Every finding on record at Gulfport Care Center

Based on record review, interviews, and facility policy review, the facility failed to ensure a resident received physician-ordered dialysis treatment by failing to arrange alternate transportation after becoming aware the scheduled transportation provider was unavailable due to a holiday, for one (1) of three (3) residents reviewed for dialysis services (Resident #1).Findings include:A review of the facility's policy titled, Non-Emergency Transportation for Residents Policy, review date 7/25, revealed, 1. Nursing facilities may ask family members, Resident Representative or friends of residents to transport residents who require non-emergency transportation. This includes transportation for medical appointments as well as transportation to and from another health facility and the nursing facility. 2. If a family member or friend is not available to transport the resident, the facility is responsible for either transporting the resident or arranging for transportation for the resident.A review of the facility's policy titled, Physician Orders, review date 5/26, revealed, It is the policy of this facility that all physician orders shall be implemented timely and carried out in a professional manner. A record review of the Face Sheet revealed the facility admitted Resident #1 on 6/11/26 with diagnoses including Dependence on Renal Dialysis.A record review of the Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, indicating her cognition was moderately impaired.A record review of Resident #1's Order Summary Report revealed an active Physician order dated 06/26/2026 for dialysis every Tuesday, Thursday, and Saturday at 11:00 AM.A record review of the View Progress Note revealed that on 07/04/2026 at 11:54 AM, the dialysis clinic contacted the facility after Resident #1 failed to arrive for the scheduled dialysis treatment. Facility staff contacted the transportation company and were informed transportation services were unavailable on 07/04/2026 due to the holiday.On 07/15/2026 at 10:30 AM, during a telephone interview, the dialysis clinic Social Worker stated Resident #1 missed the scheduled dialysis treatment on 07/04/2026 after the facility failed to provide transportation.On 07/15/2026 at 12:00 PM, during an interview, the Director of Nursing confirmed Resident #1 missed the scheduled dialysis treatment on 07/04/2026 after transportation was unavailable due to the holiday. The Director of Nursing acknowledged the facility did not arrange alternate transportation and stated staff should have arranged alternate transportation or contacted the physician or Nurse Practitioner for further direction.On 07/15/2026 at 1:00 PM, during a telephone interview, the transportation company representative stated the facility was notified on 07/02/2026 or 07/03/2026 that transportation services would not be available on 07/04/2026 because of the holiday.On 07/15/2026 at 1:15 PM, during a telephone interview, the Nurse Practitioner stated she was unaware Resident #1 missed the scheduled dialysis treatment because she was not notified by facility staff.On 07/15/2026 at 1:25 PM, during a telephone interview, Licensed Practical Nurse (LPN) #2 stated the dialysis clinic contacted the facility on 07/04/2026 after Resident #1 failed to arrive. LPN #2 contacted the transportation company's on-call representative and was informed transportation services were unavailable because of the holiday. LPN #2 stated no alternate transportation was arranged and the resident remained at the facility.On 07/15/2026 at 2:00 PM, during an interview, the Transportation Coordinator stated he received notice on 07/03/2026 at approximately 4:15 PM that transportation would not be available on 07/04/2026 and immediately notified the charge nurse before leaving for the day.On 07/15/2026 at 2:13 PM, during a telephone interview, LPN #3 stated she was not informed transportation had been cancelled for 07/04/26. She stated that if she had been notified, she would have contacted the resident's family, who could have transported the resident to dialysis.On 07/15/2026 at 2:30 PM, during a telephone interview, Resident #1's Resident Representative stated the family was not notified the resident would miss dialysis because transportation was unavailable. She stated the family would have transported the resident had they been contacted.On 07/15/2026 at 2:36 PM, during an interview, the Administrator confirmed Resident #1 missed the physician-ordered dialysis treatment because the facility did not provide transportation after learning the scheduled transportation provider was unavailable. The Administrator stated staff should have arranged alternate transportation or pursued other available options to ensure the resident received the scheduled dialysis treatment.

Based on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan that included individualized interventions to ensure physician-ordered dialysis treatments were received when routine transportation was unavailable, for one (1) of three (3) residents reviewed for care planning (Resident #1).Findings include:A review of the facility's policy titled, Care Plan Process, reviewed 3/2026, revealed, Regulations require facilities to complete.a comprehensive, standardized assessment of each resident's functional capacity and needs.Interventions are actions that should promote meeting the established goal. Each intervention shall indicate the staff responsible for intervention. A record review of the Face Sheet revealed the facility admitted Resident #1 on 6/11/26 with diagnoses including Dependence on Renal Dialysis.A record review of the Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, indicating her cognition was moderately impaired. A record review of Resident #1's Order Summary Report revealed an active Physician order dated 06/26/2026 for dialysis every Tuesday, Thursday, and Saturday at 11:00 AM.A record review of the View Progress Note revealed that on 07/04/2026 at 11:54 AM, the dialysis clinic contacted the facility after Resident #1 failed to arrive for the scheduled dialysis treatment. Facility staff contacted the transportation company and were informed transportation services were unavailable on 07/04/2026 due to the holiday.A record review of Resident #1's Care Plan Report revealed a care plan focus initiated on 06/11/2026 identifying the resident's need for dialysis. The care plan included an intervention identifying the dialysis schedule and location; however, the care plan contained no individualized interventions directing staff how to respond when routine transportation was unavailable to ensure scheduled dialysis treatments were received, such as arranging alternate transportation or notifying the physician for further direction.On 07/15/2026 at 12:00 PM, during an interview, the Director of Nursing confirmed the facility did not arrange alternate transportation after learning the scheduled transportation provider was unavailable. She acknowledged Resident #1's care plan did not include individualized interventions addressing staff actions when scheduled dialysis transportation was unavailable and stated staff should have arranged alternate transportation or contacted the physician for further direction.On 07/15/2026 at 2:00 PM, during an interview, the Transportation Coordinator stated he notified the charge nurse on 07/03/2026 at approximately 4:15 PM that transportation services would not be available on 07/04/2026 because of the holiday. He confirmed no request was made for alternate transportation.On 07/15/2026 at 2:50 PM, during an interview, the MDS Coordinator stated nursing staff were expected to follow each resident's individualized care plan and notify the interdisciplinary team when revisions were needed. She confirmed Resident #1's care plan did not include individualized interventions addressing how staff should respond if scheduled dialysis transportation became unavailable.

