nor any documentation of her vitals or condition. The NW Wing UM stated it was important for the nurse to take vitals and check the resident's overall condition including the dialysis port site after they returned from dialysis to ensure they were good to go, not bleeding out, not bottomed out [low blood pressure], and were OK. After the NW Wing UM searched resident #10's electronic medical record, he stated he was not aware of any other place where nurses would document the condition of the resident before and after dialysis per procedure. He stated not finding this documentation was eye-opening to him. On 3/11/25 at 3:00 AM, the local Dialysis Center confirmed by telephone, resident #10 received dialysis treatment at their facility on 1/09/25, 1/11/25, 1/16/25, 1/18/25, 1/21/25, 1/25/25, 1/28/25, 1/30/25, 2/01/25, 2/04/25, 2/08/25, 2/11/25, 2/13/25, 2/15/25, 2/10/25, 3/04/25, and 3/08/25, a total of 17 times since the start of the year. Review of the physician orders and the electronic Treatment Administration record (TAR) indicated that upon return from dialysis, the nurse was to monitor their pressure and site dressing after four hours, and remove it if there was no bleeding present. If bleeding was present, they were to reapply the pressure dressing and re-evaluate in four hours and remove the dressing if there was no further bleeding. It added to document findings every day and evening shift every Monday, Wednesday, Friday for ESRD and every day and evening shift every Monday, Wednesday, Friday, on dialysis days. Another order directed staff to monitor dialysis shunt site for bleeding or signs of infection every shift with a start date of 3/28/24. Since the resident's scheduled dialysis days were on Tuesday, Thursday, and Saturdays, the documentation for the order for the dressing findings was not completed on dialysis days. The TAR for Monday, 1/27/25, Wednesday, 1/29/25, and Friday, 1/31 were documented as the resident's pressure and dialysis port site were checked to indicate findings after dialysis even though the resident did not have dialysis on these days. The dates of Tuesday, 1/28/25, Thursday, 1/30/25, and Saturday, 2/01/25 had an X to indicate the resident's dressing did not need to be checked even though the resident did receive dialysis on those days. The inaccurate documentation of dressing findings per physician order rendered unreliable results of resident #10's condition post-dialysis. On 3/12/25 at 4:53 PM, the ADON stated she would expect nursing staff to document on the correct date after the resident returned from dialysis and make their manager aware of the discrepancy in the dates for dialysis assessment on the TAR, so it could be corrected. The ADON also noted from the resident's vital sign documentation in the medical record, this resident's blood pressure was documented nine times in January, zero times in February, and only once in March, totaling ten times during 2025. She then looked throughout the resident's entire electronic medical record but could not locate blood pressure measurements documented in any other areas in the medical record. The ADON stated this would not meet the standards of practice for a resident with hypertension or dialysis. She confirmed the resident went to dialysis 17 times since the beginning of the year, and blood pressure should have been monitored at least 34 times, both before and after dialysis. The ADON confirmed the facility's communication form had a place on the bottom for the facility to document vitals and the resident's condition upon their return from dialysis and added that even if the bottom of the form was not completed, the expectation would be for nurses to assess the resident when they return and record their vital signs, (blood pressure, pulse, respiration, and temperature) and to check the resident's condition (the dialysis site, dialysis access, Bruit and Thrill, symptoms of bleeding and that pressure dressing was intact), into the electronic medical record system. The ADON verified this resident's vital signs and some aspects of the resident's condition were not monitored on many days the resident went to dialysis nor were vital signs completed as would routinely be expected, even on non-dialysis days. The facility's undated Dialysis Protocol, which the ADON stated would have to have been reviewed at a minimum in the beginning of this [AGE] year, indicated the resident should be assessed for vital signs and other conditions prior to, and after the resident returns from, dialysis treatment. The ADON stated there was a batch order for dialysis residents and even though there was no specific order for the communication tool used between the facility and the dialysis center, there was a communication practice between dialysis and all facilities that occurred because it was best practice for dialysis residents.

Based on observation, interview, and record review, the facility failed to prevent a vulnerable and severe cognitively impaired resident from exiting the facility unsupervised, and failed to provide adequate supervision and a secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 29 residents, (#70). On 7/07/23 at approximately 7:05 PM, the facility failed to prevent a vulnerable, cognitively impaired resident with known behaviors of wandering and at high risk for elopement from exiting the facility unsupervised through the unalarmed dining room doors. The facility was unaware of resident #70's whereabouts for 2 hours until a Certified Nursing Assistant (CNA), who was on break, noticed the resident in the rear parking lot. The facility failed to ensure the dining room door alarms were functional, and failed to ensure the resident was adequately supervised to prevent her from exiting the facility. Resident #70 covered a total distance of approximately 300 feet in her wheelchair outside the facility. She could have fallen, sustained injuries from sharp debris, become lost or been hit by a car. The heat index at the time resident #70 was outside, unsupervised was 89 degrees Fahrenheit, which was categorized as Caution, with fatigue possible if prolonged exposure or physical activity, according to the National Weather Service. These failures contributed to the elopement of resident #70 and placed all residents who wandered at risk for serious injury, impairment, or death and resulted in Immediate Jeopardy starting on 7/07/23. Findings: Review of the medical record revealed resident #70 was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses of dementia, abnormalities of gait and mobility, nondisplaced fracture of lateral malleolus of left tibia, muscle weakness, anemia, and anxiety. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 3/30/21 revealed resident #70 was ambulatory with use of assistive device, required one-person assistance for transfers and was at risk for falls. The document indicated the resident was alert, disoriented but could follow simple instructions. The admission Minimum Data Set (MDS) with Assessment Reference Date of 7/05/23 revealed resident #70's Brief Interview for Mental Status was 3 out of 15 indicating she was severely cognitively impaired. The MDS assessment indicated resident #70 required limited assistance with transfers and extensive assistance with walking in her room and in the corridor. Resident #70 required supervision for locomotion. The resident had unsteady balance during transitions and walking and was only able to stabilize herself with staff assistance. She used a wheelchair for mobility and a wander/elopement alarm daily. The Nursing Admission Evaluation dated 3/31/21 revealed resident #70 was oriented to person only, confused, had unsteady gait, and used assistive devices for mobility. Review of an Elopement Risk Evaluation dated 4/25/23 revealed resident #70 was a high risk for elopement. The form showed she was ambulatory or self-mobile in wheelchair and was cognitively impaired with poor decision-making skills. The form revealed she had verbally expressed the intent to leave the facility and return home, packed belongings to go home or stayed near an exit door and not accepted redirection. Review of a quarterly Fall Risk Evaluation Tool dated 4/22/23 revealed resident #70 was classified as High Risk for Falls. The form showed resident #70 overestimated or forgot the limits of her ability to ambulate safely. Review of resident #70's care plan for communication related to recent head trauma/injury and language barrier, initiated on 1/04/23, revealed an intervention for staff to anticipate and meet (her) needs. Review of resident #70's care plan for risk for falls related to history of falls/injury, impaired balance, poor coordination, and unsteady gait was initiated on 3/31/21. An intervention directed staff to check routinely and as needed to ensure safety. A care plan initiated on 11/01/21 revealed resident #70 was at risk for periods of anxiety related to dementia and cognitive communication deficit. Interventions directed staff to provide quiet structure and a secure environment. A care plan revised on 9/11/21 revealed resident #70 was at risk for elopement due to her level of dementia and behaviors which included getting into other residents' rooms, and roaming hallways without direction. The goal noted, Resident will not leave facility unattended and whereabouts will be known at all times. Interventions included enhanced supervision as indicated. A progress note dated 4/25/23 revealed the electronic monitoring device system was activated and alerted staff resident #70 was located near an exit door. The note indicated staff assisted resident #70 back to the unit and she was placed on a 15-minute observation. Review of a Situation, Background, Assessment, Recommendations, (SBAR) Communication Form dated 7/07/23 read, Resident was found in the parking lot, head to toe assessment done, no skin concerns, no acute distress noted. Review of an Incident Note dated 7/10/23 revealed Licensed Practical Nurse (LPN) assigned to resident #70 learned she was not in the nursing unit until at approximately 8:52 PM. The note showed resident #70 was found at 9:05 PM behind the cars by a Certified Nursing Assistant (CNA) on her break. On 7/27/23 at 11:29 AM, in a telephone interview, resident #70's son explained on 7/07/23 he received a call from the facility informing him his mother had gotten out. He said he was alarmed as she could have been killed because the facility was located near a major highway. He stated he learned she was out of the building for approximately 20 minutes before anyone noticed it. He shared resident #70 had exhibited exit seeking behaviors but had not left the building before. He noted his mother had dementia and the facility had alarms for her. He indicated the facility neglected her because the door was not secured and they needed to pay close attention to her because she liked to get through the doors or stay near doors. On 7/27/23 at 11:39 AM, in a telephone interview, LPN C explained resident #70 became more confused at sundown. She said she noticed resident #70 looked out for her family in the afternoons, after 7 PM or 8 PM. She recalled the resident liked to open the exit door. LPN C explained the resident did not usually activate the alarm because staff brought her back to her room or the unit before she opened the door. She indicated resident #70 could be found in the memory care room with a staff member. She explained on 7/07/23 she last saw resident #70 before 7 PM sitting quietly in her wheelchair by the hallway. She said she did not see resident #70 again until CNA E asked for her. She recalled she told CNA E the resident was near the memory care room, but when they looked, no one was there. She stated while they searched the unit for resident #70, CNA D called CNA E and told her resident #70 was outside by the rear parking lot. She reported they went out and saw resident #70 with CNA D sitting in her wheelchair. She explained resident #70 was not safe to be outside by herself due to her confusion and dementia. She said she did not know exactly when the resident got out and remembered the resident told her she was looking for her mom. LPN C spoke about the hazards outside and added, Anything could have happened to her. Thank God, we saw her and got her back inside. On 7/27/23 at 12:19 PM, in a telephone interview, CNA D stated resident #70 spent most of her time in the memory care area or by the unit's hallway. She indicated resident #70 was not ambulatory but was able to self-propel in her wheelchair. She recalled resident #70 would say she wanted to go home and sat by the exit doors. She stated she did not see resident #70 opening the door because they always stopped her before she did it. She explained exit-seeking was not a daily behavior and she noticed resident #70 did it when she was not around her friends. CNA D stated the last time she saw resident #70 on 7/07/23 was between 7:00 PM and 7:30 PM in the memory care area with a staff member present. She indicated when it was time for her break, at approximately 8:50 PM, she headed to her car and saw resident #70 outside in the parking lot. She stated she asked resident #70 where she was going but she did not respond. She indicated she called CNA E and told her she found resident #70 outside. She explained she stayed with resident #70 until her assigned nurse and CNA went out to get her because she was not supposed to be out there by herself. She stated she did not know how the resident got out because she was wearing an electronic monitoring device. On 7/27/23 at 2:43 PM, the Maintenance Director stated he was responsible for the safety of the residents, staff, and property. He explained prior to the elopement, all 12 doors were tested twice daily with an electronic monitoring device bracelet, and they were all functional. He recalled he received a call from the Assistant Director of Nursing (ADON) on 7/0/7/23 after 9 PM and she said a resident had eloped. He explained he arrived that night at the facility at approximately 10 PM. He indicated he inspected all exit doors, and no issues were identified. He explained he called their alarm contractor, and the technician visited the facility on Saturday 7/08/23 to check the doors. He stated when the technician came to the facility on Saturday morning, they were not sure which door resident #70 had gone through, and one door was inspected with no issues found. He explained after they reviewed the security camera and learned which door the resident exited from, a second technician came and inspected that door. He stated resident #70 left using door on the north side, which was used for deliveries. He explained only the egress alarm sounded, but it could only be heard by the door and once the door closed, the alarm went off. He explained the interior double doors leading from the unit to the main reception area, doors to the main dining room and to the service hall were not alarmed. He explained the double doors that led to the dining room required a badge to enter but they were wide open the night of the incident. He explained resident #70 pushed on the left side door leading to the back of the building. He recalled during inspection of that door, he noticed the door did not consistently lock when tested with an electronic monitoring device. He said the technician noticed a short circuit preventing the door from functioning properly. He indicated the alarm company had special tools to inspect such equipment, but the facility's daily inspections consisted of pushing doors with the electronic monitoring device to ensure it locked and alarmed as designed. He explained there had been no inspection by the alarm system company since it was installed approximately 3 years ago as the facility had decided not to have routine