Every finding on record at Hardin County NH

Based on policy review, medical record review, and interview, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after the addition of a new mental illness diagnosis for 2 of 2 (Resident #17 and #21) sampled residents reviewed for PASRR. The findings include: 1. Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), dated 10/1/2024, revealed .PASRR requires that.all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness.A negative Level I screen permits admission to proceed and ends the PASARR [PASRR] process unless a possible serious mental disorder . arises later.An individual is considered to have a serious mental illness.Diagnosis.anxiety disorder.psychotic disorder; or another mental disorder that may lead to a chronic disability.If a significant change in status assessment (SCSA) occurs for an individual known or suspected to have a mental illness.a referral to the State Mental Health.for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.Referral should be made as soon as the criteria in indicating such are evident - the facility should not wait until the SCSA is complete. 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Depression, Conduct Disorder, Impulse Disorder, and Anxiety. Review of the facility document titled, Pre-admission SCREENING and RESIDENT REVIEW: PASRR dated 9/23/2014, revealed Resident #17 was not noted for the diagnoses of Bipolar Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact and had diagnoses including Anxiety, Depression, and Bipolar Disorder. Review of the Psychiatric Evaluation dated 12/18/2024, revealed .Recommended .add dx [diagnosis] . [bipolar disorder] to diagnosis list . Review of the medical record revealed no documentation that a PASRR had been resubmitted for Resident #17 after the addition of a new mental illness diagnosis of Bipolar Disorder on 12/20/2024. The facility failed to update Resident #17's PASSR after the addition of a new mental health diagnosis. 3. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Hyperlipidemia, and Hypertension. Review of the PASRR dated 7/19/2024, revealed Resident #21 was marked for no mental health diagnosis, no known mental health behaviors, and no prescribed psychoactive medications. Review of the medical record revealed a consent to treat form for the named psychiatric service group dated 12/4/2024, signed by Resident #21's representative. Review of the Psychiatric Periodic Evaluation dated 12/4/2024, revealed, .social services request that I see as resident is having some increasing distressing delusions at times.She is having some paranoia that is worse at night. She is having these thoughts that people are coming into her room and chasing her around. Thinks people are out to get her or trying to harm her.We talked about Parkinson's disease and how there is a high percentage of patients who to develop psychosis secondary to it. We talked about the use of Seroquel.Resident does report feeling depressed. Reports that these feelings are overwhelming and upsetting to her.Recommend adding Seroquel 25mg [milligram] po [by mouth] q [every] hs [hour of sleep] for psychotic disorder with delusions. Goal to increase over the next few visits until psychosis is improving. Review of the medical record revealed Resident #21 was newly diagnosed with Psychotic Disorders with Delusions on 1/02/2025, Anxiety Disorder on 2/12/2025, and Depression on 5/13/2025. The facility failed to update Resident #21's PASRR to reflect the new mental health diagnoses. Review of the quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. Resident #21's MDS revealed hallucinations and delusions during the assessment period. Resident #21's active diagnoses were Anxiety Disorder and Psychotic Disorder. Resident #21 received an antipsychotic and antidepressant during the last 7 days. Review of the Medication Administration Record (MAR) dated 2/2026, revealed Resident #21 received Prozac (medication used to treat Depression) 10 mg one time per day and Seroquel (medication used to treat psychiatric conditions) 100 mg at bedtime daily. Review of the Physician signed Medication Review Report dated 1/20/2026 -3/26/2026 revealed an order for Prozac 10 mg by mouth one time a day for Anxiety/Depression with an order date of 5/13/2025. Continued reviewed revealed an order for Quetiapine Fumarate (Seroquel) 100 mg by mouth at bedtime for Psychotic Disorder with delusions with an order date of 8/20/2025. During an interview on 2/19/2026 at 8:10 AM, Licensed Practical Nurse (LPN) A was asked when Psychiatric services started seeing Resident #21. LPN A stated, .her first visit was on 12/4/2024 and the consent was done on 12/4/2024. LPN A was asked when Resident #21 started taking Seroquel and Prozac. LPN A verified Seroquel was started on 12/4/2024 for psychotic disorder with delusions and Prozac started on 2/7/2025 for Depression. LPN A was asked if a new PASRR should be submitted with any new mental illness diagnoses or new orders for psychotropic medications. LPN A stated, .yes, it was my own ignorance for not auditing.all of them [referring to PASRR] since I just started doing this in August, 2025. During an interview on 2/19/2026 at 4:12 PM, the Director of Nursing (DON) was asked when a PASRR should be updated. The DON stated .when a resident has any changes related to psych medications or diagnosis.

Based on policy review, medical record review, and interview, the facility failed to ensure staff were administering medications per Physician's Orders for 1 of 5 (Resident #5) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Administration of Drugs, dated 12/2008, revealed .give medications per physician's orders. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Presence of Artificial Larynx, Hemiplegia (paralysis affecting one side of the body), Depression, Anxiety and Fractured Fibula. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #5 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Review of the Physician's Order dated 12/30/2025, revealed .Nystatin [used to treat yeast infections] External Powder 100000 UNIT/GM [gram].Apply to perineal [area between the genitals and rectum] area topically [applied to skin] four times a day for yeast. Review of the Treatment Administration Record (TAR) dated 2/1/2026 - 2/28/2026, revealed Nystatin External Powder was not administered as ordered on the following dates: a. 2/2/2026 5:00 PM b. 2/7/2026 9:00 PM c. 2/9/2026 9:00 AM, 12:00 PM, 5:00 PM d. 2/10/2026 9:00 AM, 12:00 PM, 5:00 PM e. 2/13/2026 9:00 PM Review of the Physician's Order dated 12/31/2025, revealed .Aquaphor Adv [Advanced] Therapy Healing External Ointment 41% [percent] [used to treat dry skin].Apply to legs and feet topically every day shift for dry skin. Review of the TAR dated 2/1/2026 - 2/28/2026, revealed Aquaphor Adv Therapy Healing External Ointment was not administered as ordered on the following dates: a. 2/9/2026 9:00 AM b. 2/10/2026 9:00 AM Review of the Physician's Order dated 1/5/2026, revealed .Apply Skin Prep [protects the skin from irritation] to right heel every day shift. Review of the TAR dated 2/1/2026 - 2/28/2026, revealed Skin Prep was not administered as ordered on the following dates: a. 2/2/2026 9:00 AM b. 2/9/2026 9:00 AM c. 2/10/2026 9:00 AM Observation of wound care on 2/27/2026 at 2:20PM, revealed redness to the right heel. Review of the Physician's Orders dated 1/6/2026, revealed . Left Lateral (outside) Ankle: Apply Skin Prep @ [at] HS [bedtime] for prevention. Review of the TAR dated 2/1/2026 - 2/28/2026, revealed Skin Prep was not administered as ordered on the following dates: a. 2/7/2026 9:00 PM b. 2/13/2026 9:00 PM Review of the Physicians Orders dated 1/8/2026, revealed . Apply Moisture Barrier [protects the skin from excessive moisture] cream topically to Bilateral [both] Buttocks every day shift and night shift. Review of the TAR dated 2/1/2026 - 2/28/2026, revealed Moisture Barrier was not administered as ordered on the following dates: a. 2/7/2026 night shift b. 2/9/2026 day shift c. 2/10/2026 day shift d. 2/13/2026 night shift During an interview on 2/19/2026 at 1:23 PM, the Director of Nursing (DON) was asked whether staff should administer medications as ordered by the Physician. The DON stated, Yes.

Based on facility policy review, medical record review, facility investigation, observation, and interview, the facility failed to provide adequate supervision and assistance to prevent fall accidents for 1 of 8 residents (Resident #3) reviewed for falls and failed to perform fall assessments per facility policy for 6 of 8 residents (Resident #5, #12, #14, #22, #26, and #187) reviewed for falls. The facility failed to implement the care plan intervention of staying with Resident #3 while toileting on 8/13/2024, when Resident #3 fell from the toilet and sustained an oblique (neither parallel nor at right angle, slanting) impaction fracture (bone fracture when pressure is applied to both ends of a bone, causing it to split and jam together) of the proximal tibial metaphysis (the enlarged lower part of the shinbone that meets the knee joint) and a nondisplaced transverse impaction fracture of the fibular neck (broken bone still aligned in the narrow part of bone just below the knee joint), resulting in Actual Harm to Resident #3. The Findings Include: 1. Review of the facility's policy titled, Falls, revised 12/2024, revealed .The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls .All residents will have a fall risk assessment on admission/readmission, quarterly, annually, and with a significant change of condition to identify risk for falls .The care plan will be reviewed following each fall, quarterly, annually, and with a significant change in condition .Care Plan goals and interventions will be revised as applicable . 2. Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE], with diagnoses including Fracture of Upper End of Left Tibia, Difficulty in Walking, Pain in Left Lower Leg, and History of Falling. Review of the Care Plan for Resident #3 revealed a fall intervention dated 4/15/2024, for staff to remain with resident while in the bathroom. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #3 was severely cognitively impaired, required maximal assistance with toileting and transfers, and was occasionally incontinent of urine. Review of the Progress Notes dated 8/13/2024, revealed, .3:58 PM . Called to [Resident #3]'s room, resident is on the floor, observed resident sitting on the floor back against the toilet bowl and wall. Left leg folded under resident .assist to wheelchair, noted swelling and bruising to area under L [left] knee .MD [Medical Director] and [Family Member (FM) FF] notified of incident. No orders at this time .4:20 PM .order received for a L Knee, L Tibia Fibula [the two long bones in the lower leg] Xray .8/13/2024 8:40 PM .Received results from xrays on LLE [Left Lower Extremity]. Findings showed an oblique impaction fracture of the proximal tibial metaphysis and a nondisplaced transverse impaction fracture of the fibular neck. [Director of Nursing (DON)] .notified. Dr [Doctor] .notified and order to send to ER [emergency room ] for eval [evaluation] .FM [Family Member FF] arrived at nursing home 9:15 PM Dr .called back to give order for Tramadol [pain medication] 50mg [milligram] 0.5 or 1 tab PO [by mouth] Q [every] 6HRS [hours] PRN [as needed] for moderate to severe pain and to Send to ER as long as [FM FF] approves. Resident given Tramadol 50mg po at 9:30 PM. Transferred to stretcher and taken to ER at 9:35 PM with [FM FF] present . Review of the facility's Incident Investigation dated 8/13/2024, revealed .noted resident [#3] on the floor of her bathroom .noted large bruise to L [left] knee area .Mental Status .oriented to self, confused to time and place .IDT [Interdisciplinary Team] investigated incident. [Certified Nursing Assistant (CNA) A] stepped away from resident while on toilet to check on another resident. Resident attempted to transfer unassisted due to cognitive impairment. Intervention: re-educate staff to constantly observe resident while toileting . Review of the Medication Administration Record (MAR) dated 8/2024, revealed Resident #3 received Tramadol 25 mg on 8/13/2024 post fall for a pain level of 10 on a pain scale of 1-10 (1 being the lowest and 10 being the highest). Review of Hospital #1's History and Physical Exam for Resident #3 dated 8/14/2024, revealed .EMS [Emergency Management Service] from [Hospital #2] .with complaint of left lower extremity pain. Associated symptoms include right distal thigh pain .was told she was getting off the BSC [bedside commode] about 1430 [2:30 PM] 8/13/24 [2024] and fell getting up. Her left lower extremity is bruised and dark in color .XR [x-ray] left tibia/fibula impression .There is an oblique impaction fracture of the proximal tibial metaphysis. There is also a nondisplaced transverse impaction fracture of the fibular neck. There is associated soft tissue swelling, XR right femur. No acute abnormality .Left tibia-fibula fracture was suspected, patient transferred for higher level of care. On imaging .appears to be possible horizontal fracture .Patient admitted for possible left tibial fracture, to be seen by orthopedics and consideration given to conservative versus operative intervention . Review of the MAR dated 8/2024, revealed Resident #3 received 21 doses of Tramadol 25 mg PRN from 8/15/2024-8/31/2024, with a pain range from 1-7. Further review revealed Resident #3 received 8 doses of Tylenol 325 mg PRN from 8/16/2024-8/31/2024. Review of the MAR dated 9/2024, revealed Resident #3 received 21 doses of Tramadol 25 mg PRN and 8 doses of Tylenol 325 mg tablet PRN. Review of the MAR dated 10/2024, revealed Resident #3 received 12 doses of Tramadol 25 mg PRN and 7 doses of Tylenol 325 mg tablet PRN. Review of Resident #3's Physician Orders dated 1/2025 revealed an order for a leg brace to be worn on her left leg when up in the wheelchair and with any weight bearing activity. Review of a Nursing Home Patient Encounter note for Resident #3 dated 12/26/2024, completed by the MD, revealed .Pt. [patient] continues to have pain & instability of L [left] leg-s/p [status post] tibial fracture. Continues to wear a knee immobilizer . Observation in the dining room on 1/21/2025 at 3:57 PM, revealed Resident #3 was sitting in a wheelchair with an immobilizer brace to her left leg. Resident #3's left leg was notably internally rotated. During an interview on 1/23/2025 at 7:17 AM, the DON stated, [CNA A] had stepped away to help another resident. The DON was asked if CNA A was following the care plan interventions to prevent falls for Resident #3. The DON confirmed CNA A was not following the interventions to prevent a fall. The DON stated, .I did some one-on-one education with [CNA A] . During an interview on 1/23/2025 at 7:19 AM, the MDS Coordinator reviewed the care plan for Resident #3 with the surveyor and verified the fall intervention for staff to remain with the resident, while in the bathroom, was placed on the care plan on 4/15/2024 prior to Resident #3's fall on 8/13/2024. The MDS Coordinator stated the CNAs can review the care plan and the Kardex (a system used to access patient information). The Kardex was reviewed with the MDS Coordinator which also noted for Resident #3, .Staff to remain with resident, while in bathroom . During an interview on 1/23/2025 at 9:53 AM, the Infection Control nurse stated, .we do a quarterly assessment for falls, follow the interventions, and then [the] MDS Coordinator would put it on the care plan .We provided education after the fall .stay with the resident if we place them on the toilet . During an interview on 1/23/2025 at 10:09 AM, CNA C stated, .If I take a resident to the bathroom, I will stay with them, sometimes keep [the] bathroom door cracked to give privacy but watching for residents trying to get up without assistance . 