Based on observation, interview, record review, and facility policy review the facility failed to ensure supervision and implement adequate safety interventions to prevent accidents for two (2) of four (4) residents reviewed for accidents and hazards (Resident #55 and Resident #47) as evidenced by: 1) failing to monitor door alarms and failing to immediately investigate an active exit alarm to prevent Resident #55 exiting the facility unsupervised and 2) failing to ensure safe transfer techniques when staff manually lifted Resident #47 without the use of the required stand lift, resulting in the resident's foot becoming caught under the wheelchair and causing a right ankle injury. On 5/31/25, at approximately 4:00 AM, Resident #55 exited the facility through the 400 hall exit door, which caused the door to alarm. The alarm was ignored by staff and resulted in the resident being found outside in the parking lot at approximately 4:33 AM by a dietary staff member arriving at work. The facility's failure to immediately investigate an active alarm and provide adequate supervision for Resident #55, put this resident and all other residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Elopement/wandering-General Policy, with reviewed date of 01/23, revealed . Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so . Resident #55 A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/25 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The State Agency entered the facility on June 2, 2025, .Surveyors are aware of the incident/allegation and are currently investigating . Record review of the facility's Interviews, dated 6/3/25, revealed Resident #55's BIMS score was a 12, which indicated her cognition was moderately impaired. Record review of the local weather report from www.weatherunderground.com revealed the local weather was 70 degrees at 4:00 AM on 5/31/25. An interview with Resident #55 on 6/2/25 at 11:02 AM, she stated that on 5/31/25, she felt threatened by a nurse and decided she needed to leave the facility. The resident explained that she observed staff and checked multiple doors until she located an unlocked door in the kitchen area. She reported that she exited the facility through the unlocked kitchen door and hid behind a vehicle in the parking lot. The resident stated that shortly afterward, a woman driving a car stopped and assisted her back into the building. The resident further reported that she was tired and thirsty at the time. Observation on 6/2/25 at 11:15 AM of the area where Resident #55 was located outside of the facility revealed the resident was in the parking lot approximately 15 yards from the 400 Hall exit door. There was a wooded area across from the exit door and a highway in front of the facility. An interview on 6/2/25 at 1:00 PM, Dietary #1 explained that on 5/31/25 at approximately 4:27 AM, she was arriving for work and, upon turning into the facility parking lot, observed an individual coming from around a black jeep parked outside. She stated that as she looked closer, she realized it was a resident of the facility, who was walking down the driveway toward the main road. Dietary #1 described the resident as wearing a pink shirt, capri jeans, socks, and shoes. She reported that when she stopped her car, Resident #55 approached and stated, I'm so glad you came. I need help getting out of here. A lady threatened me in the facility. Dietary #1 stated that the resident appeared confused and reported feeling tired. She assisted the resident into her car on the passenger side and immediately called the facility to notify staff that the resident was outside requesting help. Dietary #1 stated that a nurse and three (3) Certified Nursing Assistants (CNA) came out of the building with a wheelchair to assist the resident back inside. She further noted that the resident's shirt and hair were wet from the humidity. An interview on 6/2/25 at 4:30 PM, CNA #5 stated that she was assigned to care for Resident #55 on 5/31/25. She reported that she had not observed the resident attempting to exit the facility. CNA #5 explained that while she was on break, another CNA informed her that Resident #55 had been observed outside the building. CNA #5 stated that she, along with two additional CNAs and Licensed Practical Nurse (LPN) #5, went outside to assist the resident and escorted her back into the facility. She reported that the last time she saw the resident prior to the incident was at approximately 3:00 AM, when she and the nurse provided the resident with a peanut butter sandwich because the resident had been awake and wandering in the hallway. CNA #5 stated that the resident often ambulated in the hallway at night and required redirection. She reiterated that she had not previously observed the resident attempting to exit the facility and stated that the resident was in her room when she went to lunch. An interview on 6/2/25 at 5:30 PM, LPN #4 stated that on 5/31/25, an exit door alarm sounded sometime during the morning hours, but she could not recall the exact time. She explained that staff conducted a quick scan of the area and observed that everything appeared to be in place; however, they did not check each resident's room to verify all residents were accounted for. LPN #4 stated that she believed the exit door alarm was faulty and assumed it was beeping as it frequently did. She reported that a staff member from the dietary department later called the facility to inform them that Resident #55 was outside in the parking lot. LPN #4 stated that she exited the 300-hall door while one of the CNAs exited from another door with a wheelchair to assist in bringing the resident back into the building. She reported that she did not know how long the resident had been outside and was unsure who initially received the call from the dietary staff. LPN #4 stated that she believed LPN #5 notified the Administrator of the incident. She also reported that she typically worked only on Friday and Saturday nights and was not familiar with facility policies regarding alarms and elopements. LPN #4 stated that the last time she had seen the resident prior to the incident was when she arrived for her shift at 11:00 PM. An interview on 6/2/25 at 6:00 PM, LPN #5 stated that between 4:00 AM and 5:00 AM on 5/31/25, the alarm on the 400 hall exit door sounded. She reported that staff looked outside the door and scanned the immediate area but did not observe any residents out of place at that time. LPN #5 confirmed that room-to-room checks were not conducted to verify that all residents were present. She also stated that staff did not know the code required to silence the exit door alarm. LPN #5 reported that she later received a phone call from Dietary #1, who informed her that Resident #55 was outside in the facility parking lot. LPN #5 stated that she, along with three CNAs, exited the building through the front door with a wheelchair to assist the resident back into the building. She recalled that Resident #55 had been up and walking around near the nurse's station earlier that morning. LPN #5 explained that the only possible exits the resident could have used were the doors on either the 300 or 400 hall. She confirmed that staff was unaware the resident had exited the building until notified by Dietary #1. LPN #5 stated that once the resident was returned to the building, she was assessed, and a head count of all residents was conducted. She reported that Resident #55 was found sitting in the passenger seat of the kitchen staff member's car when staff arrived to assist. LPN #5 further stated that she contacted the Administrator to report that the door alarm would not stop sounding, and the Administrator provided her with the code to disable the alarm. She also informed the Administrator that the resident had been located and that all residents were accounted for. LPN #5 stated that Resident #55 did not sustain any injuries during the incident. An interview on 6/3/25 at 12:30 PM, CNA #6 stated that she was working on the 100 hall on 5/31/25. She reported that the CNA assigned to the 400 hall was on break at the time. CNA #6 stated that when the alarm sounded, staff initially believed it was the fire alarm in the nutrition room, which had been intermittently sounding for the past two days. She explained that after realizing it was not the fire alarm, staff checked the 400 hall and discovered that the exit door was open following notification from kitchen staff that a resident was outside. CNA #6 reported that she retrieved Resident #55's wheelchair and brought it outside to assist the resident. She further stated that the door was unlocked, and she was able to push it open and exit the building. An interview on 6/3/25 at 9:00 AM, Resident #55's significant other stated that the resident reported to him that she had been threatened by facility staff and feared that they were going to harm her. He stated that the resident told him she exited the facility through the kitchen door and ran down the street. The resident also reported that it was raining and cold at the time. According to the significant other, the resident stated that a woman stopped her vehicle, assisted her into the car, and brought her back to the facility. The significant other reported that the resident had not previously been this confused and expressed concern that her condition may be declining due to her Parkinson's disease. He further stated that the resident's hallucinations had increased lately. On 6/4/25, during interviews with multiple residents on the 400 hall, several reported hearing alarms sounding over the weekend. At 8:30 AM, Unsampled Resident A in room [ROOM NUMBER] stated he remembered the alarm going off during the night for approximately 20 minutes or longer, though he was unsure if it was a door or fire alarm. At 8:40 AM, Resident #26 in room [ROOM NUMBER]-A reported hearing the alarm late over the weekend, stating it sounded longer than usual, but she was unsure if something was wrong. At 9:00 AM, Resident #163 in room [ROOM NUMBER] stated he heard alarms during the night over the weekend, estimating the alarm sounded for approximately 30 to 45 minutes. He was unsure if someone was trying to exit the facility. At 9:10 AM, Resident #33 in room [ROOM NUMBER] stated that alarms had gone off approximately five or more times since his admission and recalled being awakened by the alarm on at least one occasion, though he could not recall the exact time. At 9:30 AM, Unsampled Resident B in room [ROOM NUMBER] stated that the alarm sounded for a long time over the weekend, and due to the length of time it sounded, she thought something might be wrong with the alarm system. An interview on 6/4/25 at 9:00 AM, the Maintenance Director explained that the door alarm on the 400 hall is the only door that will release and open if the push bar is held down for 10 seconds. He stated that the alarm will sound immediately upon the door being pushed. The Maintenance Director reported that he has provided education to staff on multiple occasions regarding the difference between fire alarms and door alarms. He stated that staff have also received inservice training from the Administrator on how to respond when alarms sound and the appropriate actions to take. The Maintenance Director reported that on several occasions he has arrived at the facility to find alarms sounding without staff responding to them. He further stated that he has conducted one-on-one training with various staff members but does not have any signed documentation verifying completion of those individual trainings. An interview on 6/4/25 at 10:00 AM, the Administrator stated that she was contacted by staff around 5:00 AM on Saturday morning, 5/31/25, and informed that Resident #55 had exited the building through the 400-hall door but was returned to the facility immediately. She reported that the resident was brought back into the building and that a body audit and head count were completed to ensure all other residents were accounted for. The Administrator further stated that when she arrived at work on Monday morning, a therapy staff member informed her that Resident #55 stated she did not understand why the facility had placed a WanderGuard (a type of monitoring device) bracelet on her leg. The Administrator reported that she spoke with both the resident and her significant other to explain that the WanderGuard device was being used to help staff monitor her location and ensure her safety. During this conversation, the resident reported feeling unsafe, stating that a staff member with orange fingernail polish had threatened and physically abused her. The Administrator stated that after hearing this, she contacted facility staff for clarification and was provided with additional details. She reported that LPN #5 informed her that Dietary #1 had called the facility to notify staff that Resident #55 was outside. LPN #5 also reported that she and three CNAs brought the resident back into the building. The Administrator confirmed that a body audit and head count were completed following the incident. She further stated that she reviewed the facility's surveillance footage from 5/31/25 but was unable to determine the exact time the resident exited the building. The Administrator explained that the surveillance cameras do not capture the 400 hall exit door; however, based on the resident's location and the facility layout, she determined that the 400 hall door was the only exit the resident could have used, as access through the kitchen was not possible. The footage showed the resident was last observed inside the facility at 4:06 AM and was next observed returning to the building at 4:34 AM. An interview on 6/4/25 at 1:00 PM, the Director of Nursing (DON) stated that Resident #55 is delusional, confused, and experiences hallucinations. The DON reported that she was not aware the resident had exited the building until Monday (6/2/25), after the State Agency (SA) arrived onsite. She confirmed that both she and the Administrator began investigating the incident after learning that a dietary staff member had notified nursing staff that the resident was outside the building. Resident #47 A record review of the facility's Lifting Policy, revised 10/23, revealed, .This facility will strive to provide a safe work environment by providing and requiring the use of safety materials, equipment and training designed to help prevent personnel and resident injury .Failure to utilize a mechanical lift when the use of this equipment is indicted in resident's plan of care, unless exception is met, could result in disciplinary action up to and including termination of employment .*Exception: Although the mechanical lift, if indicated by screening, is the preferred method of transfer it is recognized it may not always be possible due to certain circumstances. Circumstances to include emergencies, residents care needs, mechanical failure, and some areas in which mechanical lifts do not fit. In these circumstances it would be acceptable to transfer a resident manually with the assistance of one (1) or more staff as indicated . A record review of the admission Record revealed the facility admitted Resident #47 on 12/20/24 with diagnoses including Right Femur Fracture. A record review of the Quarterly MDS with an ARD of 3/20/25 revealed Resident #47 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the facility's incident report, dated 2/17/25, revealed Resident #47 informed therapy that she had pain in her right ankle following a transfer and the resident stated that two aides transferred her to the wheelchair and her foot got caught under the chair. The report indicated that the CNAs were educated on transfer/lift status. A record review of a consultation for Resident #47, dated 2/20/25, revealed Findings of a right ankle sprain. Recommendations including non-steroidal anti-inflammatory drugs (NSAIDs) as needed for ankle pain and ice as needed to the right ankle. New Orders included an air cast to the right ankle and elevate the right ankle. On 6/2/25 at 12:04 PM, during an interview, Resident #47 reported that in February 2025, a male CNA picked her up and transferred her into a chair without using a mechanical lift. She stated that during the transfer, her foot became caught under the wheelchair, resulting in a sprained ankle. Resident #47 confirmed that a lift was not used during the transfer. On 6/4/25 at 9:14 AM, during an interview, the Rehabilitation Director/Speech Therapist stated that the Physical Therapist Assistant (PTA) had worked with Resident #47 during a therapy session on 2/17/25. She reported that during the session, the PTA observed that the resident's right ankle was swollen. When asked about the swelling, the resident informed the PTA that a CNA had lifted her by the arms during a transfer instead of using the designated mechanical lift. The resident stated that during the transfer, her foot became caught under the wheelchair. On 6/4/25 at 12:32 PM, during an interview, the Director of Nursing (DON) stated that she was informed by the Physical Therapist Assistant that Resident #47 had sustained a sprained ankle. She reported that the resident was subsequently examined and underwent an X-ray, which revealed no evidence of a fracture. The DON stated that the CNAs involved in the improper transfer were agency staff who are no longer employed at the facility. She further explained that CNAs have since been re-educated on proper lift procedures and the importance of following each resident's assigned lift status. The DON confirmed that an incident report documenting the event was completed on 2/17/25. On 6/5/25 at 11:40 AM, during a follow-up interview, the Director of Nursing (DON) stated that agency CNAs receive an orientation similar to facility staff, although it is typically an abbreviated version, which includes a review of client charts and care plans. The DON reported that Resident #47 had requested to get up in order to attend therapy, and the CNAs informed her that no mechanical lift was available at that time. She stated that the CNAs appeared to assume the resident could assist during the transfer. The DON further stated that she believed the footrest on the wheelchair had been removed prior to placing the resident into the chair but was unable to determine to how the resident's foot became caught under the wheelchair. The DON stated that according to the facility's policy, CNAs are allowed to determine whether a manual transfer may be used in certain situations, including for resident care needs. She also stated she understood that the resident was reportedly in a hurry to get to therapy that day. The DON further explained that the facility did not consider the transfer to be neglectful because, under the facility's policy, the transfer was permissible and no significant injury, such as a fracture, occurred. The DON agreed that the incident report regarding the injury did not include an Exception reason as to why the CNAs chose to manually lift her instead of using the mechanical lift. On 6/5/25 at 12:03 PM, during an interview, the Physical Therapy Assistant (PTA) stated that Resident #47 was unable to fully participate in physical therapy for several weeks after the reported incident on 2/17/25 due to swelling in the right ankle. She reported that while the resident was restricted from performing weight-bearing exercises involving the affected ankle, she was able to continue participating in therapy. On 6/5/25 at 12:13 PM, in an interview with LPN #6 (Care Plan Nurse), she explained that a yellow sticker on Resident #47's bulletin board and the care plan both indicated the resident required a stand-assist mechanical lift. She emphasized CNAs are not permitted to determine lift methods. On 6/5/25 at 12:50 PM, during an interview with Charge Nurse/LPN #7, she stated the facility is a no-manual-lift environment and confirmed Resident #47 had required a stand-assist lift for several months. She confirmed that the CNAs involved in the incident on 2/17/25 admitted not using a lift and did not provide justification for their actions. On 6/5/25 at 12:17 PM, during an observation and follow-up interview, Resident #47 provided additional details regarding the incident that occurred on 2/17/25. She stated that there was no footrest on the wheelchair during the transfer and noted that her knee was not functioning well at the time. The resident reported that she was wearing slippers and was unsure how her foot became positioned underneath the wheelchair. She explained that she did not refuse the lift and was not rushing the staff. She said she knew the lift was available for use because the CNAs brought the lift to the door of her room when they came in for the transfer. She stated that there were two or three CNAs present in the room at the time of the transfer, and they did not explain to her why they were not using the mechanical lift. There was a yellow circle observed on the bulletin board in her room above the headboard. On 6/5/25 at 2:48 PM, during an interview, the Administrator acknowledged Resident #47 was transferred without a lift on 2/17/25 that resulted in the resident having a sprained ankle. On 6/5/25 at 3:20 PM, during an interview with Agency CNA #1, he stated he and another CNA manually transferred Resident #47 from the bed to the wheelchair. He believed a two-person assist was appropriate for Resident #47 and was unable to provide a reason or exception as to why they did not use the mechanical lift. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.

Based on interview, facility policy review, and record review, the facility failed to initiate an investigation timely when Resident #55, who had a history of hallucinations, exited the facility for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not investigated by the facility until 6/2/25 in which the Administrator stated she was unaware of the elopement and believed the resident had been returned by staff immediately, indicating that no internal investigation was initiated as required. The facility's delayed investigation prevented timely identification of root causes, such as the failure to respond to the alarm, the door's egress function, and the lack of staff awareness, which placed Resident #55 and other residents in a situation to elope and experience serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for 42 CFR 483.12(c)(2) Investigation/Prevent/Correct Alleged Violation (F610) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F609, F689 Findings include: A review of the facility's policy, Incident Investigation & Reporting reviewed 05/24 revealed, Purpose: To provide guidance to the facility for investigation .incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents .5. Additional incidents that must have a thorough investigation .G. Elopement .6. The facility will investigate all alleged violations under the direct supervision of the Administrator . A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/23 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The (State Agency) entered the facility on June 2, 2025 .Surveyors are aware of the incident/allegation and are currently investigating . On 6/2/25 at 11:02 AM, during an interview, Resident #55 reported that on 5/31/25, she became fearful after feeling threatened by a nurse and made the decision to leave the facility. She stated that she watched staff and checked several doors before finding one in the kitchen area that was unlocked. The resident stated that she went through the kitchen door and hid behind a vehicle in the facility's parking lot. On 6/2/25 at 1:00 PM, during an interview, Dietary #1 stated that at approximately 4:27 AM on 5/31/25, she was arriving for work when she saw someone walking from behind a black jeep parked outside the building. As she got closer, she recognized the individual as Resident #55, who was walking down the driveway toward the main road. She stated that when she stopped her car, the resident approached her and expressed relief that she had arrived, stating that she needed help getting out because she had been threatened by a staff member in the facility. Dietary #1 stated that the resident appeared confused, tired, and her clothing and hair were damp from the humidity. She helped the resident into her car and immediately contacted facility staff to report that the resident was outside and requested assistance. Dietary #1 stated that a nurse and three Certified Nursing Assistants (CNA) came outside with a wheelchair to assist the resident back into the building. She further stated that when the staff arrived at her vehicle, she informed them that Resident #55 had reported leaving the facility due to feeling threatened by staff. On 6/2/25 at 6:00 PM, during an interview, LPN #5 explained that on 5/31/25, between 4:00 AM and 5:00 AM, the alarms on both the 300 and 400 hall exit doors activated. She stated that she did not know the code needed to silence the alarm. While the alarm continued to sound, she received a call from a kitchen employee notifying her that Resident #55 was outside in the parking lot. Licensed Practical Nurse (LPN) #5 reported that she and three CNAs went outside through the front entrance with a wheelchair to bring the resident back into the facility. She stated that she then contacted the Administrator to report that the alarm was sounding, at which time the Administrator provided her with the code to turn off the alarm. LPN #5 recalled informing the Administrator that all residents were accounted for but was unsure if she specifically mentioned that the resident had been located outside by dietary staff, as she had been focused on silencing the alarm. The nurse stated she could not recall receiving any information regarding the reason the resident exited the building. LPN #5 also acknowledged that she did not conduct an investigation or interview the dietary staff member who observed the resident in the parking lot. On 6/4/25 at 10:00 AM, during an interview, the Administrator stated that she was contacted by LPN #5 at approximately 5:00 AM on 5/31/25. She reported that during the call, LPN #5 informed her that Resident #55 had exited through the 400 hall door and was seen by staff before being brought back into the building. The Administrator stated that at the time of the initial call, she was not told that dietary staff had located the resident outside. She explained that she first became aware of those details on 6/2/25, after returning to work and speaking with Resident #55, who reported leaving the facility due to feeling threatened and physically abused by a staff member. The Administrator stated that after learning this information, she began contacting the weekend staff involved for clarification and was informed that dietary staff had notified the nurses when the resident was found outside. She confirmed that during the initial call on 5/31/25, she had believed staff observed the resident as she pushed open the door and immediately escorted her back inside, and was not aware that staff were initially unaware of the resident's whereabouts until notified by Dietary #1. The Administrator acknowledged that she and facility staff did not initiate an investigation into the elopement until 6/2/25, after the State Agency arrived. She reported that at that point, she began reaching out to the weekend staff who had worked the night of the incident and reviewed surveillance footage to determine when Resident #55 was last seen inside the hallway. On 6/4/25 at 1:00 PM, during an interview, the Director of Nursing (DON) stated that Resident #55 is confused, delusional, and experiences hallucinations. She explained that she was not made aware that the resident had eloped from the facility until 6/2/25, when the State Agency (SA) arrived. She stated that once she and the Administrator learned that dietary staff had contacted nursing to report the resident was found outside wandering in the parking lot, they initiated an investigation into the incident. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.