annual inspection and only call when needed. He acknowledged hazards found outside included an inclined parking lot which led to the kitchen in the old adjacent building. He indicated if resident #70 went down the sloped incline in her wheelchair she could have tilted, sped ahead, fell , or injured herself. He indicated there was a drop to a concrete floor across the one-way road from where the resident exited the building. If she went into the grassy area she could have been stuck and unable to move or go forward. On 7/27/23 at 3:46 PM, CNA E stated they had always had designated staff member, sometimes two, assigned to the memory care room. She indicated resident #70 needed assistance with toileting and she checked on her every 2 hours. She explained when resident #70 was really confused she did not stay in the memory care room. She recalled resident #70 always looked for her mom, stayed near doors and pushed doors but only exit doors were alarmed, so she would activate those if she got near them. CNA E stated she would redirect resident #70 by telling her she would show her where her mom was. She recalled resident #70 did not stay in the memory care room after dinner and would be by the hallway with another resident. She indicated both residents needed to be watched because they had tried to exit when they did not stay in the memory care room, and they liked to self-propel their wheelchairs up and down the hallway. She stated everyone kept an eye on them. She explained at around 7 PM on the night of the incident, the CNA assigned to the memory care room asked her to cover while she went on her break. She could not recall the exact time she saw resident #70 but remembered she was not in the memory care room. She explained there were 4 residents in the memory care room while she was there and 2 of those residents were on her assignment. She said she continued providing care to residents until it was time for her break at approximately 8:30 PM. She repeated she did not pay attention and she did not see the resident before taking her break. She stated she did not ask anyone if they had seen resident #70 even though it was over an hour since she had last seen the resident. She recalled she went out to the porch for her break that overlooked the parking lot. She noted during her 30 minute break, she was the only one on the porch. She explained it was a little bit dark and she did not see resident #70. She indicated when she returned from her break, she asked LPN C if she had seen resident #70 so she could provide care to her. She could not recall the nurse's response, but they began looking for the resident. She reported she received a phone call a few minutes later from CNA D informing her resident #70 was outside. She noted they ran outside and got the resident. She remembered upon returning to the building, the alarm sounded loud, so she did not understand what happened and how the resident got out as she had not heard any alarms before this time. She noted that night she was suspended for 2 weeks and upon her return, she learned resident #70 left the facility through the service hall near the kitchen at about 7:00 PM. She conveyed it was not safe for the resident to be outside by herself as she could have fallen if she had tried to get up, anything could have happened because she was confused. On 7/27/23 at 5:01 PM, Security Staff H stated he was responsible to ensure all doors functioned properly and inspected the inside and outside of the facility daily. He indicated after the daytime receptionist finished her duties between 3 and 4 PM, he covered the front desk. He explained there were times he left the reception desk to fix a television in a resident's room or reset a resident's bed. He indicated when he was on a phone call or checking visitors in, he may not be monitoring the cameras located at the front desk. He stated he inspected the electronic monitoring system on 7/07/23 and there were no issues. He indicated he went out through the same door resident #70 exited approximately between 8 and 8:25 PM, and he did not see anything out of place or anyone outside. On 7/28/23 at 9:15 AM, Activities Aide I stated she was responsible for ensuring residents in the memory care room participated and were engaged in activities. She explained there were approximately 16 residents in the memory care group. She explained the assigned CNAs brought residents to the memory care unit and they assisted residents when they needed to be changed or toileted. She stated CNAs came to check on their assigned residents or the Activities Aide called them if assistance was needed. She explained if music was on, resident #70 stayed in the memory care room listening and clapping. She indicated she noticed whenever resident #70 told her she needed to go home, it meant she needed to use the bathroom. She spoke about resident #70 exiting the facility and noted the resident could have fallen from her wheelchair while she was outside by herself or she could have been hit by a car. She was not safe to be out there by herself. On 7/28/23 at 9:47 AM, the Administrator discussed the investigation of resident #70's elopement. She explained on 7/07/23 she received a call from the ADON at approximately 9:15 PM informing her resident #70 was found outside by CNA D. She indicated she instructed the ADON to start the investigation by collecting statements from staff and she headed to the facility. She arrived at approximately 9:45 PM and saw the resident resting in bed. She explained after meeting with the staff, she met with the resident's son who had arrived at the facility. She stated resident #70 was placed on one-on-one supervision, they completed a head count of all residents in the facility, and they checked all the doors again. She noted they used resident electronic monitoring device to check all doors and all of them activated without any issues. She indicated they checked placement and function of the 5 residents who had electronic monitoring at the time, and they all worked properly. She explained LPN C had assessed resident #70 upon return to the building, with no signs of injuries or distress. She explained the second alarm technician who visited the facility on Saturday discovered the alarm malfunctioned due to a faulty wire caused by normal wear and tear. She indicated that was a high traffic door as all the deliveries came in through that door, and over time, the wires disconnected causing the alarm to work sometimes and not others. She explained the technician said it was difficult to pinpoint when the malfunction began but it was corrected the same day. She stated she reviewed the video recording from the cameras located inside and outside the facility and was able to determine when resident #70 left the building. She attempted to access the video again for the surveyors but was unsuccessful. She explained after she reviewed the video recording, she obtained clarification as there was conflicting information from the written statements from staff. She shared the timeline obtained from the video recording she reviewed: On 7/07/23 approximately before 7:00 PM, LPN C saw resident sitting quietly in her wheelchair in the hallway of the North-West Wing while passing meds. On 7/07/23 at approximately 7:00 PM, assigned CNA E saw resident in the hallway in her wheelchair. CNA E was in the memory care room while the Activities staff assigned to that area took her break. On 7/07/23 at 7:05 PM, resident left unit into the main lobby area, through unalarmed double doors. On 7/07/23 at approximately 7:08 PM, resident exited the building. On 7/07/23 at approximately 7:10 PM, Speech therapist clocked out and walked to the parking lot in the rear of the facility, but did not see resident #70. On 7/07/23 at approximately 8:20 PM, CNA E took her break, sat in the screened porch which faced the rear parking lot area. She did not see resident #70. On 7/07/23 at approximately 8:55 PM, CNA E asked LPN C whereabouts of resident #70. They began searching for the resident and received a call from CNA D that resident #70 was outside. On 7/07/23 at approximately 8:50 PM, CNA D went outside facility to take her break and saw resident #70 in the rear parking lot, behind a car. She called CNA E and informed her resident was found outside. On 7/07/23 at 9:05 PM, resident #70 returned to the facility accompanied by assigned CNA E and LPN C. On 7/07/23 at approximately 9:30 PM, LPN C performed head to toe assessment with no negative findings. On 7/07/23 at approximately 9:35 PM, LPN C called resident's son, DON and physician and reported incident. The Administrator stated during the investigation they reviewed the Elopement Risk Assessment and noted all interventions had been followed. She explained during the Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) meeting they determined the root cause was the malfunction of the alarm mechanism at the exit door used by resident #70, leading to the outside of the facility. She reflected resident #70 was not safe to be outside by herself. She indicated staff was to monitor residents every 2 hours but if they exhibited exit seeking behavior, they were expected to monitor more often. She did not provide a clear definition of what more often meant. On 7/28/23 at 1:30 PM, resident #70's elopement route was retraced. Resident #70 traveled a total distance of approximately 301 feet from the Northwest Wing through the main dining room, the service corridor leading to the kitchen, the laundry and the rear parking lot where she was later found. Photographic evidence was obtained of the hazards outside the facility including a drop off to a concrete ramp within proximity to the sidewalk, broken fence, wooden pallet, uneven pavement, unlocked entrance to the trash compactor and a high voltage generator duking station. There were ramps, slopes, and stairs on the outside of the old building across the facility which resident #70 could have traversed to during the time she was outside. On 7/29/23 at 9:18 AM, the Director of Nursing (DON) explained when a CNA was assigned to the memory care area, she was not assigned residents. He stated generally residents were observed every 2 hours but if someone exhibited wandering behavior, the facility encouraged the staff to observe them more often to ensure they knew what they were always doing. He noted resident #70 would get near doors or exhibited exit seeking behavior occasionally but it was not every day. The DON stated resident #70 was to be monitored every 2 hours. He indicated the doors leading to the main dining room were left open, but they were supposed to be kept closed for staff to use their badges to access the area. He indicated residents normally did not have access to the main dining room without staff being present. He explained it was not safe for resident #70 to be out without staff supervision. He recalled he was present when the Administrator informed resident #70's son of the incident. He indicated the son was very concerned the resident got out and said they were lucky that nothing happened to her, thank God. Review of the undated document titled Supervision of Residents revealed a purpose To provide the resident with a level of supervision to meet their individual needs. The policy read, Residents are to be checked at least every 2 hours, and more often if the individual show signs of continuous exit seeking or requires a higher level of supervision due to a change in condition. Review of the Certified Nursing Assistant (CNA) job description revised on 9/16/13 revealed the essential duties of the position included to provide individualized attention, which encourages each resident's ability to maintain or attain the highest practical physical, mental, and psychological well-being. Review of the Facility Assessment updated in November 2022 revealed the facility was able to care for residents with memory care needs and continued to staff at least 1 - 2 staff members to keep the residents that need additional supervision and assistance to prevent falls . The document indicated the staff was trained upon onboarding and at least annually in how to deal with cognitively impaired residents. Review of the immediate actions implemented by the facility revealed the following, which were verified by the survey team: *On 7/07/23, at approximately 9:05 PM, resident #70 was observed outside sitting in her wheelchair in the parking area at the rear of the facility and was escorted back to the facility unharmed. LPN C completed a head-to-toe assessment and found no injuries. The physician and responsibly party were notified. *On 7/07/23, resident #70's electronic monitoring device was checked for placement and functioning against all exit doors with no issues identified. *On 7/07/23, resident #70 was placed on 1:1 observation. *On 7/07/23, resident #70's elopement risk assessment dated [DATE] was reviewed with a new one completed and noted to be consistent with the score of 18, indicating a high risk for elopement. Elopement risk assessments were reviewed and documented with no changes for 4 other residents with electronic monitoring devices. *On 7/07/23, the electronic monitoring device for the other 4 residents were checked and noted to be placed per order and functioning properly. *On 7/07/23, the care plan of resident #70 and the 4 other residents was reviewed to ensure all interventions were being followed. *On 7/07/23, a head count was completed to ensure all residents were in the facility. *On 7/07/23, all exit doors were checked two times by maintenance and security and were functioning properly and alarming when checked with the actual electronic monitoring device. *On 7/07/23, the electronic monitoring device company was contacted. In the interim and to ensure resident's safety, the door leading to the dining room was closed, and a sign posted to be kept closed/locked unless there was a supervised activity. *On 7/07/23, the physician and resident #70's family were notified. *On 7/07/23, an emergency Ad Hoc QAPI meeting was held with the Administrator, DON, ADON and the Unit Manager, and the current immediate plan was reviewed. The Medical Director was contacted via telephone and plan reviewed with him, and he agreed with the immediate plan and had no additional recommendations. *On 7/07/23, staff interviews were completed before the end of the shift. *On 7/07/23, education started and included a review of the elopement procedure, supervision of residents and enhanced supervision for residents on the electronic monitoring device program and may be increased if exit seeking behaviors observed. All staff on duty completed and staff were educated as they reported for duty on 7 AM to 3 PM and 3 PM to 11 PM shifts on 7/08/23 with remaining employees called by their immediate supervisor on 7/08/23. No staff was allowed to work if unable to reach until they received the education. 100% of active staff were educated by 7/08/23. Step by step instructions reviewed of what should be done in the event of an elopement (simulated drill). *On 7/08/23, the electronic monitoring device company performed assessment of all exit doors and identified malfunctioning door used by resident #70 to exit the facility. The door was repaired on the same day. *On 7/09/23, resident #70's elopement risk assessment was reassessed with a score of 19, indicating a high risk for elopement. Interviews were conducted with 13 facility staff including 4 CNAs, 3 licensed nurses, 3 dietary aides, 2 laundry/housekeeping aides, and 1 Activities staff between 7/27/23 and 7/29/23. Interviews revealed the facility staff received elopement education and participated in elopement drills. The sample was expanded to include 2 additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #60 & #64.

Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 4 residents sampled for medication administration, (#37,#16). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%. Findings: 1. Review of resident #37's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included osteoarthritis and fracture of the right femur. On 7/26/23 at 9:20 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #37's nine scheduled morning medications and placed a total of 9 pills into a small plastic cup. LPN A then approached resident #37 with the cup of 9 pills and the resident declined to take the Acetaminophen 325 milligrams (mg) tablet stating that she was not in pain. LPN A then went out to the medication cart and with a spoon took out the single Acetaminophen 325 mg tablet and then returned to resident #37's room and administered the remaining medications by mouth to the resident. A review of resident #37's medical record post medication administration revealed an order for Acetaminophen oral tablet 325 mg give 2 tablets by mouth four times a day for hip and back pain. On 7/26/23 at 11:42 AM, a follow up interview was conducted with LPN A. The LPN read in the MAR (medication administration record) for resident #37 an order for routine Acetaminophen 325 mg 2 tablets. The nurse acknowledged medication error as she only brought one tablet to administer with the resident's routine morning medications. LPN A explained, she usually read the orders twice to avoid making errors but didn't today. 2. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). On 7/26/23 at 9:35 AM, medication administration was observed for resident #16 and LPN B. LPN B was observed preparing the morning medications for resident #16 by placing pills in small plastic cup and taking a boxed inhaler out of the medication cart. The inhaler box label read, Breo Ellipta 100/25 mcg [micrograms]. The LPN proceeded to administer the medications to resident #16. A record review post medication administration for resident #16 revealed an order dated 1/5/23 that read, Breo Ellipta Aerosol Powder Breath Activated 200-25 mcg/inh (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day at 9 AM for COPD. On 7/26/23 at 9:23 AM, a follow up interview was conducted post medication administration with LPN B who verified the order in the MAR for resident #16's inhaler medication read, Breo Ellipta 200/25 mcg, and 100/25 mcg was dispensed by the pharmacy instead of the physician ordered dose. LPN B could not explain why she did not call the physician to clarify orders prior to administering the incorrect dose to resident #16. BREO ELLIPTA is used to treat asthma and chronic obstructive pulmonary disease. (https://www.medsafe.gov). On 7/26/23 at 11:47 AM, the Director of Nursing (DON) verified the nurses should triple check orders while preparing medication to ensure no medication errors, first by reading the mediation label, second by looking at the MAR and then third by reading the label again while preparing medications for administration. Review of the facility's policy and procedure which was undated for Medication Administration read, Purpose: To administer the 1. Right Medication 2. In the Right Dose .Equipment: Medication as ordered .7. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time .9. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR. If there is a discrepancy, check the original physician order and notify the pharmacy. Don does not give the medication until clarified .10. Verify the correct medication, expiration date, dose, route, and time again before administering .

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) Discharge assessment was transmitted within the required 14-day time frame for one of 1 of 31 sampled residents, (#1). Findings: Resident #1 was admitted from the community to the facility on [DATE] for skilled nurse care related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Discharge assessment with assessment reference date of 11/15/21 was completed on 11/26/21, but had not been transmitted as of 2/17/22, 83 days after completion. On 2/17/22 at 11:45 AM, MDS Coordinator C confirmed the resident's MDS Discharge assessment was completed, and it had not yet been submitted at the time of the interview. MDS Coordinator C stated resident #1's MDS Discharge assessment was not transmitted timely as it should have been submitted within 14 days of the completion date. The MDS Coordinator said, Usually we have alert that will show red and we did not get an alert regarding late assessment transmittal. The Resident Assessment Instrument instructions for Chapter 5 Submission and Correction of the MDS Assessments read, Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . All other MDS assessments must be submitted within 14 days of the MDS Completion Date .

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected resident status related to location prior to re-entry for 1 of 4 residents reviewed for accidents, out of a total sample of 31 residents, (#38). Findings: The Center for Medicare & Medicaid Services Resident Assessment Instrument [RAI] Version 3.0 Manual dated October 2019 revealed the results of the MDS assessment should accurately reflect the resident's status. Review of resident #38's medical record revealed she was admitted to the facility on [DATE] and readmitted from acute care hospital on 11/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/22/21 resident #38 was sent to the hospital for fracture of the left femur. She was then readmitted to the facility on [DATE]. Review of the MDS Significant Change in Status assessment dated [DATE], revealed Section A: Identification Information question A1800 titled Entered From was coded with the number 2. This code inaccurately indicated resident #38 returned to the facility from another nursing home or swing bed rather than from the acute care hospital. The number 3 should have been selected since the resident was in an acute care hospital prior to reentering the facility. On 2/17/21 at 4:00 PM, MDS Coordinator C validated resident #38's MDS Significant Change in Status assessment dated [DATE] was inaccurate. She said, The assessment should have reflected that she returned to us from the hospital and not another nursing home. Review of the RAI version 3.0 Manual revealed instructions for completing Section A 1800: Entered From. The document indicated the rationale for understanding the setting that the individual was in immediately prior to facility admission, entry or reentry could inform care planning and discharge planning discussion. The steps for assessment read, Review transfer and admission records [and] Ask the resident and/or family or significant others.