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Presence of Right Artificial Knee Joint, Psychotic Disorder with Delusions, Dementia, and Osteoarthritis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #5 was cognitively intact, received supervision with standing, chair to bed transfers, and walking, and had no falls since the prior assessment. Review of the Morse Fall Scale assessment (Fall Risk Assessment) dated 11/14/2024, revealed, .Category: High Risk for Falling .Score: 90 .Fall Risk is based upon Fall Risk Factors .Determine Fall Risk Factors and Target Interventions to Reduce Fall Risks .Complete on admission, quarterly, at change of condition and after a fall .Has the Resident ever fallen before .Yes .What ambulatory aids if any, does the resident use .Uses furniture for support .GAIT .Impaired .Mental Status .Knows own limits . Review of the facility's Incident Investigation dated 1/2/2025, revealed .Resident [#5] stated that she was sitting on the edge of the bed and began to slide off the side of the bed and landed on buttocks on the floor . Review of Resident #5's Care Plan dated 1/13/2025, revealed .The resident is at risk for falls .Anti-skid strips to be placed in floor in front of bed .Date Initiated .1/2/2025 . The facility was unable to provide a Fall Risk Assessment for the fall that occurred on 1/2/2025 for Resident #5. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Depression, Urinary Tract Infection, Dementia, Acute Kidney Failure, Diabetes, Adult Failure to Thrive, and Anxiety. Review of the significant change MDS dated [DATE], revealed a BIMS score of 3, which indicated Resident #12 was severely cognitively impaired, required maximum assistance of staff with bed mobility and transfers, used a wheelchair for mobility with assistance of staff, had 2 falls since the prior assessment, and had bed and chair alarms to alert the staff of Resident #12's movements. Review of the facility's Incident Investigation dated 8/19/2024, revealed .Resident [#12] had been propelling self in hallway during this shift and had propelled self into her room. Resident's chair alarm started going off and when the nurse went to check on her resident was sitting on edge of WC [wheelchair] before nurse could assist resident back into WC she suddenly slid off chair landing on right hip area and sustaining a skin tear to right FA [forearm] . Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #12 was severely cognitively impaired, and had behaviors including rejection of care and wandering. Review of the facility's Incident Investigation dated 10/16/2024, revealed .resident [#12] was in dining room after supper .residents' [resident's] [chair] tipped backwards while she was in it . Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated the Resident #12 was severely cognitively impaired, and had wandering behaviors. Review of the Care Plan dated 11/25/2024, revealed .The resident [#12] is at risk for falls .Bed alarm to be placed while resident is in bed. check placement and function each shift .Dycem [a non-slip, non-adhesive material] to be placed in rock and go chair [a wheelchair that is designed to either be used like a regular chair, a tilted back wheelchair, or a rocking chair] at all times . During an interview on 1/21/2025 at 4:11 PM, the DON was asked when a resident falls, when should the care plan be revised. The DON stated, On that day . The facility was unable to provide Fall Risk Assessments for the falls that occurred on 8/19/2024 and 10/16/2024, the readmission on 8/23/2024 and the significant change assessments on 8/30/2024 and 11/21/2024 for Resident #12. 6. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Atherosclerotic Heart Disease, Abnormalities of Gait and Mobility, Muscle Weakness, and Fracture of the Left Pubis. Review of the Morse Fall Scale assessment dated [DATE], revealed .Category: High Risk for Falling .Score: 75 .Fall Risk is based upon Fall Risk Factors .Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall . Has the Resident ever fallen before .Yes .GAIT .Impaired .Mental Status .Overestimates or forgets limits . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #14 was severely cognitively impaired, received maximum assistance from staff for bed mobility, transfers, ambulation and toileting, and used a walker and a wheelchair for mobility. Review of the facility's Incident Investigation dated 12/12/2024 at 2:55 PM, revealed .Heard resident talking in hallway. Checked on resident and noted her sitting in the floor in front of the shower room .Sign on bathroom door stating BATHROOM to cue resident of location of bathroom [initiated 12/12/2024] . Review of the care plan dated 12/16/2024, revealed .The resident [#14] is at risk for falls r/t [related to] history of Fracture, Confusion, Gait/balance problems, Unaware of safety needs .Place sign on bathroom door BATHROOM Date Initiated: 12/12/2024 . The facility was unable to provide a Fall Risk Assessment for the fall on 12/12/2024 for Resident #14. 7. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, and Hypertension. Review of the facility's Incident Investigation dated 7/26/2024, for Resident #22 revealed, .resident was scooting back in his wheelchair and slide off the edge of the chair . Review of Resident #22's Morse Fall Scale dated 10/13/2024, revealed .Category: High Risk for Falling .Score 75 .Instructions Fall Risk is based upon Fall Risk Factors and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall . Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #22 was severely cognitively impaired and required maximal assistance with bed mobility and sit to stand. Review of the facility's Incident Investigation dated 12/26/2024, revealed .observed resident [#22] attempting to stand from wheelchair while in the dining room. Resident not fully standing erect, lost his balance and fell to the floor landing on Left shoulder . The facility was unable to provide Fall Risk Assessments for the 7/26/2024 and 12/26/2024 falls for Resident #22. 8. Review of medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Myocardial Infarction, Fall, Coronary Artery Disease, Diabetes Mellitus, Osteoarthritis, Alzheimer's Disease, and Parkinsonism. Review of the Morse Fall Scale assessment for Resident #26 dated 12/28/2024, revealed .Category: High Risk for Falling .Score: 65 .Fall Risk is based upon Fall Risk Factors .Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall . Has the Resident ever fallen before .Yes .What type of gait does the resident exhibit .Weak .Mental Status .Overestimates and forgets limits . Review of the facility's Incident Investigation dated 1/2/2025 at 12:25 PM, revealed .Social worker was coming through the door when resident [#26] stood up and reached for the wall rail. When resident fell to the floor, he didn't hit his head .No injuries observed at time of incident .Intervention: Staff assist with ambulation as desired during periods of agitation . Review of the care plan dated 1/2/2025, revealed .The resident [#26] is at risk for falls r/t Gait/balance problems, muscular weakness .Ensure resident is wearing appropriate footwear when ambulating in w/c [wheelchair] .Staff to assist resident with ambulation as desired . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #26 was moderately cognitively impaired, received maximum assistance of staff for bed mobility, transfer, and toileting, received moderate assistance with ambulating 10 feet, used a wheelchair and walker for mobility, and had 1 fall since prior admission with no injury. Review of the facility's Incident Investigation dated 1/6/2025 at 2:50 PM, revealed .few minutes after leaving the room .heard him [Resident #26] doing something .started falling knocking everything off his table .Skin Tear .Left Elbow .Intervention: Position resident at nurse's station while up and out of bed . Review of the care plan updated on 1/6/2025, revealed: .The resident [#26] is at risk for falls r/t [related to] Gait/balance problems, muscular weakness .Occupational Therapy 5x [times] wk [week] x 30day [30 day] see order for treatment .Physical Therapy 5xwk [5 times a week] x 30days see order for treatment .Position resident at Nurses station while up and out of bed . Review of Progress Note dated 1/9/2025 at 3:55 PM, revealed .Resident [#26] sitting in wheelchair in hall at nurses' desk. Resident attempted to get up and fell in floor .no apparent injuries . Review of the care plan revised on 1/9/2024, revealed .The resident [#26] is at risk for falls r/t Gait/balance problems, muscular weakness . Instruct staff to make sure wheelchair is locked when in use by resident. Also offer an afternoon snack Date Initiated: 1/9/2025 . Review of the facility's Incident Investigation dated 1/11/2025 at 11:16 AM, revealed .At 9 am [9:00 AM] staff seen resident [#26] slide out of the chair .No injuries observed at time of incident .Resident Slid from chair. Intervention: Dycem to w/c to prevent sliding . Review of the care plan revised on 1/11/2025, revealed .The resident [#26] is at risk for falls r/t [related to] Gait/balance problems, muscular weakness .Place dycem in wheelchair . The facility was unable to provide Morse Fall Score assessments for Resident #26's falls on 1/2/2025, 1/6/2025, 1/9/2025, and 1/11/2025. 9. Review of the medical record revealed Resident #187 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Fracture Left Radius, Urinary Tract Infection, Dementia, Atrial Fibrillation, and Pacemaker. Review of the Morse Fall Scale dated 11/19/2024, revealed .High risk for falls .Score: 60.0 .Fall Risk is based upon Fall Risk Factors .Determine Fall Risk Factors and Target Interventions to Reduce Fall Risks .Complete on admission, quarterly, at change of condition and after a fall .Has the Resident ever fallen before .Yes .GAIT .Impaired .Mental Status .Overestimates or forgets limits . Review of the care plan dated 11/22/2024, revealed .[Resident #187] is at risk for falls r/t Confusion, Gait/balance problems, Muscular Weakness .Ensure that the resident is wearing appropriate footwear .needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, Side rails as ordered, handrails on walls, personal items within reach . Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #187 was moderately cognitively impaired, received maximum assistance from staff with toileting, transferring and bed mobility, used a wheelchair for mobility and had no falls since admission. Review of the care plan revised on 12/4/2024, revealed .Reclining geri-chair [a wheeled recliner that offers adjustable support and positioning for individuals with mobility challenges] as needed for positioning every shift . Review of the facility's Incident Investigation dated 12/6/2024, revealed .[Resident #187] found kneeling on the floor next to her [Resident #187] bed by CNA .Floor mats added to room r/t decreased safety awareness . Review of the care plan revised on 12/6/2024, revealed .Floor mat to be placed at bedside . The facility was unable to provide a Fall Risk Assessment for Resident #187 for the fall on 12/6/2024. 10. During an interview on 1/23/2025 at 2:00 PM, the Director of Nursing (DON) confirmed the Morse Fall Score assessments are used by the facility to determine a resident's risk for falls and are to be completed on admission, quarterly and at change of condition. The DON was asked should the physician be notified of a change in condition. The DON stated, Yes. The DON was asked if the physician should be notified after a fall. The DON stated, Yes. The DON confirmed a fall is considered a change in condition. During an interview on 1/23/2025 at 3:47 PM, the MDS Coordinator confirmed she does not document actual falls on the care plan. The MDS Coordinator stated, I did but I was told not to. I was told that it wasn't appropriate, that the intervention with the fall date would be the same thing . The MDS Coordinator confirmed that Resident #187 had an intervention of a geri chair for positioning added on to the care plan on 12/4/2024 but did not have a fall on that date. The MDS Coordinator confirmed that interventions are put in place at times when a fall has not occurred and do not necessarily reflect an actual fall has occurred. 44724 50780

Based on review of facility policy, Quarterly Payroll Based Journal (PBJ) review and interview, the facility failed to report PBJ for Quarter 1 of 2024 (October 1, 2024- December 31, 2024). The findings include: 1. Review of the undated facility policy titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal), revealed, .Direct-care staffing and census information will be reported electronically to CMS though the Payroll-Based Journal System (PBJ) system . 2. Review of the Quarterly Payroll Based Journal (PBJ) dated 10/1/2024 - 12/31/2024, revealed, .Failed to Submit Data for the Quarter . During an interview on 1/23/2025 at 3:38 PM, the Administrator confirmed the facility failed to submit the PBJ data, by the required deadline, for the first quarter of 2024.