Based on interview, facility policy review, and record review, the facility failed to timely report an instance of elopement involving a resident with a history of hallucinations for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not reported to the State Agency until 6/2/25. The delay in reporting placed this resident and other residents at continued risk for exiting the facility unsupervised which increased the likelihood of serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR 483.12 (c)(1) Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Incident Investigation & Reporting reviewed 05/24 revealed, Purpose: To provide guidance to the Facility for .reporting incidents of abuse, neglect, exploitation, misappropriation of property and or other reportable incidents .When must it be reported All alleged violations .2) Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury .5. Additional items that .may require reporting .G. Elopement . A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/25 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The (State Agency) entered the facility on June 2, 2025 .Surveyors are aware of the incident/allegation and are currently investigating . During an interview on 6/2/25 at 11:02 AM, during an interview, Resident #55 stated that on 5/31/25, she felt threatened by a nurse and decided she needed to leave the facility. The resident explained that she observed staff and checked multiple doors until she located an unlocked door in the kitchen area. She reported that she exited the facility through the unlocked kitchen door and hid behind a vehicle in the parking lot. During an interview on 6/2/25 at 1:00 PM, Dietary #1 explained that on 5/31/25 at approximately 4:27 AM, she was arriving for work and, upon turning into the facility parking lot, observed an individual coming from around a black jeep parked outside. She stated that as she looked closer, she realized it was a resident of the facility, who was walking down the driveway toward the main road. She reported that when she stopped her car, Resident #55 approached and stated, I'm so glad you came. I need help getting out of here. A lady threatened me in the facility. Dietary #1 stated that the resident appeared confused and reported feeling tired. She assisted the resident into her car on the passenger side and immediately called the facility to notify staff that the resident was outside requesting help. Dietary #1 stated that a nurse and three (3) Certified Nursing Assistants (CNAs) came out of the building with a wheelchair to assist the resident back inside. She further noted that the resident's shirt and hair were wet from the humidity. Dietary #1 stated that she told the facility staff that came to get the resident from her car that Resident #55 had told her that she left the facility because she was threatened by staff. During an interview on 6/2/25 at 6:00 PM, Licensed Practical Nurse (LPN) #5 stated that on 5/31/25, between 4:00 AM and 5:00 AM, the alarm sounded on both the 300 and 400 hall exit doors. She explained that she was not familiar with the code required to stop the alarm from sounding. While the door was alarming, she received a phone call from a kitchen staff member who reported that Resident #55 was outside in the facility parking lot. LPN #5 stated that she and three CNAs exited the front door with a wheelchair and assisted the resident back into the building. She reported that she contacted the Administrator to inform her that the door alarm was sounding, and the Administrator provided her with the code to silence the alarm. LPN #5 stated that she informed the Administrator that all residents were accounted for at that time but could not recall if she had specifically told the Administrator that the resident had been found outside by dietary staff, as she was focused on addressing the alarm. The nurse was unable to recall if she received any information regarding why the resident left the facility. During an interview on 6/4/25 at 10:00 AM, the Administrator stated that she received a call around 5:00 AM on 5/31/25 from LPN #5. She reported that LPN #5 informed her that Resident #55 had exited through the 400 hall door and was seen by staff, but had been brought back into the facility. The Administrator stated that she was not made aware at that time that the resident had exited the facility and had been found by dietary staff. She reported that she did not learn those details until she returned to work on 6/2/25, when Resident #55 reported that she had left the building because she felt threatened and physically abused by a staff member. The Administrator stated that she subsequently contacted the weekend nursing staff for clarification and was informed that dietary staff had called the facility to report that Resident #55 was outside. The Administrator stated that she had not been provided that information during the initial call on 5/31/25 and was under the impression that staff had observed the resident as she pushed the door open and immediately escorted her back inside. She further stated that she was not aware the resident had exited the building and that staff were initially unaware of the resident's whereabouts until notified by Dietary #1. During an interview on 6/4/25 at 1:00 PM, the Director of Nursing (DON) stated that Resident #55 is delusional, confused, and experiences hallucinations. She reported that she was not aware the resident had eloped from the building until Monday, 6/2/25, after the State Agency (SA) entered the facility. The DON confirmed that she did not report the alleged abuse or elopement at the time of the incident because she was unaware of the situation until 6/2/25, more than two (2) days after the event occurred. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.

Based on observation, interview, and record review, the facility failed to ensure staff followed the comprehensive care plan for three (3) of twenty (20) sampled residents reviewed for care plan implementation, Resident #164, Resident #47, and Resident #7. Specifically, the facility failed to: 1) provide Percutaneous Endoscopic Gastrostomy (PEG) tube site care for Resident #164, resulting in a purulent wound, 2) failed to ensure a call light was within reach for Resident #7, and 3) failed to use a mechanical lift as directed in the care plan for Resident #47, resulting in a right ankle sprain. Findings include: A review of the facility's policy titled Care Plan Process, with the latest review date of 12/24, revealed, . The comprehensive care plan is an interdisciplinary communication tool . The facility staff shall follow the care plan . A well developed and executed assessment and care plan .implements an interdisciplinary care plan based on the assessment information gathered . with necessary monitoring and follow-up . The Physician Orders, Medication Administration Record, and Treatment Administration Record are part of the Comprehensive Care Plan . Interventions are actions that promote meeting the established goal . Resident #164 A record review of the Care Plan Report revealed Resident #164 had a Focus, initiated on 5/14/25 of The resident requires tube feeding and Interventions/Tasks initiated on 5/14/25 to Provide care to G-Tube (Gastrostomy Tube) site as ordered and observe for s/sx (signs and symptoms) of infection . A record review of Resident #164's admission Record revealed the facility admitted the resident on 5/13/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System and Gastrostomy Status. A record review of the Order Listing Report revealed there was no PEG site care orders until 6/3/25 for Resident #164. On 6/3/25 at 8:54 AM, during an observation and interview Resident #164 reported she received a PEG tube while in the hospital. She stated no one had performed PEG site care and described the site as nasty and draining. The PEG site was observed with an old dressing that was discolored with green and black drainage and had an odor. The dressing was dated 5/30/25. On 6/3/25 at 9:45 AM, during an observation and interview Licensed Practical Nurse (LPN) #1 confirmed the PEG site dressing was dated 5/30/25 and had green and black purulent, foul-smelling drainage. Resident #164 stated the PEG site had not been assessed in several days. The site and surrounding tissue were moderately red and macerated, with a small protrusion of red tissue. Resident #47 A record review of the Care Plan Report revealed Resident #47 had a Focus, initiated 2/10/25, of Resident needs staff assistance with transfers with an Interventions/Tasks for Follow resident lift plan. Further review revealed a Focus, dated 2/4/25, of Resident Lifting Plan, with an Interventions/Tasks of Yellow - Caution - Stand Lift and Yellow; Medium. A record review of the admission Record revealed the facility admitted Resident #47 on 12/20/24 with diagnoses including Right Femur Fracture. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/25 revealed Resident #47 had a BIMS score of 15, which indicated she was cognitively intact. A record review of a consultation for Resident #47, dated 2/20/25, revealed Findings of a right ankle sprain. Recommendations including non-steroidal anti-inflammatory drugs (NSAIDs) as needed for ankle pain and ice as needed to the right ankle. New Orders included an air cast to the right ankle and elevate the right ankle. A record review of the facility's incident report, dated 2/17/25, revealed Resident #47 informed therapy that she had pain to her right ankle following transfer and the resident stated that two aides transferred her to the wheelchair and her foot got caught under the chair. The report indicated that the CNAs were educated on transfer/lift status. During an interview on 6/2/25 at 12:04 PM, Resident #47 confirmed a transfer from the bed to the wheelchair was performed manually without the mechanical lift and that the incident caused injury to her ankle. She reported the injury affected her ability to stand and participate in therapy sessions. She stated it occurred back in February. During an interview with the Director of Nursing (DON) on 6/4/25 at 12:32 PM, she stated the incident was reported to her by the Physical Therapist Assistant, and an X-ray was performed which ruled out fracture. The CNAs involved were agency staff who were no longer employed, and staff were re-educated on the proper lift procedures. On 6/5/25 at 12:13 PM, in an interview with LPN #6 (Care Plan Nurse), she explained that a yellow sticker on Resident #47's bulletin board and the care plan both indicated the resident required a stand-assist mechanical lift. She emphasized CNAs are not permitted to determine lift methods and must follow the care plan. During an interview with Agency CNA #1 on 6/5/25 at 3:20 PM, he stated he and another CNA manually transferred the resident. He believed a two-person assist was appropriate for Resident #47 and acknowledged he had not used the a mechanical lift. On 6/5/25 at 1:15 PM, during an interview with the DON regarding Resident #47, she stated her expectation was that all staff follow the resident's care plan and seek guidance if uncertain. Resident #7 A record review of Resident #7's Care Plan Report with an initiation date of 4/21/25 revealed a care plan for risk of falls with an intervention indicating, . call light is within reach . A record review of Resident #7's admission Record revealed the facility initially admitted the resident on 1/20/22 and readmitted her on 1/10/24 with diagnoses including Cerebral Infarction. During an observation and interview on 6/2/25 at 10:30 AM, Resident #7 was lying in bed and stated she needed help but could not get anyone. There was a round palm pad call light and another call light wrapped around the light fixture, not over the resident's bed and not within reach. During an observation and interview with CNA #4 on 6/2/25 at 10:50 AM, she confirmed that Resident #7's call light was wrapped around the light fixture and not within reach. She acknowledged that it was her responsibility to ensure call lights were accessible. During an interview with LPN #2 on 6/5/25 at 1:00 PM, she explained there were three (3) nurses completing care plans in the facility. She stated nurses used data from the Nurse Data Collection Assessment form, Physician Orders, medications, and other parts of the medical record to create individualized care plans. She explained the purpose of the care plan was to assist staff in providing the highest quality of care and that staff were expected to follow the care plan at all times. On 6/5/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she stated she had been notified regarding the PEG site care and call light not being in reach. She explained she expected all staff to follow each resident's plan of care at all times. On 6/5/25 at 2:48 PM, in an interview with the Administrator, she confirmed staff are expected to follow the care plan.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper care and monitoring of enteral feeding and gastrostomy sites as evidenced by not providing timely physician orders, monitoring, and dressing changes for a Percutaneous Endoscopic Gastrostomy (PEG) site which resulted in an infected site with foul-smelling, purulent drainage (Resident #164) and enteral feeding equipment not labeled (Resident #6) for two (2) of two (2) residents reviewed for tube feeding and site care. Findings included: A review of the facility's policy titled Tube Feedings with the latest revision date of 12/15 revealed, . 1. All tube feedings will be administered in accordance with . physician's orders .Procedures for administering tube feedings are in place and address . d. Care of insertion site e. Labeling of container . Resident #164 On 6/3/25 at 8:54 AM, during an observation and interview, Resident #164 reported she received a PEG tube in the hospital, had just resumed eating, and still received bolus feedings and flushes. She stated no one had performed PEG site care and described the site as nasty and draining. The PEG site was observed with an old dressing that was discolored with green and black drainage and had an odor. The dressing was dated 5/30/25. On 6/3/25 at 9:15 AM, during an interview and record review with Licensed Practical Nurse (LPN) #7, she reviewed Resident #164's physician orders and confirmed there were no orders for PEG site care or monitoring since the resident's admission on [DATE], which was approximately 21 days ago. She stated the resident was placed on antibiotics on 5/27/25 and said she would notify the wound care nurse and nurse practitioner for orders and follow-up. On 6/3/25 at 9:45 AM, during an observation and interview, LPN #1 confirmed the PEG site dressing was dated 5/30/25 and had green and black purulent, foul-smelling drainage. Resident #164 stated the PEG site had not been assessed in several days and that she continued to receive bolus feeding four (4) times a day. The site and surrounding tissue were moderately red and macerated, with a small protrusion of red tissue. On 6/4/25 at 10:40 AM, during an interview with LPN #8, she stated the last time she saw Resident #164 was on 5/27/25. She noticed bloody drainage at that time and notified the physician, who gave an order for antibiotics. She stated that she also notified the wound care nurse. On 6/5/25 at 11:45 AM, during a phone interview with the Nurse Practitioner, she stated she and the attending physician alternate visits. She recalled the attending physician had seen Resident #164 and initiated antibiotic therapy due to nurse concerns. She stated she expected staff to monitor the site daily and change dressings per orders and as needed. She confirmed improper or irregular care could result in worsening infection. On 6/5/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she confirmed the resident had recently received a PEG tube prior to admission to the facility. She was unaware that Resident #164 did not have PEG site care orders or monitoring for complications. She stated she expected staff to notify the physician of any changes and follow through with all orders. A record review of the admission Record revealed the facility admitted Resident #164 on 5/13/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System and Gastrostomy Status. A record review of the Order Listing Report revealed there was no PEG site care orders until 6/3/25 for Resident #164. An order was also noted for Clindamycin HCl 300 milligrams via PEG tube three (3) times a day for wound healing related to Encounter for Surgical Aftercare following surgery on the digestive system for seven (7) days, dated 5/27/25. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/25 revealed Resident #164 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #6 On 6/2/25 at 10:54 AM, during an observation and interview, Resident #6 was sitting upright in a Geri-chair with tube feeding infusing at 60 ml/hr (milliliters per hour) via a feeding pump. There was a feeding bag labeled with the resident's name and date, but it did not indicate the time it was hung or the type of enteral feeding being administered. A syringe labeled with the date 6/1/25 was present. During an interview, a family member, who was at the bedside, stated Resident #6 has had the feeding tube since admission but was unaware of the type of enteral feeding being administered. On 6/2/25 at 11:30 AM, during an interview and observation with LPN #1, she confirmed the resident had a Physician's Order for Diabetasource at 60 ml/hr. On 6/2/25 at 11:50 AM, during an observation and interview with LPN #1, she confirmed the feeding bag was labeled only with the resident's last name and date (6/1/25), and did not include the time, type of formula, or rate. She stated the label should include the full name, rate, time and date hung, and type of feeding. On 6/5/25 at 12:35 PM, during an interview with the Director of Nursing (DON), she stated she was aware of the issue of the unlabeled enteral feeding bag for Resident #6 and stated she expected all enteral feedings to be labeled properly at all times. A record review of the admission Record revealed the facility admitted Resident #6 on 4/24/25 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Gastrostomy Status, and Dysphagia, Oropharyngeal Phase. A record review of the Order Listing Report revealed Resident #6 had a Physician's Order, dated 5/8/25, for an enteral feeding of Diabetasource at 60 ml/hr for 20 hours. A record review of the admission MDS with an ARD of 5/1/25 revealed Resident #6 had a feeding tube and received more than 51% of total calories through tube feedings.