Based on observation, interview, and record review, the facility failed to re-assess significant weight loss of 1 of 2 residents identified at nutritional risk, of a total sample of 31 residents, (#25). Findings: Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician diet order dated 11/26/21 for No Concentrated Sweets, No Added Salt, and a regular texture. The resident's nutritional care plan dated 12/07/21, read, Residents Weight Will REMAIN STABLE THROUGH THE NEXT REVIEW. On 2/16/22 at 12:51 PM, the resident ate lunch in the main dining room. His meal consisted of macaroni beef bake, breadstick, side salad, mashed potatoes, pears, and beverages. At that time the resident was had eaten only 40% of his meal. Review of the resident's meal percentage log from 1/01/21 to 2/17/22 revealed the resident usually ate 75% to 100% of all meals, with an occasional meal 50% consumed. The Consultant Registered Dietician (RD) assessed resident #25's nutritional risk status on 12/01/21. She noted the resident's height was 68 inches and his weight was 142 pounds. The RD noted the resident's goal weight was between 139 and 169 pounds. The documented indicated the RD recommended a nutritional supplement, [MEDICATION(S)], was to be resumed. Review of the medical record revealed on 11/08/21, the resident weighed 141.6 pounds. On 12/03/21, the resident showed a weight gain and was 142.2 pounds. Over the next two weeks, the resident's weight fluctuated, and he weighed 140.8 pounds and 141.2 pounds on 12/10/21 and 12/17/21, respectively. On 12/24/21, resident #25's weight decreased to 132.6 pounds. This was a significant weight loss as it was 6.09% in 1 week. Centers for Medicare and Medicaid Services . parameters for evaluating significance of unplanned and undesired weight loss indicated a 5% weight loss in 30 days was significant, and greater than 5% was categorized as severe weight loss. On 1/26/22 the resident weighed 132.8 pounds, which was still less than the RD's recommended goal weight. Further record review revealed neither the RD nor the Interdisciplinary Team (IDT) had re-assessed resident #25 to determine if his weight loss was a self-limiting condition that would normally resolve itself, or a significant decline that required intervention. On 2/17/22 at 3:19 PM, the Certified Dietary Manager (CDM) was not able to explain why resident #25's weight loss was not re-assessed by the RD or any other member of the IDT. The CDM added that the RD was only at the facility once weekly, on Wednesdays.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to following physician orders for 1 of 1 resident sampled for gastric tube (GT) feedings out of a total sample of 31 residents, (#389). Findings: Resident #389 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A gastric tube (G-tube) is a flexible feeding tube that is placed directly into the stomach through a surgical incision in the abdominal wall. The G-tube allows nutrition, fluids, and medications to be put directly into the stomach, bypassing the mouth and esophagus (retrieved on 3/01/22 from www.medlineplus.gov). Review of resident #389's medical record revealed physician orders dated 2/13/22 for tube feeding, Glucerna 1.5 calorie at 60 cubic centimeters per hours (cc/hr) to start at 6:00 AM and stop at 12:00 AM, with water flushes of 500 cc every eight hours. On 2/14/22 at 12:13 PM, observation of resident #389 revealed Glucerna 1.5 calorie tube feeding infused via pump at 75 cc/hr. Additional observations on 2/14/22 at 2:50 PM and 2/15/22 at 11:30 AM, revealed the tube feeding continued to infuse at 75 cc/hr. On 2/15/22 at 2:23 PM, Licensed Practical Nurse (LPN) B confirmed resident #389's tube feeding was infusing at 75 cc/hr. She validated that was not the rate prescribed by the physician, and there was no physician order on the 7:00 AM to 3:00 PM Medication Administration Record (MAR) for tube feeding or enteral feed. LPN B said, Usually we ensure accuracy of the right tube feeding rate by verifying it with the physician order. On 2/15/22 at 3:10 PM, the interim Director of Nursing (DON) explained nurses on the 7:00 AM to 3:00 PM shift should be aware of a resident's tube feeding infusion rate as they received report from the off-going nurse and could access the physician orders in the computer. She stated the expectation was nurses would follow the physician orders. During review of resident #389's physician orders, and the February 2022 MAR and Treatment Administration Record (TAR) with the interim DON, no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The interim DON said, You're right. It is not there. She explained accuracy of the medical record and tube feeding rate was the responsibility of the clinical team which consisted of herself, the Supervisor, and Minimum Data Set (MDS) staff. She explained the clinical team reviewed new physician orders and checked charts to ensure orders were in the computer. On 2/17/22 at 10:21 AM, the interim dietitian stated it was important for residents to have the correct tube feeding formulas based on their needs to ensure adequate caloric intake. She stated the infusion rate was ordered by the physician and had to be followed. The interim dietitian explained tube feeding infusion rates were adjusted as needed. On 2/17/22 at 11:34 AM, the physician stated resident #389 was becoming congested, and the tube feeding rate was decreased from 75 cc/hr to 60cc/hr to address the situation. Review of the facility's in-service education for Physician Orders and Follow Up dated 10/22/21 revealed nurses were educated on topics including red-lining or reconciling orders, utilization of the 24-hour report and electronic communication, and clinical management team's consistent use of the order review report for daily monitoring. The facility's policy Physician Orders read, . Once orders are clarified and confirmed do the following: b. Transfer all orders to the MAR/TARS, whether paper or electronic. Review of the facility's policy for Administering Medications revised 2012 read, Medication shall be administered in a safe and timely manner, and as prescribed . The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #389 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/14/22 at 12:13 PM, resident #389 was observed with oxygen infusing at 3 liters per minute (L/min) via nasal cannula. Additional observations on 2/14/22 at 2:50 PM and 2/15/22 at 11:30 AM, revealed resident #389 remained on oxygen at 3 L/min via nasal cannula. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/15/22 at 1:41 PM, Licensed Practical Nurse (LPN) B confirmed resident #389 received oxygen at 3 L/min via nasal cannula. LPN B stated residents definitely needed to have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During review of the medical record, LPN B confirmed resident #389 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/15/22 at 1:54 PM, the interim Director of Nursing (DON) stated physician orders were to be reconciled on admission. She explained the nurses were responsible for verifying and confirming oxygen orders. She stated after morning meetings the clinical team, which consisted of herself, the Supervisor, and Minimum Data Set (MDS) staff, reviewed new physician orders, and checked charts. The interim DON confirmed resident #389 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/17/22 at 10:37 AM, the interim DON stated resident #389's Situation, Background, Appearance, Review and Notify (SBAR) report dated 2/08/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained the nurse who completed the document checked the recommendation for oxygen but did not enter the physician's order into the electronic medical record. The interim DON was informed the resident was observed with oxygen at 3 L/min via nasal cannula. During medical record review, the interim DON noted a baseline care plan with admitted [DATE] that did not include any documentation or revisions for oxygen listed under Special Treatments / Procedures. Review of the facility's in-service education for Physician Orders and Follow Up dated 10/22/21 revealed nurses were educated on topics including red-lining or reconciling orders, utilization of the 24-hour report and electronic communication, and clinical management team's consistent use of the order review report for daily monitoring. Review of the facility's policy for Oxygen Administration undated read, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to provide the necessary care and services to prevent the development of new advanced stage pressure ulcers for 1 of 4 residents reviewed for pressure ulcers out of a total sample of 8 residents, (#1). This failure placed resident #1 at a likelihood for serious harm, illness, and impairment (loss of limb). Resident #1 was admitted to the facility on [DATE] for rehabilitation after a fall at home. Approximately 4 weeks after admission to the facility, on 4/25/21, resident #1's wife informed the facility of a new area of skin breakdown. The facility was not aware of the new area of skin breakdown on his right heel that was identified as a facility acquired unstageable pressure ulcer which is an advanced stage of skin breakdown that is full thickness tissue loss; difficult to heal; at increased risk of infection; disfiguring; and could lead to a loss of limb. The facility's failure to accurately assess resident #1's skin and identify a new area of skin impairment, until it was an advanced stage, placed all residents at risk for skin breakdown for a likelihood of serious harm, serious illness, and impairment which resulted in Immediate Jeopardy starting on 4/25/21. The Immediate Jeopardy was removed on 4/27/21. Findings: Resident #1, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer 3008 Form dated 3/07/21 indicated the resident had a stage II sacral pressure ulcer, was non ambulatory, required two-person assistance for transfers, and was alert with disorientation but could follow simple instructions. The transfer form indicated resident #1 was at risk for developing pressure ulcers. The Nursing Admission Evaluation for resident #1 dated 3/07/21, indicated skin breakdown of his buttock, but no skin issues to his heels were noted. Review of resident #1's Order Summary Report revealed physician orders dated 3/08/21 to offload his heels at all times in bed and to apply skin prep to all bony prominences including his heels for preventative skin care. Skin prep is a liquid that when applied to skin forms a protective film or barrier (retrieved on 6/07/21 from www.[MEDICATION(S)].com-a medical supply company). The Braden Scale for Predicting Pressure Sore Risk for resident #1 dated 3/07/21 revealed a score of 12 which indicated he was at high risk for pressure ulcer development. The form showed the resident was at risk for skin breakdown related to skin moisture, very limited mobility, inadequate nutrition, and friction/shearing. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated resident #1 had a Brief Interview for Mental Status score of 9 which indicated moderately impaired cognition. The assessment showed he required extensive assistance for transfers and bed mobility. Resident #1 was at risk for developing pressure ulcers, was admitted with a stage II pressure ulcer, and had no infections or open [CONDITION(S)] on his feet. Review of the care plan for skin breakdown initiated on 3/19/21, revealed resident #1 was at risk for skin breakdown related to a stage II sacral pressure ulcer and incontinence. Interventions on the care plan included turn and reposition the resident every 2 hours, observe skin during personal care, and keep skin clean and dry. The care plan directed licensed nursing staff to conduct weekly skin assessments and report abnormal findings to the physician. Review of resident #1's Nursing-Weekly Skin Checks from 3/08/21 to 4/19/21 revealed nurses completed eight skin assessment forms. The forms showed nurses did not identify or document any areas of skin impairment to the right heel. During a telephone interview with resident #1's wife on 5/31/21 at 5:30 PM, she stated she visited her husband at the facility on 4/25/21. She said she discovered a wound on her husband's right heel after he mentioned that his foot hurt. She said, I removed his sock and discovered a large blood blister on his right heel. I know that he did not have that when he entered the facility and could not understand how this could have happened. I immediately reported this to the nurse and told her I would be taking my husband out of the facility as soon as possible. Resident #1's wife stated within a few days of taking him home, she took him to the podiatrist. She recalled the podiatrist told her his foot was in bad shape. Resident #1's wife described being very upset about the lack of care her husband suffered in the facility. During a telephone interview on 6/02/21 at 2:00 PM, the Podiatrist stated he saw resident #1 on 4/29/21. He described the resident's wound as a large circular eschar on his right heel that was kind of floating and was 4.5 centimeters in diameter. He explained he debrided (surgical removal) the eschar, or dead tissue. The podiatrist said, These types of wounds don't do well. They get contaminated and infected. It can take several days to weeks to develop and can be caused by immobility and pressure to the area. In my experience these wounds are the common cause of limb loss. On 6/01/21 at 11:05 AM, the Director of Nursing (DON) stated she was made aware of resident #1's right heel pressure ulcer after the wife visited. The DON was unable to explain why the wound had not been identified by nursing staff rather than discovered by the wife. Review of the Interdisciplinary Team Progress Note dated 4/28/21, revealed resident #1 was assessed as having an unstageable pressure ulcer to the right lateral heel that measured 6.0 cm x 5.2 cm. The note indicated there was an area of firm eschar adhering to the wound bed. An unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (retrieved on 6/08/21 from the National Pressure Injury Advisory Panel. www.npiap.com). On 6/02/21 at 11:26 AM, Certified Nursing Assistant (CNA) D remembered seeing a fluid filled blister on resident #1's heel approximately 2 to 3 weeks before the resident left the facility. She said she reported it to Registered Nurse (RN) E. CNA D revealed the resident sometimes did not allow her to remove his socks, so she did not always observe his feet. During a telephone interview on 6/02/21 at 4:45 PM, contrary to CNA D's recollection, RN E stated she was never told about any area of skin concern on resident #1's heel. Review of the facility policy and procedure titled Reporting of Unusual Skin Findings (no date) indicated CNAs were to assist in identifying resident skin problems to promote healing and prevent infection. The document noted, The nurse in charge will then perform an assessment of the finding and initiate follow-up as appropriate. Review of the 'Employee Timesheet indicated CNA D and RN E both worked the same shift on 4/12/21 and 4/14/21, approximately two weeks prior to resident #1's discharge. Review of the resident's Treatment Administration Record (TAR) from 3/07/21 through 4/27/21 showed nurses applied skin prep to all bony prominences including his heels every shift. On 6/02/21 at 4:29 PM, RN B said she usually