Based on facility policy, observations, and interviews, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions when 1 of 6 (Dietary [NAME] B) dietary staff failed to sanitize the thermometer after each use, and when the facility failed to ensure the deep fryer and the cooking stove eyes were clean. The facility had a census of 39 with 39 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, Food Preparation Area, dated 5/2013, .Our facility will maintain a clean, sanitary, and safe food preparation area . 1. Observation in the Kitchen on 1/21/2025 at 4:09 PM and 1/23/2025 at 8:28 AM, revealed the deep fryer had dark brown cooking grease with brown crumbs floating on top of the cooking oil and the cooking stove eyes had black build up. 2. Observation in the Kitchen on 1/22/2025 at 10:52 AM, revealed Dietary [NAME] B took the temperature of the broccoli, placed the thermometer into the roast beef and failed to clean the thermometer prior to taking the temperature of the roast beef. Dietary [NAME] B took the temperature of the roast beef bites, the mechanical roast, the puree beans, puree carrots, puree potatoes, baby carrots, diced potatoes, and failed to sanitize with a clean wipe in between each food item. 3. During an interview on 1/23/2025 at 9:46 AM, the CDM was asked what should staff do when taking food temperatures. The CDM stated, . take the alcohol swab and wipe the thermometer off, place the thermometer in the center of the food .remove .each time use a new alcohol pad to wipe off the thermometer before taking temperature of another, the process repeats itself . The CDM was asked when the deep fryer should be cleaned and refilled with clean cooking oil. The CDM stated The deep fryer should be cleaned weekly on Sundays .need to be able to see through the grease or if grease gets dirty need to clean and change the grease . During an interview on 1/23/2025 at 9:59 AM, the CDM confirmed there was black build up on the 6 cooking stove eyes. The CDM confirmed it was carbon build up and the carbon build up should not be on the cooking stove eyes. The CDM stated, .we should have sprayed down and removed the carbon . The CDM confirmed the deep fryer contained brown crumbs and dark brown grease that you could not see through. The CDM stated, .we for sure need to remove the grease and clean the deep fryer .

Based on policy review, medical record review, and interview, the facility failed to conduct care plan conference with the resident and/or family representative for 1 of 12 (Resident #28) sampled residents reviewed for care plan conferences. The findings include: 1. Review of the facility policy titled, Care Plan Meeting dated 12/2024, revealed .A Care Plan meeting is conducted to demonstrate to the resident, family, and resident representative that the organization is dedicated to the provision of person-centered care to achieve the resident's highest practicable well-being and outcomes of the resident's ongoing health and safety concerns .MDS Coordinator or designee will set the appointment date and time with the resident, family/representative .The Interdisciplinary Team (IDT) will introduce themselves and explain their roles on the care team. The IDT will obtain additional pertinent information regarding the resident's clinical status, prior living conditions, and the presence of family/local support to determine the resident's strengths and needs .The team will encourage the resident .resident representative to include any personal and cultural preferences to be incorporated into the goals of care during the full life conference .Educate the resident and/or representative on the realistic duration, frequency, and goals of any rehab and/ or nursing goals . 2. Review of the medical record revealed Resident #28 was admitted to facility on 2/9/2024, with diagnoses including Emphysema, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #28 was cognitively intact. Review of comprehensive MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #28 was cognitively intact. Review of the facility's Care Plan Conference sign in sheet dated 9/11/2024, revealed the Resident or responsible party (RP) where not listed in attendance for the meeting. The facility was unable to provide documentation that a Care Plan Conference was conducted with the Resident or Responsible Party (RP) regarding the quarterly Care Plan Conference dated 5/14/2024, the quarterly Care Plan Conference dated 8/12/2024, the significant change Care Plan Conference dated 9/11/2024, and the quarterly Care Plan Conference dated 11/11/2024. During an interview on 1/21/2025 at 3:07 PM, Resident #28 was asked about being invited to care plan meetings. Resident #28 stated, .I've never been to one, neither has my daughter . During an interview on 1/22/2025 at 2:52 PM, the MDS Coordinator was asked can you provide me documentation of Resident #28's involvement in care plan meetings. The MDS Coordinator confirmed Social Services sends invites to the family and everyone in attendance signs the care plan conference sheet. During an interview on 1/22/2025 at 3:17 PM, the Social Services Director was asked if the Care Plan meeting was documented in the electronic medical record (EMR). Social Services stated, I didn't, I should have. During an interview on 1/23/2025 at 4:24 PM, the Director of Nursing (DON) was asked if there was documentation to show a resident or resident representative planned to participate in and were present for care plan meetings. The DON confirmed a sign in sheet is completed for anyone in the meetings including the resident and resident family members. If family joins by phone that should also be documented on that sheet. The DON was asked how residents and resident representatives are notified of an upcoming care plan meeting The DON stated, . [Social Service Director] does that . The facility failed to provide documentation that the Resident and/or RP were included in Care Plan Conferences for 5/14/2024, 8/12/2024, 9/11/2024, and 11/11/2024.