Based on interview, facility policy review, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (2) of 20 sampled residents reviewed for assessment accuracy (Resident #7 and Resident #5). Findings included: A review of the facility's policy titled Minimum Data Set (MDS) Process with a latest revision date of 12/20 revealed, . The RAI (Resident Assessment Instrument) manual is the source document to be used for . MDS coding guidelines, time schedules and requirements . A review of the facility's policy titled Resident Assessment with the latest revision date of 9/19 revealed, . An assessment will be completed on each resident utilizing the MDS. The reason for assessment, scheduled and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment . Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed . Resident #7 A record review of the admission Record revealed the facility initially admitted Resident #7 on 1/10/20 and readmitted her on 1/10/24 with diagnoses including Cerebral Infarction. A record review of the Order Listing Report revealed Resident #7 had a Physician's Order, dated 8/29/24 to admit the resident to hospice services. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/24 revealed in Section O Resident #7 was not marked as receiving hospice care or services while a resident during the lookback period. On 6/3/25 at 2:05 PM, during an interview with Registered Nurse (RN) #3, she explained that Resident #7 had been on hospice services since 2024. On 6/5/25 at 1:00 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained that there were three (3) nurses completing MDS assessments and care plans. She stated that nurses used data from the Nurse Data Collection assessments, Physician Orders, medications, and other medical record information to complete MDS assessments. Different MDS sections were completed by different departments-Sections B, C, D, and E by Social Services; Section K by Dietary; and the remaining sections by MDS nurses. Each staff member was responsible for the accuracy of the sections they completed. She stated the verification button in the system allowed staff to review sections but did not prompt for specific verification. She added that the RN signature indicated completion, not accuracy, and there was no other system in place to ensure MDS accuracy. LPN #2 confirmed Resident #7 had been admitted to hospice on 8/29/24, and the 4/14/24 Quarterly MDS did not reflect hospice care in Section O. Resident #5 A record review of the Quarterly MDS with an ARD of 2/25/25, under Section P Restraints and Alarms revealed Resident #5 had bed rails that were used daily as a physical restraint. On 06/04/25 at 9:09 AM, an interview was conducted with LPN #2, she stated that bed rails are not considered restraints within the facility. She expressed uncertainty as to why restraints were coded on the resident's Quarterly MDS assessment and confirmed that bed rails are used to assist with resident mobility in bed, and that any designation of restraints on the MDS was an error. A record review of the admission Record revealed the facility admitted Resident #5 on 7/21/2016 with the diagnoses including Atherosclerotic Heart Disease. On 6/5/25, at 2:48 PM, an interview with the Administrator revealed she expected MDS assessments to accurately reflect the residents' status.

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS) significant change in status assessment for a resident admitted to hospice services (Resident #7) for one (1) of 20 sampled residents' MDS assessments reviewed. Findings included: A review of the facility's policy titled MDS Process with a latest revision date of 12/20 revealed, .The RAI (Resident Assessment Instrument) manual is the source document to be used for . MDS coding guidelines, time schedules and requirements . A review of the facility's policy titled Resident Assessment with the latest revision date of 9/19 revealed, .An assessment will be completed on each resident utilizing the MDS. The reason for assessment, scheduled and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment . A review of the Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2024, revealed, .Significant Change in Status Assessment (SCSA) . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than) . On 6/3/25 at 2:05 PM, during an interview with Registered Nurse (RN) #3, she explained Resident #7 had been on hospice services since 2024, as indicated on the facility's Roster Matrix report. On 6/3/25 at 3:10 PM, during an interview with the Director of Nursing (DON), she explained Resident #7 had been on hospice since 2024 and confirmed the hospice admission date was 8/29/24. On 6/5/25 at 1:00 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated when a resident experiences a significant change in condition, a Significant Change MDS must be completed within fourteen (14) days. She confirmed hospice admission is considered a reason for a significant change. LPN #2 reviewed the MDS history for Resident #7 and confirmed she was admitted to hospice services on 8/29/24 and a Significant Change in Status Assessment (SCSA) was not completed within fourteen (14) days. On 6/5/25 at 3:05 PM, during an interview with the DON and Administrator, they both stated they expected staff to complete accurate assessments and ensure submission within required timeframes to reflect the resident's current condition. A record review of the admission Record revealed the facility initially admitted Resident #7 on 1/10/20 and readmitted her on 1/10/24 with diagnoses including Cerebral Infarction. A record review of the MDS assessments report for Resident #7 from 7/29/24 through 4/14/25 revealed there was no Significant Change MDS completed or submitted within fourteen (14) days of the hospice admission date of 8/29/24. A record review of the Order Listing Report revealed Resident #7 had a Physician's Order, dated 8/29/24 to admit the resident to hospice services.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure residents' rights to privacy and confidentiality were maintained, when personal care signage was posted on the resident's door for one (1) of 20 sampled residents, Resident #14. Findings included: A review of the facility's Resident's Rights Policy, with the latest review date of 3/24, revealed, Every resident in this facility has the right to: . 12. Be treated courteously, fairly, and with the fullest measure of dignity . 16. Have their personal and medical records treated as confidential . A review of the facility's policy titled Dignity and Respect, with the latest review date of 7/22, revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility shall protect and promote the rights of the resident . On 6/2/25 at 11:28 AM, during an observation and interview, Resident #14 was not present in her room. Licensed Practical Nurse (LPN) #1 explained the resident was currently at dialysis and usually returned around 2:00 PM. Signage was observed on Resident #14's door that indicated, . Resident to have a pad underneath her on MWF (Monday, Wednesday, and Friday) before she goes to dialysis. LPN #1 confirmed the signage and reported that staff already knew this information. On 6/2/25 at 11:45 AM, during an interview with Certified Nurse Aide (CNA) #2, she reported Resident #14 went to dialysis three (3) times per week and confirmed she needed a lift pad when going. CNA #2 confirmed the signage on the resident's door and explained this information was on the resident's care plan. On 6/2/25 at 2:30 PM, during an interview, Resident #14 stated she did not request the signage be posted on her door regarding the lift pad. On 6/4/25 at 2:45 PM, during an interview and observation with Registered Nurse (RN) #1, she reported being aware of residents' rights and dignity regarding personal health information. She stated signs should not be posted for residents regarding care areas and confirmed that all resident health information was on the care plan. She acknowledged the signage on Resident #14's door and stated anyone could see the information. She removed the signage and stated she would follow up. On 6/5/25 at 12:35 PM, during an interview with the Director of Nursing (DON), she explained she was notified by staff about the signage on Resident #14's door. She acknowledged that residents' personal care information should remain confidential and confirmed the sign should not have been posted. She stated she expected staff to remove such signage or notify her if it was present. On 6/5/25 at 3:00 PM, during an interview with the Administrator, she explained that all residents should be treated with dignity and respect at all times. She stated she was aware that posting personal care information was a dignity concern and expected staff not to post such signage unless requested by the resident. If requested, she expected to be notified of the request. A record review of the admission Record revealed the facility initially admitted Resident #14 on 10/27/21 and readmitted her on 6/1/25 with diagnoses including Chronic Kidney Disease, Unspecified and Dependence on Renal Dialysis. A record review of the Order Listing Report revealed Resident #14 had a Physician's Order, dated 8/27/24, indicating that the resident receives dialysis services three (3) times weekly on Monday, Wednesday, and Friday. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/25 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Section O revealed she received dialysis.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store food in a sanitary manner to prevent the potential for foodborne illness during one (1) of three (3) kitchen observations. Specifically, expired milk and key lime juice were observed in use and/or not stored in accordance with manufacturer guidelines. Findings included: A review of the facility's policy Food Storage Labeling dated 05/2018, revealed .The facility will ensure the safety and quality of food by following good storage and labeling procedures .Procedure .3. Rotation .b. Food stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use by date or expiration date . On 6/2/25 at 9:44 AM, during an observation and interview with the Dietary Manager, there was one (1) gallon of opened reduced-fat milk with an expiration date of 5/29/25 inside Reach-In Cooler #3. The Dietary Manager confirmed that the milk was expired and expressed uncertainty regarding whether Dietary Aides may have served the expired milk during the morning breakfast service. In the dry goods storage room, there was a container of Key Lime juice stored on a shelf, with manufacturer instructions indicating that it should be refrigerated after purchase. The Dietary Manager confirmed that the Key Lime juice was improperly stored on the shelf rather than in the refrigerator and acknowledged that it was not stored per manufacturer instructions to refrigerate after purchase. On 6/5/25 at 2:48 PM, during an interview with the Administrator, she acknowledged she was aware of the findings in the kitchen and verbalized that kitchen staff are expected to ensure food is served in accordance with facility standards and that all expired foods are properly labeled and discarded in compliance with facility policy.

Based on observation, interview, facility policy review, and record review the facility failed to ensure a call light was within reach for one (1) of 20 sampled residents, Resident #7. Findings included: A review of the facility's policy titled Call Light/Bell, with the latest revision date of 1/24, revealed: Purpose: To provide the resident a means of communication with staff members To provide staff members a means of summoning assistance when they are with the resident . Procedure: 1. Ensure resident has call light in reach . On 6/2/25 at 10:30 AM, during an interview and observation, Resident #7 was observed lying in bed. Resident #7 stated she needed help but could not get anyone. A round palm pad call light and another call light were observed hanging and wrapped around a light fixture, not over the resident's bed and within her reach. On 6/2/25 at 10:50 AM, during an observation and interview with Certified Nurse Aide (CNA) #4, she explained that she completes rounds first thing in the morning and sees all her residents. CNA #1 confirmed that Resident #7's call light was wrapped around the light fixture and not in reach and that the resident could not have physically wrapped the call lights around the light fixture. CNA #1 reported she could not believe she missed it that morning and acknowledged it was her responsibility to ensure all residents' call lights were within reach. On 6/2/25 at 11:00 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that all residents' call lights should be within reach at all times and she expected CNAs to ensure they were accessible. On 6/5/25 at 12:40 PM, during an interview with the Director of Nursing (DON), she explained that she expected all staff to ensure call lights were within reach at all times. She confirmed that a call light should never be wrapped up on a light fixture and out of reach of the resident. A record review of the admission Record revealed the facility initially admitted Resident #7 on 1/10/20 and readmitted her on 1/10/24 with diagnoses including Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/25 revealed Resident # 7 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated her cognition was severely impaired.