worked night shift and remembered applying skin prep to resident #1's heels. She recalled the resident's roommate did not want the light turned on, so she applied the skin prep in the dark. RN B explained she neither used a flashlight nor observed his heels. On 6/02/21 at 5:03 PM, RN A acknowledged she initialed the TAR indicating she applied skin prep to the resident's heels. She said, Most of the time I swoosh it on and I am not trying to wake them up because I work night shift. I'm not really looking at what I am doing. On 6/02/21 at 5:15 PM, in a telephone interview, RN C indicated she was assigned to resident #1 on the day before and on the day his pressure ulcer was discovered. She acknowledged she initialed the TAR to indicate she applied skin prep to both heels on both days but wiped it on without observing the areas. On 6/03/21 at 1:35 PM, Licensed Practical Nurse (LPN) G stated she initialed the TAR on 4/22/21, applied the skin prep to resident #1's right heel but did not inspect his heels. On 6/03/21 at 1:40 PM, LPN F stated she received a written discipline for not assessing the resident's heels. She was informed by the DON that a pressure ulcer was found on resident #1's right heel a few days after she had completed a skin sweep on resident #1's right heel on 4/19/21. On 6/3/2021 at 3:39 PM, the attending physician explained the resident's unstageable pressure ulcer developed over time and definitely not within 8-12 hours. She said her expectation was that nurses look at any resident's heels or other areas when applying skin prep or any other treatment. She verbalized it was unfortunate this incident occurred. Review of the Weekly Skin Assessment Completion policy (no revision date) noted a purpose To document skin conditions upon admission and any new skin area. This assessment was to be completed weekly and updated when new areas of skin impairment were identified. The instructions directed nurses to .perform a visual assessment of resident's entire body and document findings . Review of the job description titled Certified Nursing Assistant (CNA) revised on 9/16//13, revealed essential duties included promptly reporting any changes in condition to the licensed nurse and providing care to maintain residents' skin integrity and prevent pressure ulcers. Review of the job descriptions titled Licensed Practical Nurse (LPN) and Registered Nurse (RN) revised on 9/16//13, revealed essential job functions to include a personal physical assessment of the resident weekly to prevent skin breakdown and the development of pressure ulcers. Review of the corrective measures implemented by the facility revealed the following, which were verified by the survey team. * On 4/25/21, resident #1's right heel unstageable pressure ulcer was identified and assessed. The primary physician was informed, treatment orders were obtained along with a wound care consultation. * On 4/26/21, the Advance Practice Registered Nurse (APRN) assessed resident #1's wound with no new orders written. * On 4/27/21, resident #1 was discharged to home with the wife. * From 4/25/21 through 4/27/21, full house skin sweeps were completed. One resident was found with a new skin impairment, and appropriate action was taken. * All scheduled staff were educated from 4/25/21 to 4/27/21 by 1:1 and/or small groups. All part time, as needed and unscheduled staff were educated via the On-Shift a communication/educational staffing system. All 31 of the 78 nursing staff were in-serviced via small groups which is 40%. 100% of the staff received the education material via On Shift. * The DON received informal verbal communication from the employees coming onto their shift they received information via On Shift. * On 4/26/21, a Quality Assurance Performance Improvement (QAPI) meeting was held, a Performance Improvement Plan (PIP) was initiated, and an audit tool was created to ensure adherence and compliance to skin/assessment action plan. * Stand up sheets and homework sheets were created for use in daily clinical meetings for monitoring compliance with weekly skin sweeps, new order accuracy, labs, and immunizations. * Relias training will include an introduction to pressure injury (also known as pressure ulcer and pressure sore) from annually to at least quarterly, to ensure competency for the next 12 months. Each employee must have a passing score of 80%. * An additional random check/audit of skin evaluations post completion by the assigned nurse will be conducted by clinical managers and administration to validate accuracy of checks.

Based on observation, interview and record review, the facility failed to ensure that adequate supervision and a secure environment were provided for 2 of 4 cognitively impaired residents at high risk for elopement, (#1, #2). These failures contributed to the elopement of residents #1 and #2, placing them at likely serious injury/impairment/death. While the residents were out of the facility unsupervised, there was high likelihood the residents could have fallen down the stairs, been hit by a car or become lost. On 08/08/19 at 8:30 PM, two cognitively impaired residents, #1 and #2 exited the second floor memory care unit following a dietary staff member down 2 flights of stairs to the basement level. They went through the kitchen and exited through the kitchen side door unsupervised at 9:00 PM. They walked up a steep paved incline in the dark to the facility's driveway and then walked towards the front exit gate with the intention of going home. Both residents were spotted by the Dietary Manager who had driven through the front parking lot and was attempting to park her car. The residents' whereabouts were unknown to the facility until they were notified by the Dietary Manager at 9 PM, approximately 30 minutes after the residents had exited the memory care unit. The facility's failure to provide adequate supervision and a secure environment resulted in Immediate Jeopardy level starting on 08/08/19. The Immediate Jeopardy was removed on 08/21/19. The severity and scope were reduced to D, isolated, no actual harm with potential for no more than minimal harm. Findings: Cross Reference to F610 and F835 A review of the Facility Assessment, dated 02/19/19 revealed the Facility has a memory care unit with a wanderguard system to protect the safety of the residents who may be at risk for elopement 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the National Institutes of Health, [MEDICAL CONDITION] is a term used to describe . any diffuse disease of the brain that alters brain function or structure. Causative factors could be infections and decreased blood flow to the brain. The main indicator of [MEDICAL CONDITION] is altered mental state with symptoms including progressive memory loss and decreased cognitive ability. Although treating the underlying cause of metabolic [MEDICAL CONDITION] may improve symptoms, . the [MEDICAL CONDITION] may cause permanent structural changes and irreversible damage to the brain. (www.ninds.nih.gov 09/18/19 at 2:00 PM) The resident's Fall Risk Evaluation Tool dated 07/20/19, noted that she was at high risk for falls. The evaluation documented a score of 55. A score of 45 or higher placed the resident at high risk for falls. The Elopement Risk Evaluation dated 07/20/19, noted the resident was at high risk for elopement. The evaluation documented a score of 13.5. A score of 11 or more placed the resident at high risk for elopement. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented she had moderate cognitive impairment, required supervision with locomotion on the unit, toilet use and personal hygiene. She had a history of [REDACTED]. The MDS section E0900 noted the resident had not displayed any wandering behavior. A wander guard elopement device however, was being used daily since admission. A review of the physician's orders [REDACTED]. The resident's baseline care plan dated 08/5/19, revealed that she was to remain in the facility long term. She was alert, confused, ambulatory and an elopement risk with a wander guard device on her person at all times. She was receiving physical and occupational therapy for history of a fall and was also receiving psychiatric services for depression and anxiety. The comprehensive plan of care revealed a focus for risk of falls dated 07/22/19 related to poor cognition and confusion due to [MEDICAL CONDITION]. Interventions included to assist with transfers and ambulation, encourage resident to ask for assistance and to ensure her environment was clutter free and well lit. A second focus for risk of elopement dated 07/29/19 was related to the resident's level of dementia with poor cognition and wander guard device to her right leg. The goal documented that the resident will not leave the facility unattended and whereabouts will be known at all times. The interventions included to add her information to wander list books, encourage resident to participate in activities of interest, monitor location and supervision as needed, wander guard device as ordered, psychiatric services, psychiatric medications as needed and to monitor for effectiveness and any possible side effects. Review of the multidisciplinary care conference held on 08/05/19 with resident #1's daughter, MDS nurse, dietary, social service, activities, registered nurse (RN)/licensed practical nurse (LPN) and certified nursing assistant (CNA) documented the resident was prone to bouts of confusion and had [DIAGNOSES REDACTED]. My mother always stated that she was lonely while at home and made several attempts to leave Review of the Nursing Progress Notes dated 08/08/19 at 9:21 PM, showed the resident had been located outside but was now in the lobby area with wander guard device to right lower leg. Resident #1 was redirected to the nursing station for enhanced supervision and physician, family member, administrator and south wing unit manager made aware of the situation. A second note dated 08/09/19 at 12:01 AM documented the resident was observed outside of the building in the front lobby area, believed to have followed a staff member down the stairs. On 09/12/19 at 2:17 PM, resident #1 was observed sitting in a chair adjacent to the nurses' station next to resident (#2). She was well dressed and groomed. She had her right hand over her eyes and she had no behaviors or attempts to ambulate. A wander guard device was noted to her right ankle. She was holding on to two small plastic bags which contained 3 small dinner rolls. Resident #1 stated that she was doing good and she was going to add meat to the dinner rolls for her dinner tonight. She did not remember ever leaving the facility or going outside on her own. She explained that she was able to get washed, dressed, go to the bathroom and walk around without assistance. On 09/13/19 at 2:47 PM, resident #1's daughter was contacted by telephone. She revealed that her mom had sustained 3 fractured ribs and 7 stitches to her head after attempting to climb a 6- foot fence during the middle of the night when she lived with her sister. The family was alerted by their dog barking and found my mother injured on the ground in the back yard. The decision was made that she needed to be placed in a more structured type facility to ensure her safety and to protect her from serious injury. The daughter stated that she was notified by the facility that her mom had an attempted elopement event, but she was never informed that her mom had actually exited the facility. The daughter stated that she was upset and extremely concerned because her mom was more active at night and sundowns. I expected the facility to keep my mom safe and I am finding out about this from you and not by the facility. The daughter stated that she was not informed that her mom had walked down stairs, entered the kitchen and exited the facility. According to WebMD on 9/18/19 at 2:00 PM, 1 out of 5 people with [MEDICAL CONDITION] get sundow[DIAGNOSES REDACTED]. Changes in how they act in the late afternoon or early evening with symptoms including agitation, restlessness, irritability, confusion, disorientation, demanding, suspicious, yelling, pacing, hearing or seeing things that aren't there and mood swings. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Fall Risk Evaluation Tool done at admitted d 12/18/18 showed that he was at moderate risk for falls. He had a score of 30. On 03/18/19 and 06/18/19 his fall risk was noted to be 15 indicating low risk. The resident's Elopement Risk Evaluation dated 05/13/19 noted that he was at high risk for elopement with a score of 12. The admission MDS assessment dated [DATE] revealed he was admitted from hospital with moderate cognitive impairment. He required supervision with locomotion off the unit, with toilet use, personal hygiene and was ambulatory. He was receiving antipsychotic and antianxiety medications and had a wander/elopement device on his person that was used daily. The quarterly MDS assessment dated [DATE] documented he now had severe cognitive impairment, was independent with all of his activities of daily living, ambulated independently, continued on antipsychotic and antianxiety medications and had a wander/elopement device on his person which was used daily. Review of resident #2's baseline care plan dated 12/18/18 revealed he was admitted from an assisted living setting, had confusion, and was admitted for long term care due to dementia. He was identified as at risk for wandering and had a wander guard device on his person. The wife indicated he had delusions with verbalization that he wanted to leave the facility. Review of resident #2's comprehensive plan of care revealed focus for being at risk for falls dated 01/16/19 related to daily antipsychotic medication use. Risk for elopement due to his level of dementia dated 12/19/18. He was ambulatory and making comments of going to work as he said he was a police officer. The interventions included close supervision, monitor location and supervision as needed, encourage and invite to activity that meet his interests. On 03/31/19 the resident was observed on the patio after removing the wander guard device. Staff also observed the resident attempting to remove another resident's wander guard device. On 05/12/19 his wander guard device was found in the pocket of his jeans. Resident #2's physician orders [REDACTED]. The most recent Multidisciplinary Care Conference on 07/01/19 revealed that resident #2 was alert with bouts of confusion, was able to make his needs known, attended activities, enjoyed going on field trips and was receiving psychiatric services and his mood was stable. Review of the psychiatric progress noted revealed he was seen on 05/08/19, 05/17/19 and 05/29/19 for exit seeking since admission. He had delusions, anxiety and could be difficult to redirect. Excessive worry/anxiety, delusional, disorganized/incoherent speech and/or behavior, wandering, cognitive impairment and impaired activities of daily living (ADL). On 08/20/19 he was seen again for chief complaint of being delusional, anxiety and dementia. [DIAGNOSES REDACTED]. There were no new orders added after this visit. Review of resident #2's Nursing Progress Notes dated 08/08/19 at 9:21 PM documented the resident was located outside but was now in the lobby area with wander guard device to his right lower leg. The resident was alert