Based on review of the Blood Glucose Monitoring User Guide, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters (a device used to check blood sugar levels with the use of a blood sample) were not cleaned and disinfected with facility required bleach cleansing wipes to prevent cross-contamination of bloodborne pathogens for 4 of 5 sampled residents (Residents #1, #14, #25, and #33) reviewed for blood glucose monitoring. Observations on 2/7/2024 and 2/8/2024 revealed Licensed Practical Nurses (LPN) #1 failed to clean and disinfect the multi-use blood glucose meters before and after use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don gloves during medication administration. Observations on 2/7/2024 revealed LPN #2 failed to clean and disinfect the blood glucose meters before use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don clean gloves during medication administration. The facility's failure to ensure staff properly disinfected the multi-use blood glucose meter in accordance with recommendations and the facility's policy, that was used for multiple residents, placed the residents at risk for potential contamination with bloodborne pathogens and had the likelihood to cause harm, serious injury, and/or death resulted in Immediate Jeopardy. The facility had 5 residents receiving blood glucose monitoring with a multi-use blood glucose meter and the facility's failure had the potential to affect the 5 residents receiving blood glucose monitoring with a multi-use blood glucose meter. The facility failed to ensure practices to prevent the potential spread of infections when 1 of 4 (Certified Nurse Assistant (CNA) #1) staff members placed a soiled meal tray on the meal cart with clean meal trays. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately disinfect a multi-use blood glucose meter during medication administration. The Administrator and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy (IJ) for F-880 on 2/8/2024 at 6:23 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of J. The Immediate Jeopardy began on 2/8/2024 and is ongoing. The findings include: 1. Review of the facility's policy titled, Glucometer Cleaning, revised 5/2013, revealed .Routine cleaning of the glucometer is needed to promote a clean, safe environment, and prevent the spread of infection .Clean the outside of the glucometer surface front, back, and sides before and after each finger stick by using a bleach cleansing wipe .Allow meter to dry completely between uses .Never place glucometer directly on any surface, place on a barrier (i.e. paper towel) must be utilized at all times to prevent contamination . Review of the facility's policy titled Eye Drop Administration, revised 4/2021, revealed .To assure correct administration of eye drops .Wash hands .Position resident with head back .Remove cap from bottle and place on a clean, dry surface .Use gauze to pull down lower eyelid to form a pouch, instructing resident to look up .Instill medication as follows: Place hand against resident's forehead to steady if needed .Instill required number of drops inside the lower eyelid close to outer corner of eye (Do not let dropper touch any part of the eye) .Wipe off excess solution with gauze .Recap the bottle .Wash hands . Review of the (named) glucose monitor user's guide titled, Blood Glucose Monitoring System dated 2/2023, revealed .Cleaning and Disinfecting Procedures for the Meter .The meter should be cleaned and disinfected between each patient [resident] .The following products have been approved for cleaning and disinfecting .Dispatch Hospital Cleaner Disinfectant Towels with Bleach .Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol .Clorox Healthcare Bleach Germicidal and Disinfectant Wipes .Medline Micro-Kill Bleach Germicidal Bleach Wipes .glucose manual revealed the following steps .Wash hands with soap and water .Put on single use medical protective gloves .Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be cleaned from the surface of the meter .To clean the meter, use a moist (not wet) lint-free cloth dampened with mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean .To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use . Review of the facility's policy titled Blood Glucose Level - Obtaining a Fingerstick, revised 5/2023, revealed .A licensed nurse will obtain a blood sample to determine the resident's blood glucose level to immediately determine accurate capillary glucose levels and to screen for hypoglycemia and hyperglycemia .The following are the steps to be taken to obtain a Finger stick blood glucose level: Verify there is a physician's order for this procedure .Place equipment and supplies so it can be easily reached, using a barrier between table and glucometer .Wear gloves .Choose a site .Clean selected finger with alcohol .Obtain a blood sample by using a sterile lancet .Place a drop of blood on the reagent strip .Wipe the finger with a cotton ball .Dispose of the lancet in a sharps container .Clean equipment according to policy .Remove gloves and discard appropriately. Wash hands . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Hypertension and Diabetes. Review of the Physician's Order dated 8/27/2022, for Resident #25 revealed, .Accuchecks BID [twice a day] for blood sugar . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #25 was severely impaired cognitively for daily decision making. Review of the Physician's Order dated 1/9/2024 for Resident #25 revealed to perform Accuchecks twice a day for blood sugar. Review of the Physician's Order dated 1/25/2024, for Resident #25 revealed, .If blood sugar is > [greater than] 400, Administer 10 units of Novolog [an agent used to lower blood sugar] 100 units/ml [millimeter] .blood sugar < [less than] 100 notify MD [Medical Doctor] STAT [immediately] . Observation in Resident #25's room on 2/7/2024 at 3:51 PM, revealed LPN #1 performed a blood glucose check on Resident #25 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves before and after checking the resident's blood glucose level, and failed to clean or disinfect the multi-use blood glucose meter before and after use. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hypertension, Heart Failure, and Diabetes. Review of the Physician's Order dated 9/14/2023, for Resident #1 revealed, .Humulin R Injection Solution 100 UNIT/ML [milliliters] (Insulin Regular (Human) [an agent used to lower blood sugar] Inject as per sliding scale . Review of the significant change MDS dated [DATE], revealed Resident #1 scored a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Observation in Resident #1's room on 2/7/2024 at 4:02 PM, revealed LPN #1 performed a blood glucose check on Resident #1 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves, and failed to clean and disinfect the multi-use blood glucose meter before and after use. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Kidney Failure, and Diabetes. Review of the Physician's Order dated 2/17/2023, for Resident #14 revealed, .Novolog Injection Solution [an agent used to lower blood sugar] 100 unit/ml .Inject 5 unit subcutaneously one time a day . Review of the Physician's Order dated 1/1/2024, for resident #14 revealed, .Accu check one time a day for DM [Diabetes Mellitus] . Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS score of 3, which indicated the resident was severely cognitively impaired. Observation in Resident #14's room on 2/7/2024 at 4:07 PM, revealed LPN #1 performed a blood glucose check on Resident #14 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves, and failed to clean and disinfect the multi-use blood glucose meter before and after use. Observations during medication administration on Hall 1 on the medication cart on 2/8/2024 at 11:12 AM, revealed LPN #1 removed a bottle of Novolog Insulin, the multi-use blood glucose meter and supplies, an alcohol pad, insulin syringe, and entered Resident #14's room, placed the medication and supplies on a barrier. LPN #1 obtained Resident #14's blood glucose level with the multi-use blood glucose monitor and failed to clean and disinfect before and after use. LPN #1 administered 5 units of Novolog Insulin to Resident #14's left upper arm and placed the trash into the biohazard sharps container and exited the room. LPN #1 failed to use hand hygiene and don gloves prior to administering Resident #14's insulin. 5. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the admission MDS dated [DATE], revealed Resident #33 scored a BIMS of 6, which indicated the resident was severely cognitively impaired. Review of the Medication Administration Record for 2/2024, revealed Resident #33 received blood glucose monitoring twice per day. Observation during medication administration on Hall 1 medication cart on 2/7/2024 at 7:56 PM, revealed LPN #2 removed a multi-use blood glucose meter and supplies, a bottle of Latanoprost Ophthalmic Solution Eye 0.005 % (percent), and Metformin 1000 milligram (mg) 1 tablet from a drawer on the medication cart. LPN #2 entered Resident #33's room and placed the multi-use blood glucose meter and supplies, the Metformin tablet, and eye drops on the Resident's bedside table. LPN #2 failed to cleanse the bedside table and place a barrier between the supplies and the bedside table. LPN #2 washed her hands and donned clean gloves, instilled 1 drop of the resident's eyedrop into each eye, and recapped the eye drops. Without washing her hands, LPN #2 administered the 1000 mg Metformin 1 tablet, and without washing her hands, obtained Resident #33's blood glucose level using the multi-use blood glucose meter. LPN #2 failed to cleanse the multi-use blood glucose meter prior to using it on Resident #33. After completing the blood glucose test, LPN #2 placed the testing strip and lancet into the biohazard sharps container, removed her soiled gloves and washed her hands. LPN #2 gathered the multi-use blood glucose meter and supplies and eye drops, exited the room and entered Hall 1 medication storage room and placed the multi-use blood glucose meter on the countertop in Hall 1 medication storage room. LPN #2 failed to place the multi-use blood glucose meter on a clean barrier in the medication room. 6. During an interview on 2/7/2024 at 8:10 PM, LPN #2 confirmed she does not clean the multi-use blood glucose meter before use. During an interview on 2/8/2024 at 6:11 PM, the Assistant Director of Nursing (ADON) was asked how a multi-use blood glucose meter should be cleaned and how often. The ADON stated, .Before and after use .use the orange-colored top Sani Wipes .orange has bleach . During an interview on 2/13/2024 at 9:01 AM, LPN #3 confirmed she did not know the correct technique for cleaning a multi-use blood glucose meter until 2/9/2024. During an interview on 2/13/2024 at 10:25 AM, LPN #4 was asked when her last skills check off was on how to properly clean a multi-use blood glucose meter. LPN #4 confirmed she was unsure and stated she could not remember. During an interview on 2/13/2024 at 10:27 AM, LPN #1 confirmed she had not had a skills check off on how to properly clean a multi-use blood glucose meter. The facility failed to ensure staff used an Environmental Protection Agency (EPA) approved disinfectant wipe, resulting in Immediate Jeopardy due to the potential of transmitting blood-borne pathogens between patients and healthcare professionals. 7. Observation and interview during dining on Hall 1 on 2/5/2024 at 11:57 AM, revealed CNA #1 exited Resident #1's room with a used meal tray, placed the used meal tray on the meal cart which contained clean meal trays waiting to be delivered to other Resident rooms. CNA #1 was asked whose used meal tray did she place on the meal cart. CNA #1 stated, [Named Resident #1], she has finished eating. Observation revealed CNA #1 placed the used meal tray back on the clean meal cart, and then removed a clean meal tray and entered Resident #25's room. During an interview on 2/13/2024 at 8:47 AM, the Interim Director of Nursing (DON) was asked should a meal tray that a resident had eaten off of be placed on the meal cart above the clean meal trays that were to be served to other residents. The Interim DON stated, Cannot be put back in the cart until all the clean meal trays are off because it is an infection control issue if you put a dirty food meal tray in with a clean one.