Based on interviews, record review, facility investigation, and policy review, the facility failed to treat a resident with respect and dignity during care for one (1) of four (4) residents sampled. Resident #2 Findings included: A review of the facility's policy titled, Resident Rights Policy, reviewed 12/23, revealed, Every resident in this facility has the right to: .12. Be treated courteously, fairly and with the fullest measure of dignity . A review of the facility's investigation revealed there was an allegation of verbal abuse reported to the facility on [DATE], by Resident #5, the roommate of Resident #2. Resident #5 reported that a Certified Nurse Aide (CNA) had verbally abused her roommate while providing care. Resident #5 reported that a CNA told Resident #2 that she needed to get her 'expletive' up and go the bathroom, when the resident had an accident in the bed. On 4/30/24 at 10:45 AM, during an interview with the Social Services Director (SSD), she confirmed that on 3/22/24, Resident #5, the roommate of Resident #2, informed her that during the early hours of 3/22/24, a CNA told Resident #2 to get her 'expletive' up and get into the bathroom. The SSD revealed that once she received this information, she immediately informed the Administrator and they began their investigation. On 4/30/24 at 11:00 AM, during an interview with Resident #2, she confirmed that about a month ago, during the early morning hours, she urinated on herself and called out for help. The nurse checked on her, then the CNAs entered her room, and one CNA told her something not nice and spoke ugly. On 4/30/24 at 1:00 PM, during an interview with the Director of Nurses (DON), she confirmed Resident #5 is alert/oriented and if she reported that a staff member was disrespectful to another resident, then she would have to say it did happen. Resident #5 was clear on what she heard on 3/22/24, and her statement had not changed. The DON confirmed staff should not talk to residents in a disrespectful way. On 5/1/24 at 11:10 AM, during an interview with the Administrator, she confirmed that during her investigation, both Resident #2 and Resident #5 reported that a staff member used inappropriate language when addressing Resident #2. The Administrator acknowledged that her investigation revealed the CNA that the residents described, was CNA #1. The Administrator acknowledged that the language used by CNA #1 was disrespectful but was not threatening. As this was the second time that CNA #1 had been accused of being discourteous to residents, she was terminated from her employment at the facility. The Administrator stated that after the recent incident, the facility had an emergency Quality Assurance Performance Improvement (QAPI) meeting to discuss the event and what measures needed to be implemented. As a result, in-services were conducted regarding resident rights and abuse/neglect. On 5/1/24 at 1:00 PM, an interview with Resident #5 confirmed that about a month ago, in the early morning hours, her roommate, Resident #2, used the bathroom on herself, it was a big mess, and it went onto the floor. Two (2) CNAs came in to clean her up but one of the CNAs, who had a head wrap on, stated, get your 'expletive' up and get into the bathroom. Resident #5 stated they took her roommate to the shower to clean her up and brought her back to her room. Resident #5 confirmed that she informed the Social Worker the next day of what took place earlier that morning. A review of the personnel file for CNA #1 indicated she had received training on the Vulnerable Adults Act and Resident's Rights and signed an acknowledgment of receiving training on 4/21/22, upon hire, then annually and throughout the year. Record review of the Facesheet, for Resident #2, revealed the facility admitted the resident on 12/9/22, with current diagnoses of Altered Mental Status and Chronic Kidney Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/4/24, revealed Brief Interview for Mental Status (BIMS) score is 15, which indicated the resident was cognitively intact. Record review of the Quarterly MDS, for Resident #5, with an ARD of 2/22/24, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Based on the facility's implementation of corrective actions on 3/25/24, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC), and the deficiency was corrected as of 3/25/24, before the SA's entrance on 4/30/24. Validation: On 5/2/24, the SA validated through staff interviews, record review, and facility policy review the facility began an immediate investigation when the incident occurred. A review of the emergency QAPI meeting minutes revealed the facility held a QAPI meeting on 3/25/24, the Medical Director attended via phone. The SA verified through an interview with the DON and Social Services Director that they attended the QAPI meeting to discuss the situation, and the facility policies related to violation of the resident rights were discussed, and no changes were needed. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the employee, and interview all residents with a Brief Interview for Mental Status (BIMS) score over 12, to determine if any resident experienced any violation of their resident rights. The SA reviewed in-service sign-in sheets that began on 3/22/24 related to resident rights and abuse/neglect. The Administrator and DON conducted in-services in which they had every employee sign the policies on resident rights and abuse/neglect. On 3/22/24, the SA verified the facility reported resident abuse to the SA and the Attorney General Office (AGO) on 3/22/24.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide sufficient nursing staff resulting in residents not receiving showers and call lights not answered timely for five (5) of 18 sampled residents (Resident #25, #35, #60, #4, #65) and had the potential to affect all 72 residents residing in the facility. Findings include: A record review of the facility's Nursing Services-Staffing policy, revised 11/17 revealed 1. Staffing - The facility will have sufficient nursing staff twenty-four hours every day to provide nursing and nursing related services to attain or help maintain the highest practicable physical, mental, and psychosocial well-being of each resident .2. The facility will comply with established staffing requirements by the individual state governing agencies . 6. The facility will actively recruit staff necessary to meet the requirements . Record review of the provider's reporting data [NAME] Report revealed the facility triggered excessively low weekend staffing and triggered a one star rating for one quarter dated July 1-September 30, 2023. A record review of the facility's Facility Assessment, updated 11/06/23 revealed . Staffing plan: Staffing plan includes maximizing recruitment and retention of staff consistent with increasing access to higher quality care and supporting caregivers per the President's executive order . We review our schedule and staffing needs daily based on current census, new admissions, discharges, and any other change in status by our residents. We also ensure that we are meeting at least the minimum requirements set by the State Department of Health . The Assessment also included the positions and daily average number for the following: Licensed Practical Nurse (LPNs) 8, Nurse Aides 12, Registered Nurses (RNs) 2, other staff needed for behavioral healthcare and services 1 . This tag is cross referenced to: F561- Based on interviews, record review and facility policy review, the facility failed to ensure the resident rights were honored by not consistently providing residents with their choice of receiving showers for three (3) of (18) residents reviewed for choices. Resident #25, Resident #35, and Resident #60. Resident #25 During an interview on 01/29/24 at 10:52 AM, Resident #25 complained that he does not get a shower. He explained that he was scheduled to receive a shower on the evening shift, but the facility did not have enough staff to provide showers on evenings and weekends. Record review of the Completed Care Details, dated 1/1/24 through 1/31/23 revealed Resident #25 did not receive a shower on 1/1/24, 1/3/24, 1/8/24 and 1/12/24. A record review of the Face Sheet revealed the facility admitted Resident #25 on 1/16/21 and he had current diagnoses including Chronic Obstructive Pulmonary Disease and Overactive Bladder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/23 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #35 During an interview on 01/29/24 at 11:00 AM, with Resident # 35, he revealed the facility had only one Certified Nursing Assistant (CNA) on his hall on weekends and evenings, and the CNA does not give him showers. The resident said the staff are documenting that he is receiving his showers, but they are not giving them. Record review of the Completed Care Details revealed Resident #35 did not receive a shower on 1/03/24, 1/08/24, 1/22/24 and 1/26/24. A record review of the Face sheet revealed the facility admitted Resident #35 on 1/25/23 and he had current diagnoses including Chronic Kidney Disease Stage 3, Atrial Fibrillation, and a need for assistance with personal care. A record review of the Quarterly MDS with an ARD of 12/05/23 revealed Resident #35 had a BIMS score of 15, which indicated he was cognitively intact. Resident #60 During an interview on 01/29/24 at 10:55 AM with Resident # 60 revealed the facility does not have enough staff on the weekends and evenings to provide showers. Record review of the Completed Care Details revealed Resident #60 did not receive a shower on 1/3/24, 1/8/24, 1/17/24, 1/22/24, 1/26/24 and 1/31/24. A record review of the Face Sheet revealed the facility admitted Resident #60 on 9/16/21 and she had current diagnoses including Hypertension, Diabetes Mellitus, and Vitamin D Deficiency. A record review of the Quarterly MDS with an ARD of 1/12/24 revealed Resident #60 had a BIMS score of 14, which indicated she was cognitively intact. During a phone interview on 2/1/24 at 1:36 PM, with CNA #4, she confirmed she worked the 200 Hall on the 7:00 PM to 7:00 AM (7PM-7AM) shift. CNA #4 explained that she had worked on the hall for several days without any other staff assistance. CNA #4 confirmed she was unable to give the residents showers because several of the residents required two (2) staff members to transfer them or to use the mechanical lifts and she could not do it without help. During a phone interview on 2/1/24 at 1:48 PM, with CNA #5, she confirmed she worked on the 200 Halls on the 7PM -7AM shift. CNA #5 confirmed she gave the residents bed baths because she could not provide showers to the residents without assistance from another staff member. CNA #5 said most of the residents on the hall used mechanical lifts to be transferred and she could not complete transfers without help. During a phone interview 2/1/24 at 2:00 PM, with CNA #6, she confirmed she worked the 7PM - 7AM shift on the 200 Hall. CNA #6 explained that she was unable to provide showers for the residents because they required two (2) to three (3) people to assist due to having to use mechanical lifts. CNA #6 said she tried to keep the residents as clean and dry as possible and would only give the residents bed baths when she worked the hall alone for their safety. CNA #6 said she had complained to the Director of Nursing (DON) and the Staff Development Nurse and was told that they have try to provide those showers. CNA #6 said she did not want to cause an accident with the residents or lose her certification, so she gave bed baths. During an interview on 02/01/24 at 2:37 PM, with Registered Nurse (RN) #1, she confirmed the facility failed to document resident showers. RN #1 said she has in-serviced the staff to document and the importance of residents receiving their showers. RN #1 said she notified the DON that the showers were not being documented. During an interview on 2/1/23 at 3:00 PM, with the Administrator, she confirmed the facility failed to document showers for several nights during the month of January. The Administrator said she expected the staff to provide showers on the days they were scheduled and for staff to ask for assistance to provide care for the residents. Resident #4 On 01/29/24 at 11:18 AM, during an interview and observation with Resident #4, she complained staffing was low especially on the weekends. She reported the facility used a lot of agency staff and the agency staff did not know the residents. She also complained the nurses gave medications at different times and she had to go find the nurse for her medications. Resident #4 said that staffing being low happened on all shifts. A record review of the Face Sheet revealed the facility admitted Resident #4 on 03/10/20 with current diagnoses including Atrial Fibrillation. A record review of the Quarterly MDS with an ARD of 11/30/23 revealed Resident #4 had a BIMS score of 15, which indicated she was cognitively intact. Resident #65 On 01/29/24 at 9:58 AM, during an interview with Resident #65, she reported staff would answer call lights and would say they would be right back and not come back for two (2) hours. She stated that this occurred on all shifts. A record review of the Face Sheet revealed the facility admitted Resident #65 on 01/02/24 with current diagnoses including Other Specified Fracture of Right Pubis. A record review of the Admission MDS with an ARD of 01/09/24 revealed Resident #65 had a BIMS score of 8, which indicated her cognition was moderately impaired. On 01/30/24 at 1:30 PM, in a Resident Council meeting, the council members revealed that throughout the week on the night shift, they may wait hours for a response to the call light. The residents stated the night shift CNAs would sometimes come in the room, turn off the call light, tell the resident they will be right back, and never return. The residents stated they feel the facility is often short-staffed. On 01/31/24 at 3:00 PM, during an interview with the Director of Nursing (DON), she explained she has 4 (four) full-time nurses. She explained the facility currently used an agency and contracted nursing staff, but she planned on phasing out the use of the agency. She reported the acuity of residents that were admitted to the facility was much higher than was previously admitted . On 01/31/23 at 4:30 PM, during an interview with the Administrator, she explained she expected staffing to meet the requirements and needs of residents.

Based on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items opened and exposed for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's policy Food Storage Labeling, revised 5/18, revealed POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All foods in the facility will be labeled. Information included on the label: Name of the Food . Date of storage . 3. Rotations .b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufactured use-by date or expiration date . 4. Monitoring storage temperatures .d. Product Placement Food is stored in containers that are .tightly sealed or covered . On 01/29/24 at 09:11 AM, an observation of the kitchen and interview with the Dietary Manager (DM) revealed: 1. Refrigerator #1 contained an opened package of cheddar cheese slices, loosely wrapped, with the cheese slices exposed with no opened by or use by date noted; 14 portioned glasses of milk on a tray undated and unlabeled, eight (8) portioned glasses of what the DM identified as orange juice, unlabeled and undated, (3) portioned glasses of what the DM identified as apple juice, unlabeled and undated. 2. Refrigerator #2 contained (1) opened and portioned, single serving cup of what the DM identified as pudding with no label and no date; seven (7) portioned cups of minimally processed cut strawberries with no date. 3. Freezer #1 contained (1) opened and loosely wrapped package of what the DM identified as mango bars, with no date or label, two (2) unopened packages of what the DM identified as collard greens with no label or date, (1) opened package of what the DM described as diced onions with no label or date, (1) opened package of submarine rolls, containing six (6) rolls, with visible white markings on the rolls indicative of freezer burn, with a best if used by date of May 07/2023. 4. The spice rack contained 4 containers of spices with the lids opened leaving the spices exposed. 5. The Dietary Manager acknowledged the food items were inadequately stored, outdated, exposed, undated, and unlabeled during the initial kitchen observation. The DM stated going forward he intends to conduct one on one in-services and to visibly follow up with staff for labeling and food storage. The DM stated it is the responsibility of the staff who opens the food item to label and date the item and the kitchen aides are responsible for dating and labeling foods as they are unloaded from the delivery truck. On 01/30/24 at 10:58 AM, an interview with the Cook revealed it is the responsibility of the person who opens a food item to date and label the item. The cook stated it is the responsibility of the managers to label and date foods off the truck. On 02/01/24 at 11:03 AM, in an interview with the Kitchen Aide (KA) revealed the [NAME] are responsible for labeling and dating foods as they are unloaded from the truck. The KA revealed it is the responsibility of the person who opens the food item to label and date the item.