with confusion, resident redirected to nursing station for enhanced supervision and physician, family member, administrator and south wing unit manager made aware of the situation. A second note dated 08/09/19 at 12:01 AM documented the resident was observed outside of the building in the front lobby area, believed to have followed a staff member down the stairs. On 09/12/19 at 2:28 PM, resident #2 was observed to be well dressed and groomed. He was sitting in a chair adjacent to the nurses' station next to resident #1. A wander guard device was observed on his right ankle. He stated that he was independent with most of his ADL's and usually walked around with resident #1. We are partners and are usually together in activities and go to breakfast and lunch together. On 09/13/19 at 3:07 PM, resident #2's daughter was contacted by telephone. She stated that she was informed that her dad had tried to leave the facility on 08/08/19 but was not told that he had actually exited the facility through the kitchen with his female friend. She stated that she was aware that her dad had a wander guard device and the facility should have monitored his whereabouts. She was very upset stating, The facility is responsible for caring for my father and keeping him safe and they did not do that. She stated that the facility accepted him and that he had been in the facility for almost a year. They should be able to take care of him and make sure he is safe. On 09/13/19 at 6:19 PM, the Administrator and DON stated that care plan interventions were to be resident centered and individualized. When asked about the intervention noted on resident #1's care plan, whereabouts will be known at all times, they responded, It is not feasible, it just can't happen. They both stated that they did not have the means to monitor residents' whereabouts at all times. When asked about the intervention on resident #2's careplan for close supervision, they said that these residents constantly walked about the unit and were independently ambulatory. They could be anywhere at any time. They stated that all residents were observed at least every 2 hours whether they were at risk for elopement risk or not. The administrator stated that the facility did not have a policy for supervision of residents but it was the expectation that all residents were observed at least every 2 hours. On 9/12/19 at 2:11 PM, Certified Nursing Assistant (CNA) A stated that she knew both residents #1 and #2 and was aware that they were at risk for elopement. She said that the residents' whereabouts were monitored every 2 hours. On 9/12/19 at 2:30 PM, Licensed Practical Nurse (LPN) B stated that she had been at the facility for only a few months. She said that residents' whereabouts were monitored every 2 hours. When questioned whether residents at risk for elopement were supervised more frequently, she stated that most of them walk about the unit and were observed by staff. On 9/12/19 at 2:57 PM, the 2nd floor unit manager stated that all residents were observed every 1-2 hours. On 9/12/19 at 3:13 PM, CNA C stated that she observed all her elopement risk residents every 1-2 hours. On 09/12/19 at 10 AM, the facility doors were observed with the Maintenance Director and the Administrator. The Maintenance Director stated that the doors were wander guard protected and some doors required a card to be swiped and some required a number code to allow staff entry and exit. For the doors that required the number code to be entered on the key pad, the door unlocked and the wander guard device alarm system becomes disarmed so it will not sound. The Maintenance Director stated that on 08/08/19 the video recording showed 2 residents (#1, #2) on the 2nd floor standing by the elevator. The dietary aide entered the number code into the key pad for the door leading onto the stairwell. This disengaged the magnetic lock system and disarmed the wander guard alarm system allowing the two residents with wander guard devices to exit the door without sounding the alarm. The surveyor retraced resident #1 and #2's elopement route of 8/8/19 from the 2nd floor with the Maintenance Director and the Administrator. The Maintenance Director entered the number code on the key pad for the second floor stairwell door which was located to the left of the elevator. He opened the stairwell door to exit. There were 8 steps going down to the landing of the 1st floor and then another 8 steps down to a landing with a door leading to the basement level. The Maintenance Director entered the number code into the key pad which disarmed the wander guard system. Through the door was the basement level rotunda. There were 5 hallways, one leading to the elevator, one leading to a door to the outside, one leading to the kitchen, one leading to the activity area and a hallway to the therapy department which also had doorways to the housekeeping, maintenance and laundry areas. The residents had entered the kitchen area, passed by the long preparation table, stoves, 2 ovens, deep fryer and a variety of small food preparation equipment. The residents had then exited through the kitchen's side door. They then walked up a paved embankment to the paved driveway. If the residents had continued walking straight they would have been led directly to the facility's exit gate leading to a busy, heavily traffic congestion 4 lane highway. If they had turned left they would have been directly in front of the facility with a gate at the far end of the parking lot. Observations of the entire exterior of the facility revealed that the paved driveway extended around the facility leading to a second gate (used to exit only) in the back of the facility. The Maintenance Director stated that the 2 gates were activated when a car's weight automatically opened the gate. A black metal type fencing was observed to be around the perimeter of the facility's property except on the left side of the facility where a construction chain link fence was erected due to construction on the adjacent lot. On 09/12/19 at 12:30 PM, the DON explained that she was not the DON at the time of the elopement incident on 08/08/19. An investigation was conducted and it was found that on 08/08/19 at 9 PM, residents #1 and #2 had exited the facility through the kitchen side door. They had followed a dietary aide off the 2nd floor onto the stairwell and walked down the stairs They were last seen on the memory unit at 8:30 PM and then observed outside of the facility at 9 PM by the Dietary Manager who happened to be coming back to the facility. Both residents were returned to the facility and escorted back to the memory care unit. They were assessed for injuries and their physicians and the residents' responsible parties were notified. They did not have any injuries. On 09/12/19 at 1:05 PM, the Administrator revealed that on 08/08/19 at 9 PM, residents #1 and #2 were observed outside near the kitchen side door. She stated that she did not know how the residents got out of the facility. The Administrator stated that the Corporate Nurse reviewed the facility video recording and determined that the 2 residents had followed a kitchen staff member through the doors, down the stairs, through the kitchen and then they exited the facility through the kitchen's side door. We did not keep a copy of the video recording from the elopement incident on 08/08/19. On 09/12/19 at 1:59 PM, the Administrator stated that she could not find her investigation which included the staffs' statements related to the incident. She stated that she had reviewed the 08/08/19 video and that the 2 residents followed Dietary Aide (A) who had worked at the facility for less than a year. She stated that she had spoken to dietary aide A and he stated that he saw the residents following him to the basement level but he thought they were visitors. Once he was at the basement level, he gathered the trash and went outside to place it in the dumpster located in the back of the facility. On 09/12/19 at 4:19 PM, an interview was conducted with Dietary Aide A, the administrator and the Director of Risk Management. Dietary aide A stated that he had worked at the facility since 07/01/19. As part of his orientation, he had taken an elopement test and he confirmed that he had scored 100%. On 08/08/19 at approximately 8:30 PM, he went to deliver food items to the second floor. When returning from the second floor he entered the number code into the key pad on the second floor door. He went through the door and did not check to ensure that no one had followed him. He went down the first flight of stairs to the landing. When he looked back he saw 2 people standing on the steps half way down the first flight of stairs. They looked like they were trying to figure out whether to go up or down the stairs. I had seen them a couple of times before but thought they might be visitors. He did not check to find out who they were. He entered the number code on the key pad for the door at the bottom of the stairs and when he looked back, he saw that the two people were at the bottom of the stairs. He still did not question the two people. He stated that the door must have only closed half way as the two then entered the rotunda area. He proceeded and gathered up the trash and took it out to the dumpster located at the back of the facility. He came back into the facility through the therapy department. He stated that he did not see the 2 residents when he came back in so he went up the stairs to the first floor and clocked out. He then left the facility through the front entrance door. I was nervous when I saw the 2 residents, but at that time I was focused on getting my work done. They don't want me to have overtime. I know not to give the door code to anyone. If a resident was behind you, you need to make sure they don't follow you. I know that the stairs are for staff only and residents are not allowed to use the stairs for safety reasons. I saw the 2 residents on the basement level. They came through the basement level door and were in the rotunda. I never spoke to the residents or asked them if they were lost or needed help. On 09/13/19 at 9:20 AM, an interview was conducted with the Dietary Manager by phone. She stated that on 08/08/19 at 9 PM, she happened to be returning to the facility to return some items to the kitchen. She entered through the front guard gate and drove straight through the parking lot. As she was about to turn right to park her car by the kitchen's back door, she saw 2 residents walking along the paved driveway holding hands. She stopped her car and asked the residents where they were going. They stated that they were going home. She said she saw Dietary Aide B walking to her car and she called her for help to get security. Review of Dietary Aide A's Elopement Prevention and Action Post Test revealed he scored 100%. Review of the POS [REDACTED]. Although Dietary Aide A was educated and tested to be knowledgeable regarding resident elopement, he allowed 2 cognitively impaired residents to tailgate him as he exited the 2nd floor memory care unit resulting in the residents exiting the facility. Despite having seen these two residents before, he did not question why they were following him down two flights of stairs and did not report this to any other staff member. This action placed both residents #1 and #2 at high risk for serious injury from falls, becoming lost and/or being hit by a car on the busy, 4 lane highway directly in front of the facility. According to the facility's Resident Elopement Defined Policy, not dated, read, Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so Our facility strives to prevent resident/patient elopement The Risk Reduction Elopement Program is an interdisciplinary process designed to reduce the risks for elopement while maximizing independence The center will maintain a plan to prevent elopement through components that may include, but are not limited to, the following: . regular rounds, structured group activities, environmental modifications, staff supervision and interventions, resident/patient and family education. Purpose: 1. Identify residents/patients at risk for elopement. 2. Develop individualized interventions based on assessment. 3. Modify environment, when possible, to reduce risk. 4. Should an elopement occur, act quickly and decisively to prevent or minimize injury. Review of the facility's Elopement Prevention Policy, read, Procedure: 1. Complete the admission assessment including, but not limited to the following: Complete the admission assessments .2. Review and analyze assessments . 3. Determine elopement risk factors . 4. Document risk factors . 5. Develop interventions . 6. Communicate risk and interventions to the care giving team 7. Review interdisciplinary assessment and documentation at plan of care meeting 8. Review possible causes for wandering and develop individualized interdisciplinary interventions and goals to reduce wandering . 15. In-service and strive to assure that all staff (including temporary help) are aware of the system and what steps to take to prevent or interrupt elopement attempts. Review of the facility's corrective measures completed by 08/21/19 revealed the following: Residents #1 and #2 were observed on the memory care unit with wandergaurd wanderguard elopement devices placed on their right ankles. They remained on every (Q) 15 minute observations with licensed staff documentation. Education was completed with Dietary Aide A related to the door codes, monitoring for residents before and after opening doors and elopement policy and procedure. Elopement education for 100% of facility staff was verified. This included as needed (PRN) staff being educated by phone by the DON. Computer tablets were purchased for the security staff to monitor the entrance and exit gates at all times. Elopement books on the nursing units and at the reception desk were updated to include information and pictures of all residents assessed as wandering/elopement risk. Elopement drill were conducted with Dietary Aide A to ensure his knowledge and ability to follow the facility policy and procedure for elopements. The elopement drills were on-going for all staff on all shifts (including contracted staff). Letters were sent to the families and resident's responsible party regarding unattended residents and what to do if they saw residents outside of the facility unattended. Letter verified. New number code lock was placed on the main kitchen doors to ensure the kitchen was locked at all times to prevent anyone except kitchen staff from entering the kitchen. The receptionists' hours were extended until 8 PM Monday-Sunday. Security staff were to continue checking all facility doors on each shift. Maintenance staff were to continue checking the wander guard system function weekly. All facility residents were re-assessed for wandering/elopement risk and no new residents were identified. Audits verified. The care plans for residents with wander guard elopement devices were reviewed and updated. The survey team expanded the sample to include residents #3 and #4 identified as wander/elopement risk with wander guard elopement devices. Observations and interviews were conducted with no concerns. Observations, interviews, education and audits were verified regarding wandering/elopement and door security.