Based on policy review, medical record review, facility investigation review, observations, and interview, the facility failed to ensure each resident's environment was safe and each resident received adequate supervision to prevent accidents and hazards for 1 of 1 (Resident #8) residents reviewed for smoking, and 1 of 5 (Resident #98) reviewed for wandering and elopement. On 2/7/2024 Resident #8, a moderately cognitively impaired, legally blind resident, was observed to be smoking unsupervised in the smoking area. Resident #8 had a lit cigarette and burn marks on his clothing. On 9/21/2022, Resident #98, a vulnerable, severely cognitively impaired resident exited the facility without staff knowledge or supervision through a malfunctioning facility door, down the ramp and into the facility's back parking lot, and when bleach wipes were found in Resident #40's, a cognitively impaired resident, room. The facility failed to ensure fall interventions were implemented in accordance with the care plans for 2 of 6 (Resident #9 and #26) residents reviewed for falls. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to follow the Safe-Smoking Screen for Resident #8, and when the facility failed to ensure a safe and secure environment for Resident #98, a vulnerable and severely cognitively impaired resident assessed for wandering and elopement behaviors, who eloped from the facility. The Administrator and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 on 2/12/2024 at 6:49 PM, in the Conference Room related to Resident #8's unsupervised smoking. The Administrator, Interim Director Of Nursing, and the Assistant Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-689 on 2/14/2024 at 2:15 PM, related to the elopement of Resident #98. An extended survey was conducted from 2/8/2024 to 2/14/2024. The facility was cited at F-689 for unsupervised smoking and elopement at a scope and severity of J which is Substandard Quality of Care. The facility was cited F-689 for unsupervised smoking and elopement which is Substandard Quality of Care. The findings include: 1. Review of the facility's policy titled Tobacco and Electronic Cigarette/Vaping Use, revised 11/2022, revealed .Residents are allowed to use tobacco products .in designated areas only .The designated smoking area for residents is the patio outside the resident dining area .These residents will be supervised and established smoking times will be observed .Smoking will be allowed as weather permits and residents must wear a smoking apron while smoking . Review of the facility's policy titled Resident Elopement, dated 1/2021, revealed .One of the most challenging issues related to care of the resident with dementia is wandering behavior. The most dangerous form of wandering is elopement, in which the confused resident leaves the nursing home and possibly experiences injuries such as hypothermia, a serious fall, or is hit by a car. These injuries may result in death .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .The Charge Nurse will assume control of the search and gather all available staff to begin an immediate preliminary search of the area and premises .While staff is conducting the search, the Charge Nurse will notify the Administrator and Director of Nursing (DON) and determine if others are needed to participate in the search .While a resident who was missing is found, the nurse will .Examine the resident for possible injuries .Notify the Attending Physician for consultation .Notify the Administrator or designee .Notify the resident's designated representative .Notify the Medical Record .Discuss with the Administrator, DON, or designee if it is prudent to provide the resident with 1:2 or other level of supervision .Complete an incident report .Complete appropriate documentation in the resident's medical record .Re-evaluate the resident's risk for possible elopement regardless if this event may constitute an elopement or not .Follow-up investigation .DON or designee will obtain video evidence to establish timeline of events and resident exit point .DON or designee is responsible [for] obtaining staff, resident and bystander statements regarding incident .DON will moderate an adhoc [impromptu meeting conducted for a particular purpose] QAPI [Quality Assurance and Performance Improvement] Meeting, within 24 hours after event .Corrective actions will be developed with intent to mitigate root cause and prevent future similar events . 2. Review of the medical record revealed Resident #8 was readmitted to the facility on [DATE], with diagnoses including Cognitive Communication Deficit, Tobacco Use, Shortness of Breath, Dementia, Depression, and Legal Blindness. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired, exhibited wandering behaviors, assessed for tobacco use, and had severe vision impairment (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). Review of the Care Plan revised 1/31/3024, revealed the following interventions for smoking, .Observe clothing and skin for signs of cigarette burns .Smoking Assessment to be done quarterly .for smoking safety .requires a smoking apron .staff to accompany to smoking area and supervision noted . The care plan did not include information on how the resident should wear the smoking apron and the facility's policy did not address how to wear the smoking apron. Review of the Smoking-Safety Screen (tool used to assess a resident to safely smoke) dated 2/2/2024, revealed Resident #8 had a visual deficit, dexterity problems and a Team decision was made that required the resident to have supervision to smoke. Observation in the dining room on 2/6/2024 at 7:49 AM, revealed Resident #8 wanted to smoke, and Registered Nurse (RN) #1 put a smoking apron on Resident #8 and scanned her badge to unlock the door to the smoking area and assisted the resident out to the smoking area. RN #1 stated, .let me know when you want in, well I guess I'll sit out here with you . Resident #8 lowered the lit cigarette and it touched the smoking apron and left a brown stain. RN #1 asked the resident to hold the cigarette up. Observation in Resident #8's room on 2/6/2024 at 2:56 PM, revealed Resident #8 was wearing a pair of black sweatpants with 2 holes that were charred around the edges that appeared to be burn marks in the upper leg of the sweatpants. Observation on 2/7/2024 at 7:51 AM, revealed Resident #8 was outside on the patio in the smoking area unattended and unsupervised by staff, smoking a cigarette, with no staff within view of the resident. Resident #8 had on a smoking apron underneath his jacket and had a Wander Guard. The temperature outside was 36 degrees. Observation in the dining room on 2/7/2024 at 7:55 AM, revealed the Activities Director entered the dining room area from the skilled unit hallway and went to her desk. Resident #8 was observed knocking on the patio door to alert staff to let him back into the facility. The Activities Director walked over to the locked patio door, unlocked the door, and assisted Resident #8 back into the facility. During an interview on 2/9/2024 at 11:20 AM, RN #1 was asked if they supervise Resident #8 when he is smoking. RN #1 confirmed that staff does not always go out with the resident when he smokes. During an interview on 2/12/2024 at 6:41 PM, the Interim Director of Nursing (DON) was asked when a resident with a BIMS score of 8, legally blind, and an elopement risk goes outside to smoke should staff be present during the smoking time for supervision. The Interim DON stated, .Yes . During an interview on 2/13/2024 at 9:44 AM, the Social Worker was asked if he ever saw Resident #8 smoke outside by himself. The Social Worker stated, .I noticed he was not able to handle the cigarettes' correctly .BIMS score .decreased .new BIMS score should have been done for safety . During an interview on 2/13/2024 at 11:19 AM, Laundry Staff was asked if she has seen Resident #8 smoking outside unsupervised by himself. The Laundry Staff stated, .yes, I see him outside smoking unsupervised . During an interview on 2/13/2024 at 3:09 PM, Licensed Practical Nurse (LPN) #1 was asked if she unlocked the patio for Resident #8 to go out to smoke on 2/7/2024. LPN #1 stated .yes . LPN #1 confirmed no staff was outside on the patio in the smoking area when Resident #8 was smoking and she did not remain with the resident. The failure of the facility to follow the Safe-Smoking Screen assessment could result in the likelihood of serious harm, serious bodily injury, and/or death and Immediate Jeopardy to Resident #8. 3. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Anxiety, Conduct Disorder, Wandering, and Hypothyroidism. Review of the Care Plan dated 5/19/2022, revealed, .The resident is an elopement risk/wanderer r/t [related to] History of wandering and Dementia .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering Is wandering purposeful, aimless, or escapist? Is resident looking for something .Monitor for wander guard placement, correct band, any new skin issues noted to wander guard site, and expiration date that is written on wanderguard alarm, every shift .Resident to be assisted to wanderguard controlled door per staff to assess proper functioning alarm once daily every day shift for proper function of wanderguard equipment .Resident wander alert will be posted at strategic location throughout facility .Wanderguard maybe applied upon as assessment and MD [Medical Doctor] order .Weekly Behavior Assessment on Friday day shift and more often if needed .11/17/2022 .Resident to be assisted to wanderguard controlled door per staff to assess proper functioning alarm once daily every day shift for proper .function of wanderguard equipment .Resident wander alert will be posted at strategic location throughout facility . Review of the facility's Wandering Risk Assessment, dated 8/23/2022, revealed .High Risk for Wandering . Review of the Weekly Behavior Note, dated 9/2/2022, revealed .Observed Behaviors .Refusing Medications .Wandering .Delusional .Agitated .Behavior Management Intervention . Redirection .Food/Fluids .Medication offered .Comments .will become agitated at times, refusing meds and care, redirection occasionally successful . Review of the progress notes dated 9/3/2022, revealed .Resident was wandering in the halls & [and] exit seeking earlier today .requires constant observation since is an active exit seeker & wanderer . Review of the Weekly Behavior Note, dated 9/9/2022, revealed .No Threat . Review of the Weekly Behavior Note, dated 9/12/2022, revealed .No Threat .Behaviors Observed .Wandering .Comments .occasionally wanders, becomes agitated, and resistive to care, redirection occasionally successful . Review of the Weekly Behavior Note, dated 9/16/2022, revealed .No Threat .Observed Behaviors .Combative .Refusing Medication .Potential for elopement .Wandering . Agitated .Comments .occasionally wanders, becomes agitated and resistive to care and medication . Review of the progress notes dated 9/16/2022, revealed .Observed resident ambulating unassisted in hall walls [ways], attempted to sit in chair at the end of hallway, lost her balance and fell to the floor hitting her head on the floor. Laceration noted to L [left] eyebrow and skin tear to L elbow. Areas cleansed and steri striped. Pt [patient] is alert to self per residents normal, confused to place and time . Review of the progress notes dated 9/16/2022, revealed .Resident awake and alert. Ambulating with supervision only. Continuously walking around facility exit seeking. She walks to each door, pushes on it, then walks to the next door. Resident becomes frustrated with staff whenever redirection in [is] tried . Review of the progress notes dated 9/21/2022 at 4:10 PM, revealed .LATE ENTRY .resident had been wandering all day and was noted to be out in back yard near recreation patio .resident was immediately brought inside by staff . Further review of the progress notes dated 9/21/2022 at 4:26 PM, revealed .Resident has had exit seeking behavior today by pushing on doors. Resident redirected . The facility failed to implement effective interventions on 9/21/2022 for Resident #98's wandering and exit seeking prior to the resident's elopement from a safe environment to an unsafe environment. Review of the progress notes dated 9/22/2022, revealed .Behavior noted x [times] 1 when she threw her linen out in the hall . Review of the progress notes dated 9/23/2022, revealed .discussed resident behaviors and elopement at length with [named medical director] .discussed dx [diagnoses] and current medication regime .recommends Risperdal [medication used to treat schizophrenia, bipolar disorder, or irritability .should not be used to treat behavioral problems in older adults who have dementia] 1 mg [milligram] Bid [twice a day] spoke with daughter .explained medication and meeting to discuss resident care .[daughter] concerned that medication is a antipsychotic medication which resident doesn't usually tolerate well .assured [daughter] that [named medical doctor] wants updates from staff on resident behaviors and the medication effectiveness . Review of the Weekly Behavior Note, dated 9/23/2022, revealed .No Threat . Review of the progress notes dated 9/24/2022, revealed .Continue to round on resident every 15 min [minutes] and door checks. Review of the progress notes dated 9/26/2022, revealed .has been wandering in hall all morning with exit seeking behavior. Staff continuing with q [every] 15 min checks and rounding to check all doors . Review of the progress notes dated 9/27/2022, revealed .Resident has been alternating between resting in bed napping and wandering in hall with exit seeking behavior. Resident became aggressive during shower but calmed down as soon as shower was over .Wears pull-ups but will remove pull-up or brief & urinate in room or down the hall and will become very aggressive when staff attempts to provide peri-care . Review of the Weekly Behavior Note, dated 9/30/2022, revealed .No Threat .Rejection of care .Observed Behaviors .Refusing Medications .Potential for elopement .Wandering . Agitated .Comments . frequently wanders, exit seeking, resistive to cares, re-direction occasionally successful . Review of the progress notes dated 10/1/2022, revealed .Resident has had exit seeking /wandering behavior throughout this shift . Review of the progress notes dated 10/2/2022, revealed .Resident continues with wandering & exit seeking behavior today . Review of the progress notes dated 10/5/2022, revealed .Resident will frequently remove her pull-up which allows her to have dribbling urine . Review of the Weekly Behavior Note, dated 10/7/2022, revealed .No Threat .Observed Behaviors .Combative .Refusing Medication .Potential for elopement .Wandering . Agitated .Comments . frequently wanders about facility, exit seeking, resistive to cares at times, re-direction occasionally successful . Review of the Weekly Behavior Note, dated 10/14/2022, revealed .No Threat .Observed Behaviors .Refusing Medications .Potential for elopement .Wandering . Agitated . Comments . occasionally wanders, exit seeking, becomes agitated and resistive to cares and medication . Review of the progress notes dated 10/15/2022, revealed .Resident is alert but confused & combative with exit seeking behavior .Resident is hitting, biting, slapping, yelling, and pinching . Review of the Weekly Behavior Note, dated 10/17/2022, revealed .Observed Behaviors .Cursing . Refusing Medications .Potential for elopement .Wandering . Agitated .Anxiety .Fighting . Comments .Resident wanders, exit seeks, refuses medication and care, resident gets agitated with redirection, interventions attempted with no success at times, family made aware of residents behaviors and has to come out when staff makes aware . Review of the progress notes dated 10/20/2022, revealed .Resident has been wandering in the hall with exit seeking behavior this morning. Refused medication & personal care .was combative . Review of the significant change MDS dated [DATE], revealed Resident #98 was severely cognitively impaired with delusions, physical, verbal, and other behavioral symptoms. Resident #98 rejected care, put other residents at risk of physical injury, significantly intruded on the privacy of others and significantly disrupted care or living environment and wandered, required extensive assist to total assist