Based on staff interview and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the staffing hours for the appropriate care of the residents) was accurately submitted to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. (4th Quarter) Findings include: Review of the provider's [NAME] reporting data revealed the facility triggered excessively low weekend staffing for the 4th Quarter (July 1, 2023 - September 30, 2023). On 01/31/24 at 09:45 AM, during an interview with the Administrator, she explained she was not aware the facility had triggered for low weekend in the 4th Quarter of 2023. She stated that she approved the facility's employee hours for PBJ submission and advised the corporate office that the hours were approved and were ready to be submitted. The Administrator advised that after reviewing the audit report, there were contract staff that were not included in the hours that were submitted to CMS. She confirmed there were four (4) contract/agency staff that did not have hours inputted into PBJ and therefore the information submitted to CMS regarding staffing hours was inaccurate.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure residents had access to their personal fund accounts on weekends for nine (9) of 18 sampled residents with the potential of affecting 40 residents with personal funds. (Residents #2, 4, 19, 35, 37, 42, 46, 48, and 55) Findings include: A record review of the facility's policy General Resident Trust Fund Policies, revised 1/20, revealed .Residents have the right to manage their financial affairs .The law and regulations are intended to assure that residents have access to cash funds within a reasonable period of time . On 1/29/24 at 11:05 AM, during an interview, Resident #19 complained about not getting personal funds on the weekends. She explained she must plan on requesting money on Friday if she wanted money on the weekend because there was no staff at the facility to distribute funds on the weekend. She stated she could get money on the weekend by the Business Office Manager (BOM). On 1/30/24 at 1:30 PM, during the facility's resident council meeting, all the residents stated they were only able to get money from their personal trust fund accounts Monday through Friday. The residents confirmed if they wanted money for Saturday and Sunday, they would have to get it before Friday at 5:00 PM. On 2/01/24 at 12:10 PM, during an interview with the Administrator, she explained an activity staff member was responsible for handing out personal funds on the weekend, but she had quit last week, and the Administrator had not designated any other staff member to take on that responsibility. She was not aware residents were complaining about not having personal funds available on the weekend and she planned on meeting with the resident counsel later this month and discuss personal funds availability. At 12:25 PM on 2/01/24, during an interview with Activity #1, she explained she had been at the facility for two (2) years, and she or any other activity staff have never had access to residents' personal funds. At 12:35 PM on 2/01/24, during a phone interview with Activity #2, the previous activity staff member for the weekend, she explained she never had access to the residents' personal funds on the weekend and had never been made aware of any information regarding personal funds on the weekend. A record review of the Trial Balance, dated 2/1/24, revealed Residents #2, #4, #19, #35, #37, #42, #46, #48, and #55 had a personal trust fund account at the facility. Resident #2 A record review of the Face Sheet revealed the facility admitted Resident #2 on 08/22/14 with current diagnoses including Cerebral Palsy. A record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 12/11/23 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #4 A record review of the Face Sheet revealed the facility admitted Resident #4 on the 03/10/20 with current diagnoses including Atrial Fibrillation. A record review of the Quarterly MDS with an ARD of 11/30/23 revealed Resident #4 had a BIMS score of 15, which indicated she was cognitively intact. Resident #19 A record review of the Face Sheet revealed the facility admitted Resident #19 on 04/06/23 with current diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the Quarterly MDS with an ARD of 01/09/24 revealed Resident #19 had a BIMS score of 15, which indicated she was cognitively intact. Resident # 35 A record review of the Face Sheet revealed the facility admitted Resident #35 on 1/25/23 with current diagnoses of including Chronic Kidney Disease Stage 3 and Atrial Fibrillation. A record review of the Quarterly MDS with an ARD of 12/05/23 revealed Resident #35 had a BIMS score of 15, which indicated he was cognitively intact. Resident #37 A record review of the Face Sheet revealed the facility admitted Resident #37 on 11/17/22 with current diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System. A record review of the Quarterly MDS with an ARD of 11/7/23 revealed Resident #37 had a BIMS score of 15, which indicated she was cognitively intact. Resident #42 A record review of the Face Sheet revealed the facility admitted Resident #42 on 07/20/21 with current diagnoses including Atrial Fibrillation. A record review of the Quarterly MDS with an ARD of 01/15/24 revealed Resident #42 had a BIMS score of 15, which indicated she was cognitively intact. Resident #46 A record review of the Face Sheet revealed the facility admitted Resident #46 on 09/06/23 with current diagnoses including Periprosthetic Fracture Around Internal Prosthetic Hip Joint. A record review of the Quarterly MDS with an ARD of 01/05/24 revealed Resident #46 had a BIMS score of 15, which indicated she was cognitively intact. Resident #48 A record review of the Face Sheet revealed the facility admitted Resident #48 on 02/10/21 with current diagnoses including Chronic Kidney Disease. A record review of the Annual MDS with an ARD of 12/07/23 revealed Resident #48 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #55 A record review of the Face Sheet revealed the facility admitted Resident #55 on 02/17/23 with current diagnoses including Encephalopathy. A record review of the Quarterly MDS with an ARD of 11/17/23 revealed Resident #55 had a BIMS score of 15, which indicated she was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to provide resolution to grievances related to call lights not being answered and Certified Nursing Assistants (CNAs) turning off the call light and not returning for three (3) of six (6) months of Resident Council grievance logs reviewed. Findings Include: A review of the facility's Grievances-Residents, revised 10/23, revealed, .The facility shall make prompt efforts to resolve the grievances .The Administrator and his/her designee will conduct an impartial investigation of the allegations and will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant . In all grievance cases, the resident and/or legal representative will be informed of the result of the investigation . On 01/30/24 at 1:30 PM, an interview with the members of the Resident Council revealed, the residents reported unanimously, that on the night shift, throughout the week, they can wait hours for a response to the call light. The residents stated the night shift CNAs will sometimes come in the room, turn off the call light, tell the resident they will be right back and never return. The Residents stated at other times they may wait for hours before they receive a response to the call light. The residents stated they feel the facility is often short-staffed. Residents in attendance were Resident #2, #4, #19, #35, #37, 42, #46, #48, #55, #57, and #178. On 01/30/24 at 1:44 PM, an interview with the Activities Director (AD) revealed she takes notes in the Resident Council meetings. The AD reported she is aware of the repeated grievances regarding the call light response times and lack of response by the night shift. The AD stated when she receives grievance reports from the Resident Council Meeting, she reports the grievances from to the Administrator for follow up. On 01/31/24 at 11:57 AM, an interview with the Director of Nursing (DON) acknowledged that she was aware of the past grievances related to slow response time to call light, no response time to call light, and staff who answer the call light, turning it off and not returning. The DON stated she recently did an in-service with the staff on answering call lights. The DON acknowledged the biggest complaint she has previously heard from the residents is the call light being answered by the CNA and then turning the light off and not coming back. The DON stated she attributes the call light response issue is due to a lack of staff availability. The DON stated she will continue to in-service the staff and will conduct off hour visits. On 02/01/24 at 7:30 AM, an interview with the Administrator revealed she acknowledged that she was aware of the past grievances reported at the Resident Council meeting for the months of November 2023, December 2023 and January 2024 related to call lights going unanswered and staff answering and not coming back. The Administrator stated the staff are in-serviced on answering the call light. The Administrator stated that her plan is to make odd hour visits to make sure the call lights are answered, monitor the surveillance video to check for problems, order individual bells as a backup and continue to in-service the staff. A record review of six months of Resident Council meeting minutes dated August 2023 through January 2024 revealed that for the months of November 2023, December 2023, and January 2024 the residents repeatedly expressed grievances regarding unanswered call lights and CNAs answering the call light, saying they will be right back and not coming back. There was no documented attempts on the meeting minutes form to resolve the grievances.

Based on interviews, record review and facility policy review, the facility failed to ensure the resident rights were honored by not consistently providing residents with their choice of receiving showers for three (3) of (18) residents reviewed for choices. Resident #25, Resident #35, and Resident #60. Findings include: Review of the facility's policy, Bathing revised 1/24, revealed, .Purpose .To ensure resident comfort and dignity .Processes 1. Inquire with the resident concerning bathing preferences (e.g., time of day, type of bathing- shower, bed bath, etc.) 2. Offer the resident choice in their bathing routine .8. Follow resident preferences as stated . Record review of the Inservice Training document, dated 11/7/23, 12/5/23, and 1/15/24, revealed the staff were educated by Registered Nurse (RN) #1/Staff Development on giving showers to residents and completing shower documentation. Record review of the Assignment Sheets revealed the facility had one Certified Nursing Assistant (CNA) Scheduled for the 200 Hall on night shift which housed approximately 27 Residents on 1/1/24, 1/5/24, 1/6/24, 1/7/24, 1/11/24, 1/22/24, 1/24/24, 1/26/24, 1/27/24, 1/28/24 and 1/31/24. Record review of the weekly Shower Sheets for the night shift for January 2024 revealed: The week of 1/1/24 through 1/6/24 there were no documented showers on Monday, Tuesday, Wednesday, or Thursday on the shower list. The week of 1/15 through 1/20/24 revealed no documented showers on Wednesday. The week of 1/22/24 through 1/27/24 revealed there were no documented showers for Monday, Tuesday, Wednesday, or Friday. The week of 1/29 to 1/31/24 there was no documentation of showers given for Tuesday or Wednesday. Resident #25 During an interview on 01/29/24 at 10:52 AM, Resident #25 complained that he does not get a shower. He explained that he was scheduled to receive a shower on the evening shift, but the facility did not have enough staff to provide showers on evenings and weekends. Record review of the Completed Care Details, dated 1/1/24 through 1/31/23 revealed Resident #25 did not receive a shower on 1/1/24, 1/3/24, 1/8/24 and 1/12/24. A record review of the Face Sheet revealed the facility admitted Resident #25 on 1/16/21 and he had current diagnoses including Chronic Obstructive Pulmonary Disease and Overactive Bladder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/23 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #35 During an interview on 01/29/24 at 11:00 AM, with Resident # 35, he revealed the facility had only one CNA on his hall on weekends and evenings, and the CNA does not give him showers. The resident said the staff are documenting that he is receiving his showers, but they are not giving them. Record review of the Completed Care Details revealed Resident #35 did not receive a shower on 1/03/24, 1/08/24, 1/22/24 and 1/26/24. A record review of the Face Sheet revealed the facility admitted Resident #35 on 1/25/23 and he had current diagnoses including Chronic Kidney Disease Stage 3, Atrial Fibrillation, and a need for assistance with personal care. A record review of the Quarterly MDS with an ARD of 12/05/23 revealed Resident #35 had a BIMS score of 15, which indicated he was cognitively intact. Resident #60 During an interview on 01/29/24 at 10:55 AM, with Resident # 60 revealed the facility does not have enough staff on the weekends and evenings to provide showers. Record review of the Completed Care Details revealed Resident #60 did not receive a shower on 1/3/24, 1/8/24, 1/17/24, 1/22/24, 1/26/24 and 1/31/24. A record review of the Face Sheet revealed the facility admitted Resident #60 on 9/16/21 and had current diagnoses including Hypertension, Diabetes Mellitus, and Vitamin D Deficiency. A record review of the Quarterly MDS with an ARD of 1/12/24 revealed Resident #60 had a BIMS score of 14, which indicated she was cognitively intact. During a phone interview on 2/1/24 at 1:36 PM, with CNA #4, she confirmed she worked the 200 Hall on the 7:00 PM to 7:00 AM (7PM-7AM) shift. CNA #4 explained that she had worked on the hall for several days without any other staff assistance. CNA #4 confirmed she was unable to give the residents showers because several of the residents required two (2) staff members to transfer them or to use the mechanical lifts and she could not do it without help. During a phone interview on 2/1/24 at 1:48 PM, with CNA #5, she confirmed she worked on the 200 Halls on the 7PM -7AM shift. CNA #5 confirmed she gave the residents bed baths because she could not provide showers to the residents without assistance from another staff member. CNA #5 said most of the residents on the hall used mechanical lifts to be transferred and she could not complete transfers without help. During a phone interview 2/1/24 at 2:00 PM, with CNA #6, she confirmed she worked the 7PM - 7AM shift on the 200 Hall. CNA #6 explained that she was unable to provide showers for the residents because they required two (2) to three (3) people to assist due to having to use mechanical lifts. CNA #6 said she tried to keep the residents as clean and dry as possible and would only give the residents bed baths when she worked the hall alone for their safety. CNA #6 said she had complained to the Director of Nursing (DON) and the Staff Development Nurse and was told that they have try to provide those showers. CNA #6 said she did not want to cause an accident with the residents or lose her certification, so she gave bed baths. During an interview on 02/01/24 at 2:37 PM, with Registered Nurse (RN) #1, she confirmed the facility failed to document resident showers. RN #1 said she has in-serviced the staff to document and the importance of residents receiving their showers. RN #1 said she notified the DON that the showers were not being documented. During an interview on 2/1/24 at 2:38 PM, with the DON, she confirmed she knew the staff were not documenting or providing showers to the residents. The DON also confirmed that after the Staff Development Nurse had provided in-services and education to the staff regarding documentation and providing showers, there was nothing else put in place to ensure the residents were getting their showers. During an interview on 2/1/23 at 3:00 PM, with the Administrator, she confirmed the facility failed to document showers for several nights during the month of January. The Administrator said she expected the staff to provide showers on the days they were scheduled and for staff to ask for assistance to provide care for the residents.