Based on interview and record review, the facility failed to conduct a complete and thorough investigation to determine the root cause of an elopement and failed to maintain records of the facility's investigation of the elopement of 2 cognitively impaired residents (#1, #2) residing on the memory care unit. On 08/08/19 at 8:30 PM, two cognitively impaired residents, #1 and #2 exited the second floor unit following a dietary staff member down 2 flights of stairs to the basement level. They went through the kitchen and exited through the kitchen side door unsupervised at 9:00 PM. They walked up a steep paved incline in the dark to the facility's driveway and then walked along the facility's driveway towards the front exit gate with the intention of going home. Both residents were spotted by the Dietary Manager who happened to be returning to the facility to drop off some items and was attempting to park her car. The residents' whereabouts were unknown to the facility until they were notified by the Dietary Manager at 9 PM, approximately 30 minutes after the residents had exited the memory care unit. The facility's failure to complete a thorough investigation to determine the root cause of how 2 cognitively impaired residents were able to exit the memory care unit, enter the facility's kitchen and exit the facility resulted in Immediate Jeopardy level. A thorough investigation to determine the root cause is necessary to prevent reoccurrence of these or occurrence of other vulnerable residents from wandering to unsafe places and/or exiting the building without supervision. The Immediate Jeopardy started on 08/08/19, and was removed as of 08/21/19. The scope and severity were reduced to D, isolated no actual harm with potential for no more than minimum harm. Findings: Cross Reference to F689 On 08/08/19 at 8:30 PM, residents #1 and #2 followed a dietary staff member as he disarmed the second floor stair door's wanderguard system and exited the memory care unit. Despite being aware that 2 residents had followed him down the stairs, the dietary aide then proceeded to disarm a second door leading onto the ground level rotunda area. The dietary aide did not question the 2 residents as to who they were or where they were going. He did not report to any facility staff that 2 residents had followed him off the memory care unit. The dietary aide was preoccupied with finishing his work duties on time and continued with the task of taking the trash out to the dumpster at the back of the facility. The 2 cognitively impaired residents entered the kitchen area where they were exposed to ovens, stoves, oil fryer, multiple sharp kitchen cutlery, small food processing machinery, walk-in refrigerator and walk-in freezer. The 2 residents then exited through the kitchen's side door to the outside at 9:00 PM. They were observed by the Dietary Manager, who happened to be driving back to the facility to drop off some items. She spotted the two residents as she was attempting to park her car and summoned assistance from another dietary staff member. On 09/12/19 at 12:30 PM, the Director of Nursing (DON) confirmed that there was an elopement on 08/08/19. She stated that she was not the DON at the time of the elopement. She stated that residents #1 and #2 were last seen on the memory care unit at 8:30 PM and at 9 PM they were seen outside of the facility by the Dietary Manager. The DON confirmed that an investigation of the elopement was completed. On 09/12/19 at 1:05 PM, a review of the investigation of the elopement was conducted with the Administrator and DON. The Administrator stated that she did not know how the residents got out of the facility. She stated that she had reviewed the facility video with the Corporate Nurse and it was determined that the residents followed a kitchen staff member. The camera in the kitchen showed that a light was on in the dry storage, but I never reviewed the video of the kitchen. The Administrator did not say why she had not viewed the video in its entirety. She stated that the determination of the elopement incident was, human error. A viewing of the video recording was requested but the administrator stated, I don't think we saved the video. She stated that the video was only available for a certain length of time then was automatically deleted. Although this was a serious incident, the administrator could not explain why she did not make a copy of the video recording. On 09/12/19 at 1:30 PM, an interview was conducted with the Director of Risk Management (DRM). She stated that the Administrator was responsible for the facility. As the DRM, she was responsible for auditing systems, conducting inservice and training and reviewed resident events. She stated that she had reviewed the video recording with the Maintenance Director, Security Director and the Administrator. She said the Administrator did not view the kitchen portion of the video recording as she was called away. The DRM stated that a complete and thorough investigation needed to be done to determine the root cause of the elopement. The investigation needed to include a review of the video recording review of the incident, staff statements, security statements, dietary employee statements, and statements of all staff in the facility at the time of the incident including the interdisciplinary team. At this time, a request was made by the surveyor to review the completed elopement investigation. On 09/12/19 at 1:59 PM, the Administrator stated that she could not find the elopement investigations of 8/8/19 which included staff statements but said she would continue to search. On 09/12/19 at 4:20 PM, the surveyor again requested to review the investigation. The DON was reminded that it had been 4 hours since the first request was made to review the investigation. On 09/12/19 at 5:39 PM, the Administrator and DRM were interviewed. The Administrator stated that she had found the Dietary Aide A's hand-written statement of the elopement. The statement noted that a Dietary Aide, B was in the kitchen at 8:30 PM on 8/8/19. This may have explained the lit storage room in the kitchen that was viewed on the video. The Administrator was asked if Dietary Aide B may have seen the residents in the kitchen. She stated that she had not interviewed Dietary Aide B. The Administrator stated that she had interviewed Dietary Aide A but she had not documented the interview. The administrator stated that the DRM and DON had also interviewed Dietary Aide A but did not document their interviews. The DRM stated that she had interviewed Dietary Aide A on 2 separate occasions but those interviews were also not documented. The Administrator and DRM were asked who they had interviewed. They stated that they had not interviewed residents #1, #2, their responsible parties, nor the evening supervisor that worked at the time of the elopement. When asked how they would determine the root cause of the incident, the DRM stated that they had not done a complete and thorough investigation of the elopement incident. On 09/13/19 at 8:30 PM, the time of exit, the facility had not produced the documentation of the 08/08/19 elopement investigation and failed to determine the root cause of how residents #1 and #2 were able to get into the kitchen area and out of the facility unattended. Review of the facility's corrective measures completed by 08/21/19 revealed the following: Residents #1 and #2 were observed on the memory care unit with wander guard elopement devices placed on their right ankles. They remained on every (Q) 15-minute observations with licensed staff documentation. Education was completed with Dietary Aide A related to the door codes, monitoring for residents before and after opening doors and elopement policy and procedure. Elopement education for 100% of facility staff was verified. This included as needed (PRN) staff being educated by phone by the DON. Computer tablets were purchased for the security staff to monitor the entrance and exit gates at all times. Elopement books on the nursing units and at the reception desk were updated to include information and pictures of all residents assessed as wandering/elopement risk. Elopement drill were conducted with Dietary Aide A to ensure his knowledge and ability to follow the facility policy and procedure for elopements. The elopement drills were on-going for all staff on all shifts (including contracted staff). Letters were sent to the families and resident's responsible party regarding unattended residents and what to do if they saw residents outside of the facility unattended. Letter verified. New number code lock was placed on the main kitchen doors to ensure the kitchen was locked at all times to prevent anyone except kitchen staff from entering the kitchen. The receptionists' hours were extended until 8 PM Monday-Sunday. Security staff were to continue checking all facility doors on each shift. Maintenance staff were to continue checking the wander guard system function weekly. All facility residents were re-assessed for wandering/elopement risk and no new residents were identified. Audits verified. The care plans for residents with wander guard elopement devices were reviewed and updated. The survey team expanded the sample to include residents #3 and #4 identified as wander/elopement risk with wander guard elopement devices. Observations and interviews were conducted with no concerns. Observations, interviews, education and audits were verified regarding wandering/elopement and door security.