for activities of daily living (ADLs). Resident #98 had four falls, 2 with no injury and 2 with minor injuries and received antipsychotic, antianxiety, and insulin medications. Review of the progress notes dated 11/12/2022, revealed .Resident exhibiting behavioral issues of fighting, hitting, scratching, clapping, yelling, refusing care, removing clothes & smearing feces, wandering & exit behaviors noted . Review of the facility's Wandering Risk Assessment, dated 11/25/2022, revealed .High Risk for Wandering . Review of the progress notes dated 12/15/2022, revealed .Resident is wandering in the hall, around the nurses station and exit seeking to front entrance . Review of the progress notes dated 12/25/2022, revealed .Resident ambulating in hall to dining area, around nurses station & back to her room. Exit seeking while wandering . Review of the facility's Wandering Risk Assessment, dated 2/27/2023, revealed .High Risk for Wandering . During an interview on 2/8/2024 at 4:25 PM, LPN #1 was asked about Resident #98's getting out of the building. LPN #1 stated, .She was a wanderer but still walking, she would go to doors and push on them sometimes she was redirected and sometimes redirecting aggravated her. She removed brief and walk [walked] in hall and dribble urine in hall. She didn't usually show aggression toward other residents . During an interview on 2/12/2024 at 11:22 AM, the Administrator was asked had there been a Quality Assurance Performance Improvement meeting prior to 2/9/2024. The Administrator stated, .On 2/13/2024 we had an Adhoc meeting with the Medical Director. The Administrator was asked how the staff had been monitoring elopements, wandering residents, and the doors for the prevention of elopement. The Administrator stated, I got here January 3, 2024 and we have not had any elopement drills. I check doors each day to make sure they are locking appropriately . The Administrator was asked have door checks, random monitoring of the doors and wander guard checks been conducted. The Administrator stated, Any documented door checks I believe [named Maintenance Supervisor] told me door checks done in January, I'm not certain about that . The Administrator was asked has any elopement drills been conducted since your arrival. The Administrator stated, No. The Administrator was asked how often elopement drills should be conducted. The Administrator stated, Yes, elopement drills should be done .I believe someone felt that [the new wander guard system] may have negated elopement drills, I would have done one annually . The Administrator was asked has there been a process and procedure put in place for new staff and agency staff to follow related to elopement. The Administrator stated, I have no knowledge of new staff or agency staff having that training . During an interview on 2/12/2024 at 2:33 PM, the Maintenance Assistant Director was asked when the new wander guard system was installed. The Maintenance Assistant Director stated, .Badges for doors opening occurred 2019, by the time we started to upgrade the hospital doors the nursing home decided to upgrade also. We had a wander guard system in nursing home that was prone to problems and outdated. Mid to late 2022 wander guard system was added .We had a couple [elopements] over a period of time. It [wander guard system] would lock the doors but failed to alarm to notify staff [that] residents were at the door. The new system was after she [Resident #98] got out the door on 9/21/2022. So, wander guard was invoiced for 1/3/2023 . During a telephone interview on 2/14/2024 at 10:03 AM, Governing Body Member #1 was asked if the Governing Body was notified about the elopement on 9/21/2022. Governing Body Member #1 confirmed they were made aware of the elopement that occurred on 9/21/2022 and a new door system was installed to fix the problem. Governing Body Member #1 confirmed the facility made improvements and no one can enter the facility without being let in by staff. Governing Body Member #1 confirmed the issue had been resolved and education and in services were given on the new door system. Governing Body Member #1 confirmed that education and orientation with newly hired staff needs to be ongoing and elopement drills should be regularly conducted. During a telephone interview on 2/14/2024 at 10:16 AM, Governing Body Member #2 confirmed that he is the chairman and the Governing Body meets monthly. Governing Body Member #2 confirmed that the board addresses compliance issues, falls, and how to improve the safety of residents and patient satisfaction. Governing Body Member #2 confirmed that at one time there was a problem with an elopement and that the board addressed those issues and those implementations are still secure. Governing Body Member #2 confirmed that drills and education are conducted and that an action plan was made and there are no new issues with the doors to their knowledge. The facility failed to implement effective interventions to prevent the elopement of Resident #98. After Resident #98's elopement on 9/21/2022 the facility took the following actions: The facility did hourly door checks beginning 9/22/2022 through 10/17/2022. The facility implemented 15 minutes checks for Resident #98 beginning on 9/26/2022 at 7:00 PM through 10/13/2022 at 6:30 PM. The facility completed elopement drills on 9/23/2022, 9/26/2022, and 9/27/2022 for all shifts. Ad Hoc meeting on 9/23/2022 to discuss elopement of Resident #98. The facility installed the new door alarm system on 9/29/2022. Ad Hoc meeting on 9/30/2022 to discuss elopement of Resident #98. The facility installed a new wander guard system on 1/3/2023. 4. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoporosis, Orthostatic Hypotension, Anxiety, Depression, and Macular Degeneration. Review of the quarterly MDS dated [DATE], revealed Resident #9 was assessed with a BIMS score of 3 indicting the resident was severely cognitively impaired, had behaviors directed toward others, range of motion impairment on both upper and lower extremities, wheelchair for mobility, and was incontinent of both bowel and bladder. Review of the Care Plan dated 12/14/2023 revealed, .The resident is at risk for falls r/t Gait / Balance problems .Fall mat at side of bed .Initiated 7/26/2021 . Observation in Resident #9's room on 2/5/2024 at 12:30 PM, 2/6/2024 at 8:15 AM, and 2/7/2024 at 8:00 AM, revealed Resident #9 was in bed, and the bed was in low position with no fall mat at bedside. The facility failed to ensure the intervention of a fall mat was implemented in accordance with Resident #9's care plan. 5. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses of Orthostatic Hypotension, Cognitive Communication Deficit, Anxiety, Depression, and Irritable Bowel Syndrome. Review of the Care Plan dated 1/15/2024, revealed, .The resident has an ADL self-care performance deficit r/t [related to] Activity Intolerance, Limited Mobility, and Musculoskeletal impairment .The resident has cognitive/communication problem r/t confusion .the resident is at risk for falls r/t Gait/balance problem .Pad sensor alarm at all times in bed and chair .check placement and function every shift for alarm .scoop mattress on bed .initiated 7/21/2022 . Review of the quarterly MDS dated [DATE], revealed Resident #26 was assessed with a BIMS score of 3, indicating the resident was severely cognitively impaired, exhibited physical/verbal behavior toward others, rejection of care, range of motion limitations both extremities lower and upper, and was incontinent of both bowel and bladder. Observations in Resident #26's room on 2/5/2024 at 3:30 PM, 2/6/2024 at 8:21 AM, 2/7/2024 at 9:04 AM, and 2/8/2024 at 9:00 AM, revealed Resident #26 was in the bed and there was no scoop mattress on the bed. The facility failed to follow the care plan for the use of a scoop mattress as a fall intervention. 8. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with the diagnosis of Abnormalities of Gait and Mobility, Muscle Weakness, and Lack of Coordination. Review of the admission MDS dated [DATE], revealed Resident #40 was assessed with a BIMS of 9, indicating the resident was moderately cognitively impaired and was assessed for wandering behavior. Review of the Care Plan dated 12/15/2023 revealed, .resident has impaired cognitive function .resident has an elopement risk/wanderer d/t [due to] impaired safety awareness .Wanderguard [electronic device that alarms when resident attempts to exit the building] placement to be placed on LLE [left lower extremity] and checked every day and night shift and documented . Observation in Resident #40's room on 2/5/2024 at 10:38 AM and 2/5/2024 at 11:18 AM, revealed 1 plastic container of sani-cloth bleach wipe sitting in the window sill of Resident #40's room, labeled keep out of reach of children. Observation in Resident # 40's room on 2/5/2024 at 11:55 AM, revealed 1 plastic container of sani-cloth bleach wipes sitting in the window sill and housekeeping staff entered the room and removed the container and put on the housekeeping cart. During an interview on 2/14/24 at 11:21 AM, the Administrator was asked where should cleaning chemicals such as bleach wipes be stored. The Administrator confirmed that chemicals should be stored under lock and key, out of reach of residents, and not in resident's rooms.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 5 of 11 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #6, and Licensed Practical Nurse (LPN) #5) failed to knock and/or announce themselves before entering a resident's room during dining, stood to assist with dining, and failed to use courtesy titles when addressing residents. The findings include: 1. Review of the facility's policy titled, Dignity, dated 7/2018, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Staff will knock and request permission before entering residents' rooms .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs .Staff shall promote dignity and assist person served as needed by .sitting while feeding person served . Review of the facility's policy titled Dignity and Privacy, dated 8/2017, revealed .To provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .Always knock on the resident's door prior to entering their room .Wait for permission or a response from the resident before you enter the room .Always address the resident in the name that they prefer . 2. Observation during the Skilled Hall dining on 2/5/2024 at 11:24 AM, revealed LPN #5 removed a tray from the meal cart, entered Resident #18's room and failed to knock or announce themself before entering the resident's room, placed the tray on over the bed table, sanitized her hands and exited the resident's room and returned to the meal cart. LPN #5 removed a tray from the meal cart, entered Resident #8's room and failed to knock or announce themself. 3. Observation during the Hall 1 dining on 2/5/2024 at 11:30 AM, revealed CNA #6 in the hallway passing meal trays and stated out loud while speaking to other staff, .down to our feeders. 4. Observation during the Hall 1 dining on 2/5/2024 at 11:42 AM, revealed CNA #1 standing in the hallway speaking out loud to CNA #3, CNA #1 stated to CNA #3, .the rest are feeders right. CNA #3 replied yes and then entered Resident #2's room and failed to knock or announce themselves prior to entering the resident's room. 5. Observation during the Hall 1 dining on 2/5/2024 at 11:44 AM, revealed CNA #1 removed a tray from the meal cart, entered Resident #1's room and stated, ready honey and assisted the resident with their meal while standing. CNA #1 failed to use a courtesy title when addressing Resident #1 and stood to assist the resident with her meal. 6. Observation during dining in Resident #25's room on 2/5/2024 at 11:58 AM, revealed CNA #1 stood over the resident while assisting the resident with their meal. CNA #1 stated do you want some drink honey. CNA #1 stood to assist Resident #25 with their meal and failed to use a courtesy title when addressing the resident. 7. Observation during the Hall 1 dining on 2/6/2024 at 4:18 PM, revealed CNA #1 entered Resident #298's room and failed to knock or announce themself before entering resident's room. 8. Observation during the Hall 1 dining on 2/6/2024 at 4:39 PM, revealed CNA #2 entered Resident #11's room and failed to knock or announce themself before entering the resident's room. 9. During an interview on 2/13/2024 at 8:47 AM, the Interim Director of Nursing (DON) confirmed staff should address the residents by their name unless they are care planned to be called by a different name. The DON was asked if honey an appropriate name to address or refer to a resident. The Interim DON stated No. The Interim DON confirmed that staff should knock before entering the resident's room and should be seated when assisting the residents with their meal.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and labeled when expired medications were observed in 1 of 1(Hall 1 Medication Cart) medication storage areas. The findings include: 1. Review of the facility's policy titled Storage of Medications, revised 5/2013 revealed .Drugs and biologicals shall be stored in a safe and orderly manner .No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this facility . 2. Observation at Hall 1 Medication Cart on 2/8/2024 at 3:39 PM, revealed 2 opened bottles of Latanoprost Ophthalmic Solution 0.005% (percent) (eyedrops). One of the bottles of Latanoprost Ophthalmic Solution 0.005% had an opened date of 12/26/2023 and a discard by 2/6/2024 date, the other bottle of Latanoprost Ophthalmic Solution 0.005% had an opened date of 12/25/2023 and no use by date on the bottle. During an interview on 2/8/2024 at 3:46 PM, Licensed Practical Nurse (LPN) #1 was asked how long are eyedrops good for use after they have been opened. LPN #1 stated, .30 days . LPN #1 confirmed the eyedrops should have been discarded and reordered. During an interview on 2/12/2024 at 10:16 AM, the Interim Director of Nursing (DON) was asked how long prescribed eye are drops good for once they have been opened. The Interim DON stated, They should be good 30 days .get from pharmacy .once ready for use .it should have an open date .after opened for 30 days .should not be on the cart . Interim DON confirmed that staff should go through the medication cart to make sure there are no expired medications.