Based on staff interview, record review, and facility policy review, the facility failed to include the reason for resident transfers in a manner they could understand in the written notification of transfer provided to the resident and the Resident Representative (RR) for two (2) of two (2) sampled residents reviewed for hospitalization . (Resident #16 and Resident #77) Findings include: Review of the facility's policy, Discharge Transfer and Planning revised 9/23, revealed, .Before a facility transfers or discharges a resident, the facility must .Notify the resident and the resident's representatives of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand . Resident #16 A record review of the Face Sheet revealed the facility admitted Resident #16 on 7/20/21 and he had current diagnoses including End Stage Renal Disease. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/23 revealed Resident #16 was discharged on [DATE] to the hospital. A record review of the Departmental Notes, dated 11/20/23 at 11:33 AM, revealed Resident #16 was sent to a local acute care hospital for shortness of breath. A record review of the written transfer or discharge notification for Resident #16 revealed the facility completed a transfer notification on 11/20/23 and indicated the reason for the transfer as, We are no longer able to meet your needs in this facility and the transfer is necessary for your welfare . The notification did not include the reason for the transfer as shortness of breath. Resident #77 Record review of the Face Sheet revealed the facility admitted Resident #77 on 10/30/23 and he had diagnoses including Peripheral Vascular Disease. Record review of the Discharge MDS with an ARD of 11/06/23 revealed Resident #77 was discharged to the hospital on 11/6/23. Record review of the Physician's Telephone Order, 11/06/23 revealed Resident #77 had a Physician's Order to be transferred to the hospital due to abdominal distention. Record review of a Departmental Notes dated 11/6/23 at 5:33 PM revealed Resident transported to (proper name of local hospital) d/t (due to) abdominal distention . A record review of the written transfer or discharge notification for Resident #16 revealed the facility completed a transfer notification on 11/6/23 and indicated the reason for the transfer as, We are no longer able to meet your needs in this facility and the transfer is necessary for your welfare . The notification did not include the reason for the transfer as abdominal distension. During an interview on 01/30/24 at 1:44 PM, with the Director of Nursing (DON), she explained that the nurses call the RR to notify them when a resident is transferred to the hospital and the written notifications are sent out by the Administrator. During an interview on 1/31/24 at 9:00 AM, with the Administrator, she confirmed she was responsible for sending out the transfer notifications to the RR. The Administrator confirmed the written notifications indicated that the facility was unable to meet the resident's needs, but did not include the specific reason resident was transferred. 43283

Based on observation, staff and family interview, record review, policy review, and facility investigation review, the facility failed to follow Resident #2's plan of care to use a total lift for transfers. As a result, Resident #2 fell , and sustained a fracture to the left pelvis, and hip. This concern was identified for one of four (1 of 4) sampled residents, and three (3) unsampled residents reviewed for transfer requirement/need care plans. Findings include: Review of the facility's policy titled, Care Plan Process, revised (MONTH) (YEAR), revealed: The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Interventions are actions that should promote meeting the established goal. Each intervention shall indicate the staff responsible for the intervention. Review of the facility's policy, titled, Lifting Policy, revised (MONTH) (YEAR), revealed: Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff. Review of Resident #2's Care Plan, revealed a Problem Onset, dated 05/15/15, for a risk for falls related to impaired physical mobility and total dependence for locomotion, and impaired safety awareness. The Approaches included a total lift for transfers. Review of the facility's investigation and incident reports revealed Resident #2 was not lifted/transferred as directed in her plan of care and assessment. On 10/04/17 at 2:00 PM it was reported by a CNA that Resident #2 slid to the floor from the side of the bed, due CNA #1 was getting the resident ready to go to the shower in the shower chair. CNA #1 did not have a lift, or second person in the room to assist with the transfer. Review of Resident #2's Transfer Assistance Screen, dated 08/30/17, revealed the Resident's Lifting Plan was marked Red, for a total lift. Review of the Care Kiosk for Resident #2 revealed when transferring Resident #2, the staff was to use a total lift with a small sling with two (2) person assist. A phone interview with Certified Nursing Assistant (CNA) #1, on 5/23/18 at 2:50 PM, revealed CNA #1 confirmed if the correct lift or the correct number of people to assist is not present when assisting a resident during a transfer then the resident's plan of care is not being followed. CNA #1 stated she was attempting to sit Resident #2 up on the side of the bed to take her to the shower. CNA #1 stated Resident #2 slid off the bed onto the floor. CNA #1 confirmed she was alone in the room at the time, and a lift was not in the room, only a shower chair. CNA #1 stated she asked CNA #2 to assist her to get Resident #2 off the floor, and together they picked Resident #2 up off the floor and sat her in the shower chair. CNA #1 reported Resident #2 was a sit to stand lift for transfers, and not a total lift. She stated she would chart in the Kiosk, and her care plan would always show a sit to stand lift not a Hoyer (total lift). CNA #1 stated Resident #2 had been assessed for the sit to stand lift, since I started working there in (MONTH) (YEAR). The SA was unable to reach CNA #2 because her phone has been disconnected, and no other employees at the facility had a current number where she could be reached. An interview with the Director of Nurses (DON), on 5/22/18 at 1:20 PM, revealed CNA #1 did not follow Resident #2's plan of care for lifting and transferring when the fall occurred on 10/4/17. The DON stated CNA #1 did not have another staff member in the room, or a total lift to assist with Resident #2's transfer. The DON stated the Smart Chart in the Care Plan is what comes up on the Kiosk for the CNAs to see what lift/transfer needs are required, and Resident #2's Care Plan was red, which indicated a Total Lift with two (2) person assist at the time of the incident on 10/04/17. Resident #2 was changed from a Sit to Stand Lift to a Total Lift with two (2) person assist on 6/23/17. During an interview with Resident #2's son, on 5/22/18 at 8:30 AM, he stated he had observed staff lifting his mother alone without a lift. He stated it depended on the CNA, and if they were strong enough to lift her alone. He stated some could not, and some could. An interview with CNA #3, on 5/24/18 at 11:35 AM, revealed Resident #2 had been changed from a Sit to Stand Lift to a Hoyer/Total Lift around (MONTH) (YEAR). An interview with Licensed Practical Nurse (LPN) #2, on 5/24/18 at 11:45 AM, revealed she did not remember which lift Resident #2 was assessed for at the time of her fall. LPN #2 stated she supervised staff to ensure they are following the residents lift and transfer care plans by observing for the correct number of staff, and type of lift required. An interview with the Quality Assessment (QA) Nurse, on 5/23/18 at 10:40 AM, revealed the Nurse Case Manager is responsible for the lift assessments, and they are done as needed and quarterly. The QA Nurse stated the previous Director of Nursing (DON) would do spot checks to make sure the care plans were being followed for the correct lifts, and number of staff required. An interview with LPN #1, on 5/24/18 at 11:12 AM, revealed she supervised staff to ensure the care plans were being followed for the correct lifts to transfer and lift the residents. LPN #1 said she would conduct spot checks. LPN #1 stated she had not identified concerns related to staff not using the right lift, or have the correct number of people present. An interview with LPN #3, on 5/24/18 on 11:22 AM, revealed she checks the card on the corkboard as well as well as the Kiosk and the Care Plan to ensure the residents are transferred with the required lift, and staff present. LPN #3 stated she does daily checks to ensure the care plans are followed, and she has not identified any concerns with the use of the lifts. An interview with LPN #4, on 5/24/18 at 11:30 AM, revealed she worked the night shift, and supervised the staff to ensure the correct lift was used for resident transfers, and the care plan was being followed. LPN #4 said she would look at the communication board in each residents room to see what lift was needed. LPN #4 stated if there was a change in a resident's transfer status the nurses or CNAs would notify the Minimum Data Set (MDS) Nurse. During the survey, the SA made observations of lifts/transfers for Unsampled Residents A, B, and C. No concerns regardding following the care plan for lifts/transfers were identified. Review of the Face Sheet revealed Resident #2 was admitted by the facility, on 5/15/15, with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 8/30/17, revealed Resident #2 scored 03 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Further review of the MDS revealed Resident #2 required extensive assistance with one person physical assist with bed mobility, transfers, dressing, and toilet use. Resident #2 required extensive assist with limited personal physical assist with locomotion on and off the unit, eating, personal hygiene, and bathing. Resident #2's balance was not steady, and was only able to stabilize with staff assistance with moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #2 had Range of Motion (ROM) impairment to both lower extremities.

Based on staff interview, record review, policy reveiw, and facility investigation review, the facility failed to report Resident #2's, fall on [DATE], which resulted in a fracture to the left pelvis and hip, to the State Agency (SA). This concern was identified for one of four (1 of 4) residents reviewed for accidents and injuries. Findings include: Review of the facility's policy, titled, Incident Investigation and Reporting, revised (MONTH) (YEAR), revealed the facility administrator shall ensure that any incident involving an allegation or suspicion of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported not later than two (2) hours after the allegation is made to local law enforcement and the state agency, if the events that cause the allegation involve abuse or result in serious bodily injury are reported to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with state law. In this policy, Serious Bodily Injury is defined as any injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Review of the facility's Resident Incident Report, dated [DATE] at 2:00 PM, revealed the following: reported by CNA (Certified Nursing Assistant) that resident was assisted to the floor from the side of the bed. 2 (two) CNAs assisted resident into shower chair and took her to the shower. After shower resident was assisted back to bed and began complaining of pain. (Name of Doctor) in house and made aware of situation after assessment by (Name of Doctor), He ordered for her to be sent to ER (emergency room ) for xray of hip. Review of the facility's Incident Investigation regarding Resident #2's fall on [DATE] at 2:00 PM, revealed, CNA reported that she sat resident up on side of bed in preparation to transfer when resident started to slide off of mattress. CNA reported that she intervened and assisted resident to floor onto floor mat at bedside. 2 (two) CNAs assisted resident into shower chair from floor and too (take) her to the shower, then assisted back to bed. At that time, it was reported that resident starting c/o (complaining of) increased pain. MD (Medical Doctor) in house, assessed and ordered for resident to (be) sent for x-ray-eval for possible fx'd (fractured) hip. X-ray was positive for fx'd hip. Resident was admitted to hospital, returned to facility following brief hospitalization ; hip was not surgically repaired. Resident was sent back to hospital again not long after return, did not return to facility. The report was signed by the Administrator. On [DATE] at 2:50 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed she worked the day shift, but was unsure of the time she went into Resident #2's room to get her up for a shower. She sat the resident up on the side of the bed, and she just slid to the floor. CNA #1 confirmed there was no other CNA or staff member in the room at this time, or a lift to transfer the resident, only the shower chair. CNA #1 stated she went to get another CNA to assist her to get Resident #2 off the floor. CNA #2 helped her to get Resident #2 off the floor by manually picking her. CNA #1 confirmed she did not report this incident to the nurse until after the resident's shower when she began to complain of hip pain. An interview with the facility's Administrator, on [DATE] at 1:05 PM, revealed during the investigation regarding Resident #2's fall on [DATE], it was determined Certified Nursing Assistant (CNA) #1 attempted to get Resident #2 up alone, and not with two (2) people in the room to assist, which resulted in the fall. CNA #1 was terminated that day for failure to follow facility policy. The Administrator stated the event was discussed with the Regional Director and the Regional Nurse Consultant, and it was determined Resident #2's fall was caused by a facility policy violation, and not an abuse/neglect concern, and therefore did not need to be reported. A phone interview with the Registered Nurse (RN) who was the Director of Nurses (DON) at the time of the incident, on [DATE] at 8:17 AM, revealed she did remember the incident involving Resident #2. She stated she remembered a discussion regarding reporting the incident to the State Agency (SA), but stated it was decided by the Administrator and the Corporate Office if it was to be reported or not. Review of the hospital's Admission History and Physical (H&P), dated [DATE], revealed the Chief Complaint was left hip pain after a fall during a transfer at the nursing facility. Resident #2 was admitted to the hospital, on [DATE], with the [DIAGNOSES REDACTED]. Resident #2 was returned to the facility on [DATE]. Review of Resident #2's Departmental Notes revealed, on [DATE] at 2:09 AM, the resident had a change in the level of consciousness, and was transferred to the hospital for evauation and treatment. The next note, at 7:13 AM, revealed Resident #2 was admitted to the hospital for Altered Mental Status, Decreased Renal Function, and Urinary Tract Infection. Resident #2 expired at the hospital. Review of Resident #2's Death Certificate listed the immediate cause of death to be [MEDICAL CONDITION], and other conditions as [MEDICAL CONDITION] on [DATE] at 12:14 AM. Review of the Face Sheet Resident #2 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of [DATE], revealed Resident #2 scored 03 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment.