Based on observation, interview and record review, the facility administration failed to use its resources effectively to ensure the safety of residents at risk for elopement and failed to secure doors for entering and exiting the memory care unit for 2 of 4 sampled residents (#1, #2). These failures contributed to the elopement of residents #1 and #2 placing them at risk for serious injury/impairment/death. While the residents were out of the facility in the dark, unsupervised, there was high likelihood the resident could have fallen, become lost or been hit by a car. Both residents were ambulatory and capable of leaving the facility at the time of the event. The facility administration failed to ensure that a thorough investigation of the elopement incident was investigated to determine the root cause to prevent reoccurrence of these residents or the occurrence of other vulnerable residents from wandering to unsafe places and/or exiting the building without supervision. On 08/08/19 at 8:30 PM, two cognitively impaired residents, #1 and #2 exited the second floor unit following a dietary staff member down 2 flights of stairs to the basement level. They went through the kitchen and exited through the kitchen side door unsupervised at 9:00 PM. They walked up a steep paved incline in the dark to the facility's driveway and then walked towards the front exit gate with the intention of going home. Both residents were spotted by the Dietary Manager who happened to be returning to the facility to drop off some items and was attempting to park her car. The residents' whereabouts were unknown to the facility until they were notified by the Dietary Manager at 9 PM, approximately 30 minutes after the residents had exited the memory care unit. The facility's failure to identify the need to maintain a secure environment and thoroughly investigate this incident resulted in Immediate Jeopardy starting on 08/08/19. The Immediate Jeopardy was removed as of 08/21/19. The severity and scope were reduced to D, isolated no actual harm with potential for no more than minimal harm. Findings: Cross Reference to F610 and F689 Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] after sustaining multiple right sided rib fractures and head injury while trying to climb a 6-foot fence during the middle of the night. Her [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented she had moderate cognitive impairment, required supervision with locomotion on the unit. She had a history of [REDACTED]. The MDS assessment section E0900 noted that resident #2 did not have any wandering behavior. A wander guard elopement device was being used daily since admission. Her baseline care plan dated 08/5/19, revealed that she was to remain in the facility long term. She was alert, confused, ambulatory and an elopement risk with a wander guard device on her person at all times. She was receiving physical and occupational therapy for history of a fall and was also receiving psychiatric services for depression and anxiety. The comprehensive plan of care revealed a focus for risk of falls dated 07/22/19 related to poor cognition and confusion due to [MEDICAL CONDITION]. Interventions included to assist with transfers and ambulation, encourage resident to ask for assistance and to ensure her environment is clutter free and well lit. A second focus for risk of elopement dated 07/29/19 was related to dementia with poor cognition and wander guard device to her right leg. The goal documented that the resident will not leave the facility unattended and whereabouts will be known at all times. Her interventions included to add her information to wander list books, encourage resident to participate in activities of interest, monitor location and supervision as needed, and wander guard device. The resident's Fall Risk Evaluation Tool dated 07/20/19, noted that she was at high risk for falls. The evaluation documented a score of 55. A score of 45 or higher placed the resident at high risk for falls. The Elopement Risk Evaluation dated 07/20/19, noted the resident was at high risk for elopement. The evaluation documented a score of 13.5. A score of 11 or more placed the resident at high risk for elopement. Resident #2 was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] documented he now had severe cognitive impairment, was independent with all of his activities of daily living, ambulated independently, continued on antipsychotic and antianxiety medications and had a wander/elopement device on his person which was used daily. Review of his comprehensive plan of care revealed focus for being at risk for falls dated 01/16/19 related to daily antipsychotic medication use. Risk for elopement due to his level of dementia dated 12/19/18. He was ambulatory and making comments of going to work as he said he is a police officer. The interventions included close supervision, encourage and invite to activity that meet his interest. On 03/31/19 the resident was observed on the patio after removing his wander guard device and staff also observed resident attempting to remove another resident's wanderguard. On 05/12/19 his wander guard device was found in the pocket to his jeans. The resident's Fall Risk Evaluation Tool done at admitted d 12/18/18 showed that he was at moderate risk for falls. He had a score of 30. On 03/18/19 and 06/18/19 his fall risk was noted to be 15 indicating low risk. The resident's Elopement Risk Evaluation dated 05/13/19 noted that he was at high risk for elopement with a score of 12. On 09/12/19 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON explained that an investigation was conducted and it was found that on 08/08/19 at 9 PM residents #1 and #2 had exited the facility through the kitchen side door. They were last seen on the memory unit at 8:30 PM and then observed outside of the facility at 9 PM by the Dietary Manager. On 09/13/19 at 6:19 PM, the Administrator and DON stated that care plan interventions were to be resident centered and individualized. When asked about the intervention noted on resident #1's care plan, whereabouts will be known at all times, they responded, It is not feasible, it just can't happen. They both stated that they did not have the means to monitor residents' whereabouts at all times. When asked about the intervention on resident #2's careplan for close supervision, they said that these residents constantly walked about the unit and were independently ambulatory. They could be anywhere at any time. They stated that all residents were observed at least every 2 hours whether they were at risk for elopement risk or not. The administrator stated that the facility did not have a policy for supervision of residents but it was the expectation that all residents were observed at least every 2 hours. On 9/12/19 at 10:00 AM, the surveyor retraced resident #1 and #2's elopement route of 8/8/19 from the 2nd floor with the Maintenance Director and the Administrator. The Maintenance Director entered the number code on the key pad for the second floor stairwell door which was located to the left of the elevator. He opened the stairwell door to exit. There were 8 steps going down to the landing of the 1st floor and then another 8 steps down to a landing with a door leading to the basement level. The Maintenance Director entered the number code into the key pad which disarmed the wander guard system. Through the door was the basement level rotunda. There were 5 hallways, one leading to the elevator, one leading to a door to the outside, one leading to the kitchen, one leading to the activity area and a hallway to the therapy department which also had doorways to the housekeeping, maintenance and laundry areas. The residents had entered the kitchen area, passed by the long preparation table, stoves, 2 ovens, deep fryer and a variety of small food preparation equipment. The residents had then exited through the kitchen's side door. They then walked up a paved embankment to the paved driveway. If the residents had continued walking straight, they would have been directed to the facility's exit gate leading to a busy, heavily traveled 4 lane highway. On 09/12/19 at 1:05 PM, the Administrator revealed that on 08/08/19 at 9 PM, residents #1 and #2 were observed outside in the dark, unsupervised near the kitchen side door. She stated that she did not know how the residents got out of the facility. The Administrator stated that the Corporate Nurse reviewed the facility video recording and determined that the 2 residents had followed a kitchen staff member through the doors and then exited the facility through the kitchen's side door. Although there was video recording of the elopement, the administrator stated that she had not viewed the video in its entirety. She had not seen the kitchen portion of the video which noted that Dietary Aide B may have been in the kitchen at the time and may have seen the residents. Dietary Aide B however was never interviewed about the incident. Although this was a serious event, the Administrator had not kept a copy of the video, stating the video automatically deleted after a certain time frame which she was not able to explain. Review of the Administrator/Risk Manager job description revealed the Administrator is the designated and empowered person responsible for the implementation and oversight of the facility and risk management/quality assurance program (QA). Responsibilities included ensuring that medical and nursing services are planned, implemented, and evaluated to maximize resident quality of life and quality of care. Ensure the planning, implementation and evaluation of an environmental safety program that will maintain health, welfare and safety of residents, staff and visitors. Responsible to investigate or oversee investigations for all reportable incidents. Responsible to oversee communication of all reportable incidents to resident families and responsible parties. On 09/12/19 at 1:05 PM, the Administrator stated, I am the Administrator and responsible for the facility, the residents, the staff and all of its operations. Security is important at the facility due to its location and the facility has 24 hours security staff to monitor the facility. As part of the security staff's responsibilities they monitor the gates, all facility doors and assist staff as needed. She said that residents should never be out of the facility unattended but unfortunately 2 residents, #1 and #2 did exit the facility unsupervised on 8/8/19. She stated that the 2 residents followed Dietary Aide (A) out of the memory care unit door as he exited. The Dietary Aide A had worked at the facility for less than a year. She stated that she had spoken to dietary aide A and he stated that he saw the residents following him to the basement level but he thought they were visitors. Once he was at the basement level, he did not check to see who these two individuals were or ask them where they were going. He did not report them to the evening supervisor. He continued with his job tasks and gathered the trash and proceeded outside to the dumpster located in the back of the facility. The Administrator stated that the elopement incident involving resident #1 and #2 was serious but they were returned to their unit unharmed. She stated that although she had investigated the incident, she could not find her investigation file containing staffs' statements related to the incident. It was noted that the Administrator had failed to speak to the residents, their responsible parties, the evening supervisor nor the other dietary aide, B who may have been in the kitchen at the time the two residents exited the facility. The facility's Elopement Prevention Policy (not dated) documented to view possible causes for wandering and develop individualized interdisciplinary interventions and goals to reduce wandering and to inservice and strive to assure that all staff (including temporary help) are aware of the system and what steps to take to prevent or interrupt elopement attempts. Review of the Facility assessment dated [DATE], documented the facility accepted residents who were ambulatory with [DIAGNOSES REDACTED]. The assessment showed that the facility had a memory care unit with a wander guard device system to protect the safety of the residents who may be at risk for elopement. Although the Facility Assessment noted that the facility would protect residents at risk for elopement, the Administrator, DON and Director of Risk Management were unable to explain how on 08/08/19 at 9 PM, residents #1 and #2 were able to exit the memory care unit, descend two flights of stairs, access two secure doors, enter the kitchen, and exit the facility via the kitchen's side door to the outside where it was dark and hazardous. On 09/13/19 at 6:15 PM a review of the facility's Quality Assurance (QA) process was conducted with the Administrator and DON. They explained that they had their last QA meeting on 08/27/19 and the Medical Director was not present but was contacted by phone. They identified that the root cause of the elopement was due to human error and interventions were put into place to correct further issues with elopement risk. The DON stated that they had re-evaluated all residents for wander/elopement risk and there were no new residents identified as wander/elopement risk. The Administrator stated that Dietary Aide A received 1:1 education and a simulated elopement drill. A new number code lock was placed on the main kitchen door to prevent anyone (except kitchen staff) from entering the kitchen. The following interventions had been in place since 08/21/2019. Review of the facility's corrective measures completed by 08/21/19 revealed the following: Residents #1 and #2 were observed on the memory care unit with wandergaurd elopement devices placed on their right ankles. They remained on every (Q) 15 minute observations with licensed staff documentation. Education was completed with Dietary Aide A related to the door codes, monitoring for residents before and after opening doors and elopement policy and procedure. Elopement education for 100% of facility staff was verified. This included as needed (PRN) staff being educated by phone by the DON. Computer tablets were purchased for the security staff to monitor the entrance and exit gates at all times. Elopement books on the nursing units and at the reception desk were updated to include information and pictures for all residents assessed as wandering/elopement risk. Elopement drills were conducted with Dietary Aide A to ensure his knowledge and ability to follow the facility policy and procedure for elopements. The elopement drills were on-going for all staff on all shifts including contracted staff. Letters were sent to the families and resident's responsible party regarding unattended residents and residents outside of the facility unattended. Letter verified. New number code lock was placed on the main kitchen doors to ensure the kitchen was locked at all times to prevent anyone except kitchen staff from entering the kitchen. The receptionists' hours were extended until 8 PM Monday-Sunday. Security staff were to continue checking all facility doors on each shift. Maintenance staff were to continue checking the wander guard system function weekly. All facility residents were re-assessed for wandering/elopement risk and no new residents were identified. Audits verified. The care plans for residents with wander guard elopement devices were reviewed and updated. The survey team expanded the sample to include residents #3 and #4 identified as wander/elopement risk with wander guard elopement devices. Observations and interviews were conducted with no concerns. Observations, interviews, education and audits were verified regarding wandering/elopement and door security.