Based on observation, staff and family interview, record review, policy review, and facility investigation review, the facility failed to prevent a fall with serious injuries as evidenced by Certified Nursing Assistant (CNA) #1's failure to transfer Resident #2 with the correct number of staff, and use of a total lift. As a result, Resident #2 sustained a fracture to her left pelvic bone and hip.This concern was identified for one of four (1 of 4) sampled residents. Findings include: Review of the facility's policy, titled, Lifting Policy, revised (MONTH) (YEAR), revealed: The facility will strive to provide a safe work environment by providing and requiring the use of safety materials, equipment and training designed to help prevent personnel and resident injury. Failure to utilize a mechanical lift when the use of this equipment is indicated in resident's plan of care, unless exception is met, could result in disciplinary action up to and including termination of employment. When any mechanical lift is used, one (1) or more staff members must be in attendance. Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff. Dots to identify type of lift will be color coded as follows: Green - No assistance with Lifting Required - Independent for lifting. Blue - No mechanical lift required - Hold hand or assist x 1 (times one). Yellow - Stand -n- Lift - 1 (one) or more person transfer. Red - Total lift - 1 (one) or more person transfer. This information will be posted in a designated area and on Resident's ADL (Activies of Daily Living) documentation by writing the color, red, green, blue or yellow with the transfer instructions. The appropriate color dot will be placed at the head of the bed. A large red dot will be placed on the total lift and a yellow dot on the stand-n-lift. Review of the facility's Resident Incident Report revealed, on [DATE] at 2:00 PM, the following: reported by CNA (Certified Nursing Assistant) that resident was assisted to the floor from the side of the bed. 2 (two) CNAs assisted resident into shower chair and took her to the shower. After shower resident was assisted back to bed and began complaining of pain. (Name of Doctor) in house and made aware of situation after assessment by (Name of Doctor), He ordered for her to be sent to ER (emergency room ) for xray of hip. Review of the facility's Incident Investigation regarding Resident #2's fall on [DATE] at 2:00 PM, revealed, CNA reported that she sat resident up on side of bed in preparation to transfer when resident started to slide off of mattress. CNA reported that she intervened and assisted resident to floor onto floor mat at bedside. 2 (two) CNAs assisted resident into shower chair from floor and too (take) her to the shower, then assisted back to bed. At that time, it was reported that resident starting c/o (complaining of) increased pain. MD (Medical Doctor) in house, assessed and ordered for resident to (be) sent for x-ray-eval for possible fx'd (fractured) hip. X-ray was positive for fx'd hip. Resident was admitted to hospital, returned to facility following brief hospitalization ; hip was not surgically repaired. Resident was sent back to hospital again not long after return, and did not return to the facility. The report was signed by the Administrator. Resident #2 expired at the hospital on [DATE]. Review of the hospital's Admission History and Physical (H&P), dated [DATE], revealed the Chief Complaint was left hip pain after a fall during a transfer at the nursing facility. Resident #2 was admitted to the hospital, on [DATE], with the [DIAGNOSES REDACTED]. Resident #2 was returned to the facility on [DATE]. On [DATE] at 2:50 PM, a phone interview with Certified Nursing Assistant (CNA) #1 revealed she did not ask for assistance, or use the total lift to transfer Resident #2 to the shower chair on [DATE]. CNA #1 said she was attempting to sit Resident #2 up on the side of the bed, and she began to slide off the bed onto the floor. CNA #1 confirmed she was alone in the room at the time and a lift was not in the room, only a shower chair. CNA #1 stated she asked CNA #2 to assist her to get Resident #2 up off the floor, and together they picked Resident #2 up off the floor, and got her in the shower chair. CNA #1 confirmed she did not notify the nurse, so Resident #2 was not assessed for any injuries. CNA #1 stated she did not consider this a fall. CNA #1 stated Resident #2 began to complain of pain in her hip after her shower, and not before. CNA #1 stated Resident #2 was a sit to stand lift and had been assessed for the sit to stand lift, since I started working there in (MONTH) (YEAR). CNA #1 confirmed any resident requiring a lift, required two (2) people to be in the room to assist. CNA #1 stated Resident #2 was not a Hoyer/total lift. When asked if there should have been two (2) people in the room to sit Resident #2 up, CNA #1 stated, Yes ma'am and then stated, I was just going to sit her up, but then she just slid to the floor, I was unable to stop her once she started sliding. I should have had someone helping me. CNA #1 reported she worked the day shift that day, but could not recall what time the incident occurred. Review of the facility's Time Cards, dated [DATE], for CNA #1and #2 revealed CNA #1 clocked in at 6:49 AM and clocked out at 2:00 PM, and CNA #2 clocked in at 7:00 AM, and clocked out at 3:00 PM. Review of the facility's Lifting Policy Acknowledgement Form revealed CNA #1's signature at the bottom of the page, and dated [DATE]. The form stated this facility has implemented a Lifting Program for the safety of the staff, and comfort of it's patients. A sufficient number of lifting aids are availiable on each unit for the purpose of various types of difficult lifting. The specific lift to be used for each patient will be shown via a color coded sticker and other charting methods. Any staff member found physically lifting a patient who has been designated a Lift or Stand and Lift candidate could be subject to disciplinary action unless an exception occurs. Review of the facility's Inservice Training sheets, dated [DATE], revealed titled inservices for (1) All Incidents Must Be Reported, CNAs must notify the Charge Nurse. (2) If there is a fall (Resident, Staff, Visitor) and the person cannot get off the floor without assistance, a total lift must be used. This is to prevent injury. CNA #1's signature was documented on both of the inservice sign in sheets. The SA was unable to reach CNA #2 because her phone had been disconnected, and no other employees at the facility had a current number where she could be reached. On [DATE] at 8:17 AM, a phone interview, with the Director of Nurses (DON) at the facility at the time of the incident, revealed she did remember the event involving Resident #2, and stated CNA #2 came to her and reported something was suspicious, and felt like something wrong had occurred with Resident #2. CNA #2 reported CNA #1 asked her to help pick Resident #2 up off the floor and put her into the shower chair. The DON stated CNA #2 confirmed there was no lift in the room at the time of the event, only the shower chair. The DON stated after the investigation, CNA #1 was terminated for failure to follow the facility lift policy, and failure to notify the nurse of Resident #2's fall/slide to the floor until after the incident, and therefore the resident was not assessed for any sign of injury. The DON stated CNA #1 and CNA #2 picked Resident #2 up off the floor without the use of a lift, and took Resident #2 to the shower room. The DON reported CNA #2 stated in the investigation that she felt like CNA #1 was trying to hide something. An interview, on [DATE] at 1:05 PM, with the facility Administrator revealed during the investigation regarding Resident #2's fall, on [DATE], it was determined CNA #1 attempted to get Resident #2 up alone, and not with a lift and two (2) people in the room to assist, which resulted in the fall. CNA #1 was terminated that day for failure to follow facility policy. An interview, on [DATE] at 1:20 PM, with the DON revealed Resident #2 was changed from a sit to stand Lift to a total lift with two (2) person assist on [DATE]. The DON confirmed CNA #1 did not follow Resident #2's lift and transfer needs when the fall occurred, on [DATE], due to not using the total lift, and having two persons present in the room.The DON stated that was the reason CNA #1 was terminated that day. Review of Resident #2's most recent Transfer Assistance Screen, dated [DATE], revealed the Resident's Lifting Plan was marked Red, for a total lift. An interview, on [DATE] at 3:40 PM, with the DON revealed CNA #1 did not immediately notify the nurse that Resident #2 had fell during a transfer on [DATE], and then asked CNA #2 for assistance to get Resident #2 off the floor, and put her into the shower chair and take her for a shower. Resident #2 then began to complain of pain on return from the shower. The Nurse assessed Resident #2, and notified the Primary Care Physician (PCP). Resident #2 was sent to the emergency room (ER) for an evaluation. The DON stated Neuro checks were initiated because they were not sure if Resident #2 hit her head during the fall. The DON stated CNA #1 failed to follow Resident #2's lift status, to report the fall/incident immediately, and therefore failed to follow facility policy when she got another staff member to help get Resident #2 off the floor instead of notifying the nurse. CNA #2 also did not follow the facility policy, but later in the day did report the incident, and she no longer works here either. The DON stated she was not the DON at the time of the incident, but was a Nursing Supervisor. An interview, on [DATE] at 8:35 AM, with Resident #2's Primary Care Physician (PCP) revealed Resident #2 was a frail, elderly, demented, and non-communitive resident. The PCP stated when making rounds, on [DATE], he was notified Resident #2 had a fall, and had pain. The PCP stated he went in the room to check on Resident #2 but she was asleep, and he continued to make rounds. The PCP stated when he completed making rounds he returned to Resident #2, and after his assessment, Resident #2 was sent to the emergency room (ER) for an evaluation because of hip pain. The PCP stated it was reported to him that Resident #2 started having leg and hip pain after she was not transferred correctly, and had a fall to the floor. The PCP stated he remembers being upset because of the lack of documentation as to what actually happened, and documented this in his progress notes for that day. Resident #2's son was present, and was notified of the occurrence, and the need for Resident #2 to be transferred to the ER for an evaluation. When Resident #2 returned to the facility, she had an inoperable hip/pelvis fracture, but then had to return to the hospital. The PCP stated he was not sure what was listed as to the cause of death for Resident #2. Review of the physician progress notes [REDACTED].#2's PCP documented: poorly documented fall this AM, resident C/O (complained of) right hip pain, slept for three (3) hours this afternoon, awakens with continued right hip pain and pain with movement of right leg, family present and will transport to the ER for evaluation. Review of the physician progress notes [REDACTED].#2's PCP documented: back from fx. (fracture) has [MEDICAL CONDITION] ramus of the pelvis and impacted femoral neck fx pt (patient) has slept all day. Poorly arousable An interview, on [DATE] at 8:30 AM, with Resident #2's son revealed he was informed of the incident by the PCP on his arrival to the facility for a visit, and prior to the transport to theER on [DATE]. He stated Resident #2 was in a lot of pain, and drowsy. He also stated he never really got a clear explanation by the facility as to what happened to his mother, only that something occurred during her being transferred from the bed to the shower chair. The son also stated he had observed staff lifting her alone without a lift. He stated it depended on the CNA, and if they were strong enough to lift her alone. He stated some could not, and some could. He stated Resident #2 was admitted to the hospital with [REDACTED]. He stated she was sent back to the facility after about a day and a half, but in the next day or two was sent back to the hospital, and had a [DIAGNOSES REDACTED]. He stated Resident #2 died in less than two weeks after her fall and [MEDICAL CONDITION], and she never really woke up good she just worsened and died . Review of Resident #2's Departmental Notes, dated [DATE] at 2:09 AM, revealed the resident had a change in the level of consciousness, and (Name of Doctor) was called. A new order was received to send the resident to the ER (emergency room ) for evaluation and treatment. The next note, at 7:13 AM, revealed Resident #2 was admitted to the hospital for Altered Mental Status, Decreased Renal Function, and Urinary Tract Infection. Review of the hospital's H&P, dated [DATE] at 5:59 AM, revealed upon Resident #2's arrival to the ER, the nursing staff reported reports of altered mental status, low blood pressures, and oxygen saturations (O2 sats). Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's Discharge Summary, dated [DATE], revealed the final [DIAGNOSES REDACTED]. Review of Resident #2's Death Certificate revealed the immediate cause of death to be [MEDICAL CONDITION], and other conditions as [MEDICAL CONDITION] on [DATE] at 12:14 AM. The SA made observations of lift transfers for Unsampled Residents A, B, and C during the survey, and no concerns were identified. An interview, on [DATE] at 11:35 AM, with CNA #3 revealed Resident #2 had been changed from a sit to stand lift to a Hoyer/total lift around (MONTH) (YEAR). CNA #3 stated Resident #2's lift status was changed because Resident #2 would complain of hurting underneath her arms when she was lifted alone, so the facility started using a lift. An interview, on [DATE] at 11:45 AM, with Licensed Practical Nurse (LPN) #2, revealed she did not remember which lift Resident #2 was assessed for at the time of her fall. LPN #2 stated when she supervised the staff, she would observe to ensure they were using the correct lifts, there were two (2) staff members, the lift was connected correctly, and they were following facility policy. An interview, on [DATE] at 12:00 PM, with CNA #4 revealed she had been employed at the facility for three (3) years. CNA #4 stated any lift requires two (2) staff members to be present. CNA #4 stated if the wrong lift was used, you could hurt yourself, the resident, or your partner. CNA #4 stated a card is placed behind the bed that includes the type of lift, red is for the Hoyer/total lift, yellow is for the sit to stand lift, and blue means the resident can stand and pivot, and only needs assistance of one (1) person. An interview, on [DATE] at 10:40 AM, with the Quality Assessment (QA) Nurse revealed the Nurse Case Manager is responsible for the lift assessments, and they are done as needed and quarterly. This nurse stated the previous Director of Nursing (DON) would do spot checks to make sure the correct lift was being used, and if the Care Plan was followed. The QA nurse stated an emergency QA meeting was held this morning to address the concerns identified on Resident #2's fall on (MONTH) 4, (YEAR), and the use of the lifts. The QA Nurse reported all Administrative staff were present, and the Medical Director was by phone. The QA Nurse reported now audit tools would be added, and monitoring of these would be done as well. An interview, on [DATE] at 11:12 AM, with LPN #1 revealed during her supervision of the lifts, she would ask the CNAs who they were lifting, what is their lift status, and make sure the correct number of people are present to assist with the lift. LPN #1 stated she had not identified concerns related to staff not using the right lift, or have the correct number of people present because this is a No Lift facility, no one is to use a lift alone, and if they do it is grounds for immediate termination. An interview, on [DATE] at 11:22 AM, with LPN #3 revealed part of her responsibility for supervising staff was making sure the proper number of staff, and proper equipment was used for lifting and transferring residents. LPN #3 stated she would observe if the correct lift is used, if it is hooked properly, and the right number of people are present. LPN #3 stated she also checks to make sure the lift being used is correct. LPN #3 confirmed daily checks are done, and has not identified any concerns with the use of lifts. An interview, on [DATE] at 11:30 AM, with LPN #4 revealed she worked the night shift, and would assist the CNAs with transfers, and check to make sure the right lift is being used, and the right number of people were assisting. LPN #4 stated if there was a change in a resident's lift/transfer status the nurses or CNAs would notify the Minimum Data Set (MDS) nurse. LPN #4 stated when supervising the staff for resident lifts and transfers, she would look at the communication board in the room to see each resident's lift status. Review of the Face Sheet revealed Resident #2 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of [DATE], revealed Resident #2 scored 03 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Further review of the MDS revealed Resident #2 required extensive assistance with one person physical assist with bed mobility, transfers, dressing and toilet use. Resident #2 required extensive assist with limited personal physical assist with locomotion on and off the unit, eating, personal hygiene, and bathing. Resident #2's balance was not steady, and only able to stabilize with staff assistance with moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #2 had Range of Motion (ROM) impairment to both lower extremities.