Based on policy review, medical record review, observation, and interview, the facility failed to update and revise the Care Plan for Physical Restraints, Smoking Safety Screen, and Wandering Risk Assessments for 1 of 1 sampled resident (Resident #8) reviewed. The findings include: 1. Review of the facility's policy titled Care Plan, dated 5/2013, revealed .An individual care plan for activity is developed and maintained for each resident . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Cognitive Communication Deficit, Chronic Obstructive Pulmonary Disease, Tobacco Use, Dementia with Behavioral Disturbance, Depression and Legal Blindness. Review of the most current Wandering Risk Assessment revealed the last assessment was done on 8/17/2023. There was no documentation the Wandering Risk Assessment was conducted after 8/17/2023 and quarterly. Review of the quarterly MDS dated [DATE], revealed Resident #8 had a BIMS score 13 which indicated resident was cognitively intact, had severely impaired vision, and used a Wanderguard daily. Review of the Physician's Orders dated January 2024, revealed .Complete assessments every 3 months after admission .Wander Risk .Monitor for wanderguard placement .Test resident biweekly to assure he can release seat belt when in w/c [wheelchair], self-release velcro seat belt while up in w/c .Weekly Behavior Assessment . Review of the significant change MDS (Minimum Data Set) dated 1/25/2024, revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident #8 was moderately cognitively impaired with behaviors, wandering significantly, intruding on the privacy or activities of others, wandering worse compared to prior assessment, vision severely impaired and uses a Wanderguard (a monitoring device) daily. Review of the Care Plan dated 1/31/2024 for Resident #8 revealed .resident has .poor vision .a smoker .Observe clothing .for signs of cigarette burns .Smoking Assessment to be done quarterly every day shift starting on the 23rd of month for smoking safety .The resident requires a smoking apron while smoking .an elopement risk .The resident has impaired visual function r/t [related to] Legally Blind .Velcro release seat belt while up in w/c. Nursing to assess resident bi-weekly to assure he can remove seatbelt . Review of the February 2024, Medication Administration Record (MAR) revealed .Test resident biweekly to assure he can release seat belt when in w/c . Review of the February 2024, Treatment Administration Record (TAR) revealed . self release Velcro seat belt while up in w/c . Review of a Smoking-Safety Screen dated 2/2/2024, revealed .Does resident have visual deficit .[checked] Yes .Does the resident have dexterity problem(s) .[checked] Yes .Team Decision .Safe to smoke with supervision [checked] Yes . Observations in Resident #8's room on 2/5/2024 at 4:09 PM, on 2/6/2024 at 7:49 AM, on 2/5/2024 at 2:56 PM, on 2/7/2024 at 7:55 AM, and on 2/8/2024 at 7:40 AM, revealed he did not have on the velcro belt. During an interview outside Resident #8's room on 2/8/2024 at 9:45 AM, RN #2 confirmed that if a resident is care planned for a lap belt (self-releasing safety belt with velcro fasteners) they should be wearing it. During an interview in the MDS office on 2/12/2024 at 8:33 AM, the Interim DON (Director of Nursing) verified that smoking assessments are to be done quarterly. During an interview in the Conference Room on 2/12/2024 at 6:41 PM, the ADON confirmed that smoking assessments should be done quarterly.

Based on policy review, Administration job description review, Director of Nursing (DON) job description review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to neglect, residents with wandering behaviors, investigation of incidents of elopement, and falls, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to incidents of elopement, neglect, resident behaviors, falls, and investigation and reporting of incidents. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI committee to ensure residents were free from neglect, incidents of elopement, and falls with major injuries resulted in Immediate Jeopardy (IJ) when Resident #11 was left unsupervised beside an exit door, after she exhibited exit-seeking behaviors, exited the facility when the door malfunctioned, and was found 5-6 minutes later on the back patio of the facility, sitting at a picnic table alone. The facility's failure to thoroughly and timely investigate and follow care planned interventions for falls, resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Acting Administrator was notified of the Immediate Jeopardy for F-867 on 3/27/2022 at 5:39 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 5/21/2022 through 5/28/2022. The facility was previously cited F-600, F-610, F-835, and F-867, at a scope and severity of J on a complaint survey on 5/30/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 3/28/2022 at 4:47 PM. The corrective actions were validated onsite by the surveyors on 3/28/2022 through policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled Quality Assurance Performance Improvement Program, dated 5/2018, revealed .The [Named Facility] Center's Quality and Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers .employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time .collaborative and interdisciplinary approach .measures, analyzes, and tracks .adverse Resident events, infection control and other aspects of performance that included care and services furnished in the facility .The purpose .is to facilitate a review of the organization's systems and functions as they impact the organization's customers .We will continuously strive to provide health care, service, and education, which consistently meet or exceeds the expectations of Residents .[QAPI] program will show measurable improvement in resident health outcomes and improvement in resident safety .and by the identification and reduction of medical error .Methodology .The Facility will use the data collected to do the following .Monitor the effectiveness and safety of services and quality of care .Identify opportunities that can lead to improvements and changes in Resident care .Medical records will be reviewed to identify any areas demonstrating a pattern of neglect of concern .Resident Falls .The organization will collect data and investigate all falls monthly .The organization develops and maintains a comprehensive Risk Management Program that protects the life and welfare of Residents .The Director of Nursing is the Facility's Risk Manager, reporting to the Administrator .Activities are reported to the QAPI committee and to the Board .Elements of the Risk Management Program include review of the following .Resident safety .Unexpected or adverse occurrences .Active surveillance for detection and prevention of disease, infection, and potential communicable infective sources . Review of the facility's Administrator job description, dated 7/10/2017, revealed .Provides leadership for the Nursing Home .supervises nursing home staff and resources. Oversees all activities of a nursing home in accordance with established policies and federal and state guidelines .is accountable for all operations and programs .KNOWLEDGE .Quality/Safety Standards .Healthcare Laws and Regulatory Agency Standards .Ensures department employees are accountable and adheres to all .policies and procedures, government laws, and regulatory agency standards .Provides leadership .Able to handle emergency or crisis situations . Review of the facility's Director of Nursing job description, dated 7/10/2017, revealed .The Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practical physical, mental, and psychosocial well-being .KNOWLEDGE .Healthcare Laws and Regulatory Agency Standards .Knowledge of long-term care management, policies .Develops, maintains, and implements nursing policies and procedures that conform to current standards of nursing practice .knowledge of and application of Key Quality Indicators .overall supervision of resident assessments and care plans .Reviews 24-hour report from every unit to daily monitor and ensure timely, effective responses .unexplained injuries, falls, behavioral episodes . Review of the medical record, revealed Resident #11 sustained a fall on 10/7/2021. An investigation was not conducted, staff statements were not obtained, and no interventions to prevent further falls were implemented at that time. Review of the facility's investigation dated 3/10/2022, revealed Resident #11 was found lying in the floor of her room. She was confused which was her normal baseline, had a small skin tear on her left elbow, her wrist was displaced and painful, and she had a hematoma on the left back side of her head. She was taken to the emergency room (ER) and radiology revealed that her left radial and ulnar bones were broken. The facility's failure to investigate Resident #11's fall on 3/10/2022 and implement appropriate fall interventions from a previous fall, resulted in Actual Harm when Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones. Review of the facility's investigation dated 3/23/2022, revealed that on the evening of 3/21/2022, Resident #11, a cognitively impaired, vulnerable resident, exhibited exit-seeking behaviors and attempted to leave the facility. Resident #11 was taken outside to walk around the facility by a staff member, brought back into the facility a few minutes later, and left in a chair beside the North Hall Exit Door. When Nursing staff on the hall entered a resident's room to administer medications, Resident #11 exited the facility unsupervised, through the malfunctioning North Hall Exit Door and was found outside the facility, sitting at a picnic table on the back patio, approximately 5-6 minutes later. The following timeline was documented: a. 3/23/2022 at 3:20 PM Notified the Medical Director of the elopement. b. 3/23/2022 at 3:25 PM Notified Resident #11's Physician of the elopement. c. 3/23/2022 at 3:45 PM An ad Hoc (as needed) QAPI meeting took place. d. 3/23/2022 at 4:00 PM Notified Resident #11's daughter to talk to the family about psychiatric services. e. 3/23/2022 at 4:00 PM One on One observation was implemented with hourly behavior and location log. f. 3/23/2022 All exit doors were checked by maintenance. The door near room [ROOM NUMBER], across the hall from Resident #11's room, had an alarm that did not work. A staff member was told be posted there, monitoring the door as well as Resident #11. g. 3/23/2022 Maintenance were to begin daily exit door checks on 3/24/2022 and log the results. Following Resident #11's incident of elopement, the facility did not convene a QAPI meeting until 3/23/2022, 2 days after the resident eloped from the facility. The State Survey Team entered the facility on 3/21/2022 to begin their annual survey, but they were not notified of the incident of elopement after it occurred. The elopement was discovered by the State Survey Team on 3/23/2022, through medical record review and staff interviews. Review of the medical record, revealed Resident #10 sustained 8 falls in the past 120 days. The intervention of gait belt with all transfers was implemented on 2/4/2022. Review of the facility's investigation dated 3/7/2022, revealed Resident #10 fell on [DATE], and the fall was not documented or reported by staff at that time. On 3/7/2022, the resident had [CONDITION(S)], bruising, tenderness, warmth to touch, and complained of pain to her right hand. The facility's investigation revealed, .resident stated that she had fallen yesterday .called the charge nurse [Licensed Practical Nurse (LPN) #3 who worked on 3/6/2022] . LPN #3 confirmed Resident #10 fell on [DATE] and Certified Nursing Assistant (CNA) #1 was present. Gait belt re-education was provided for LPN #3 and CNA #1. During an interview on 3/25/2022 at 3:45 PM, the DON confirmed CNA #1 did not use the gait belt for Resident #10's transfer and was re-educated on the use of a gait belt with all transfers for Resident #10. The facility's failure to follow Care Plan fall interventions resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fractured right fifth metacarpal. During a telephone interview on 3/23/2022 at 4:50 PM, the Administrator was asked if she had any reportable incidents or any incidents that the State Survey Team needed to investigate while in the facility. The Administrator stated, No . During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed an Ad Hoc QAPI meeting to discuss the incident of elopement was not conducted until 3/23/2022, 2 days after Resident #11 eloped from the facility. The Administrator was asked what interventions the facility put in place immediately after the incident of elopement. The Administrator stated, .there were no specific interventions until today. The Administrator stated, .My Medical Director is on vacation, and I did speak with her and told her the results of QAPI [today about 3:30] .we're doing an hourly behavior log while somebody is with her to see if new trends or patterns exist [begun 3/23/2022] .we are getting a new door system .that's been ongoing . The Administrator confirmed that prior to the incident of elopement that occurred on 3/21/2022, the facility doors were only checked monthly, and she was unaware that the double doors on the Skilled 1 Hall opened freely to an outside courtyard which contained 3 sets of steep steps, the door locking mechanism had been removed and there were hanging wires when the door was opened. The Administrator confirmed the investigation into the incident of elopement was not begun until 3/23/2022 and that she did not notify the state or any other regulatory entity about the elopement. During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she attended QAPI meetings and stated, We had a QAPI meeting Wednesday [3/23/2022] and we discussed [Named Resident #11] but I don't remember discussing wandering residents prior to that. The DON was asked if she was familiar with the resident elopement and Immediate Jeopardy (IJ) that occurred at the facility in 5/2020. The DON stated, I know about it, but I wasn't here at the time. The DON confirmed that she was not familiar with the Plan of Correction (POC) that was implemented after that incident of elopement. The Acting Administrator and DON confirmed that the POC implemented 6/3/2020, following the previous elopement IJ in 5/2020, should still be followed. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed that he was not made aware of Resident #11's elopement on 3/21/2022 until 3/23/2022 at approximately 3:00 PM. The CEO confirmed he should have been notified of the incident on 3/21/2022. The CEO confirmed that he had not yet reported the Immediate Jeopardy to the Hospital Board. During a telephone interview on 3/28/2022 at 12:32 PM, the Chairman of the Board confirmed he was notified of the elopement on Wednesday, 3/23/2022. The Chairman of the Board stated, .[incidents the Board should be notified of] certainly anything that does or could lead to harm of one of the residents . The Chairman of the Board confirmed the Board should have been notified of Resident #11's elopement prior to 3/23/2022. The Chairman of the Board stated, We receive as part of the monthly quality report, sections on the various indicators for the hospital and a separate one for the nursing home .also receive the minutes of the QAPI meeting . The Chairman of the Board was asked if anyone from the Board attended the facility's QAPI meeting. The Chairman of the Board stated, I'm not aware of a separate long term care meeting [QAPI] . During an interview on 3/28/2022 at 5:55 PM, the Healthcare Consultant stated, .She [the Administrator] pretty much knew she should have reported .just the decision part that was not right . Refer to F-600, F-609, F-610, F-689, and F-835. The surveyors verified the Removal Plan by: 1. The DON will begin daily Interdisciplinary Team (IDT) Clinical meetings during the Daily Stand-up Meeting to include the DON, Minimum Data Set (MDS) Coordinator, Dietician, Therapy, and Social Services to review Falls, Incidents, Weight loss, Pressure Wounds, and all at Risk issues that will aid in communicating issues to the Care Plan on 3/28/2-22. On 3/29/2022 and Agenda will be used for meetings. The surveyors reviewed the daily IDT Clinical Meeting/Stand-up Meeting Agenda and interviewed the DON. 2. The Administrator will ensure Clinical Information will be added to the Daily Stand-up Meeting Monday through Friday with Department Heads to review Resident issues and facility issues beginning 3/28/2022. The surveyors reviewed the Daily Stand-up Meeting notes and interviewed the Acting Administrator. 3. The DON and Assistant Director of Nursing (ADON) conducted an in-service on 3/24/2022 with the Nursing Staff (Registered Nurses (RN), LPNs, Certified Nursing Assistants (CNAs)) on the Revised Abuse, Neglect and Misappropriation of Funds Policy, including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System, Wandering/Missing residents, and Caring for Residents with Wander guards (a monitoring device to alert staff when a resident attempts to exit a door in the facility).These in-services were either in-person, in a classroom setting, or 1:1 either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the in-services, in-service sign in log, and interviewed nursing staff on all shifts. 4. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified beginning 3/25/2022. This will continue for 3 months or until QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 5. The Administrator and the Healthcare Consultant will audit all records of reported Abuse, Neglect, Exploitation, and/or Misappropriation of Property for completion of investigation and reporting to the state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant and the Acting Administrator. 6. The Healthcare Consultant conducted a one-on-one training with the Administrator reviewing Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and the responsibility to conduct timely reporting and investigation of potential instances requiring reporting to the State Incident Reporting System (IRS) on 3/24/2022. The surveyors reviewed the training and interviewed the Healthcare Consultant and Acting Administrator. 7. An outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/POC beginning 3/24/2022. Monitoring will consist of implementation of the Removal Plan/POC at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, CEO, and the full QAPI committee and determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant. 8. The outside Healthcare Consultant will report findings to the Governing Body, the full QAPI Committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the outside Healthcare Consultant. 9. Effective 3/28/2022, the Administrator/Interdisciplinary Team will develop an evaluation process to be conducted yearly through the QAPI program and reported annually to the QAPI Committee and Governing Body that includes a mechanism to ensure the residents with wandering behaviors, exit doors are working correctly, incidents are investigated and reported if necessary, and residents have up to date Care Plans, and are assessed and monitored as defined in the Care Plan. The surveyors reviewed the evaluation process and interviewed the DON and the Acting Administrator. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation reviewed, medical record review, observation, and interview, the facility failed to provide supervision and a safe environment to prevent elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering behaviors and elopement; failed to conduct fall investigations, implement, and follow fall interventions for 2 of 9 sampled residents (Resident #10 and #11) reviewed for falls; failed to perform neurochecks after falls and accurately assess for fall risk for 9 of 9 sampled residents (Resident #4, #6, #7, #10, #11, #19, #20, #35, and #38) reviewed for falls; and failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 1 of 3 Shower Rooms (Skilled 1 Hall). The facility's failure to provide supervision and ensure a safe environment resulted in Immediate Jeopardy when Resident #11, a cognitively impaired, vulnerable resident, exited the facility unsupervised through the North Hall Door unsupervised, and was found approximately 5-6 minutes later, sitting in a chair at a picnic table on the back patio, 13 feet from the door of the facility, and 134 feet from the driveway in front of the nursing home. The facility's failure to thoroughly and timely investigate and follow care planned interventions for falls, resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:07 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was previously cited an Immediate Jeopardy in F-689 at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy existed from 3/21/2021 through 3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/25/2022 at 3:26 PM, and was validated onsite by the surveyors on 3/27/2022 through 3/28/2022 through policy review, medical record review, review of education records, auditing tools, observation, and staff interviews. The findings include: Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 7/2017, revealed .All accidents or incidents involving residents .on our premises shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following data, as applicable, shall be included on the Report of Incident/Accident form .date and time .nature of injury .circumstances surrounding the accident or incident .Where the accident or incident took place .names(s) of witnesses and their accounts of the accident or incident .injured person's account of the accident or incident .time .time the person's Attending Physician was notified .the time the physician responded and his or instructions .date/time the injured person's family was notified and by whom .condition of the injured person, including his/her vital signs .disposition of the injured .corrective action taken .Follow-up information .signature and title of the person completing the report .facility is in compliance with current rules and regulations governing accidents .Nurse Supervisor/Charge Nurse and or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident .Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident .analyze any individual resident vulnerabilities . Review of the facility's policy titled, Care of Residents at Risk for Wandering, dated 6/2020, revealed .This policy serves to provide guidelines to staff regarding causes of and injury prevention strategies for residents at risk for wandering .Signs of wandering .Residents, speaking about being unhappy and desiring to leave the facility .speaking about going to visit a loved one . Review of the facility's policy titled, Resident Elopement, dated 1/2021, revealed .One of the most challenging issues related to care of the resident with dementia is wandering behavior. The most dangerous form of wandering is elopement, in which the confused resident leaves the nursing home .It is the intent of the facility to be aware of its resident's usual habits and locations .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .Procedure to follow in event of missing resident .Staff will also search the unit in order to identify any other residents that may be missing .the Charge Nurse will notify the Administrator and Director of Nursing .When a resident who was missing is found, the nurse will .Examine the resident for possible injuries .Notify the Attending Physician for consultation .Notify the Medical Director .Discuss with the Administrator or DON [Director of Nursing], or designee if it is prudent to provide the resident with 1:1 [one to one] or other level of supervision .Complete an incident report .Complete appropriate documentation in the resident's medical record .The supervisor or designee will also instruct staff members to verify any other resident that has been identified as at risk for wandering is in the building to affirm their safety .If the resident uses an electronic device that alarms, the Charge Nurse or designee will .note location of the device on the resident's body .Test any electronic protection device both on the resident and attached to or associated with any doorways .In the event that there is an equipment or doorway malfunction, provide supervision of that area .provide 1:1 observation to the resident .Re-evaluate the resident's risk for possible elopement .Follow-up Investigation .DON or designee will obtain video evidence to establish timeline of events and resident exit point .responsible [for] obtaining staff .statements regarding incident .ensure notification of medical director, CEO [Chief Executive Officer], administrator, resident family, and primary physician .will moderate an adhoc [done for a particular purpose] QAPI [Quality Assurance Performance Improvement] Meeting, within 24 hours after event, to discuss possible contributing factors and discover primary root cause of the event . Review of the facility's policy titled, Falls Management Program, dated 2/2022, revealed .Purpose: To provide a coordinated system to minimize the incidence of falls among residents identified to be at risk for fall/injury. To keep our residents .safe .Within 24 hours of admission to the facility, the nurse will complete the Falls Risk Assessment on all residents .Procedure: Nurses will document at the time of the fall regarding the intervention put in place. MDS [Minimum Data Set] will add the intervention to the care plan .When a resident falls .Neuro checks are to be initiated immediately and continue as follows .Every fifteen minutes times four .Every thirty minutes times two .Every two hours times two .Every four hours times 24-48 hours .depending upon severity of injury .The nurse is to complete the incident report and notify the physician and family .that a fall has occurred .If the fall is with injury the physician, family or responsible party should be notified immediately. This should be documented in the appropriate space on the incident report as in the patient record .medical record should be flagged with a Q [Every] SHIFT sticker for frequent monitoring and documentation .Review of the current care plan for any necessary updates/revisions. Any updates/revisions should be noted on the CNA [Certified Nursing Assistant] Assignment Sheet . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Closed Fracture of Right Radius, Closed Fracture of Right Ulna, Dementia with Behavioral Disturbance, Anxiety, Hypertension, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for mental Status (BIMS) score of 4, which indicated severe cognitive impairment, 1 fall since admission or prior assessment, and exhibited wandering behaviors 1 to 3 days of the 7 day look back period. Review of the Wandering Risk Assessment, dated 1/7/2022, revealed Resident #11 was a moderate risk for wandering and had a known history of wandering. Review of a Progress Note dated 1/7/2022 at 5:45 PM, revealed .res [resident] trying to get out of facility went to door thinking her daughter was outside, nurse talked to res and got her away from the front door and res was mad and stated I will get out .Im [I'm] going home . Review of a Progress Note dated 1/7/2022 at 5:53 PM, revealed .res at door again for second time looking out and pushing on door CNA to get her .she stated that's [that's] my family and I will leave .res sitting in chair by door in front by nurses [nurses'] desk . Review of the significant change MDS dated [DATE], revealed Resident #11 had a BIMS of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Care Plan revised 1/14/2022, revealed .The resident is an elopement risk/wanderer .Assess for fall risk .Distract resident from wandering by offering pleasant diversions .Monitor for wanderguard [wander guard] placement .every shift for wandering/exit seeking .Document wandering behavior and diversional interventions in behavior log .Weekly behavior assessment every Friday . Review of a Weekly Behavior Note dated 1/14/2022, revealed potential for elopement and wandering behaviors were not documented. Review of a Progress Note dated 1/21/2022 at 3:10 PM, revealed .res pacing up and down hallways [hallways] looking out doors and pushing on them to see if she can get out , she stated Ill [I'll] find one unlocked and Ill be gone . Review of a Weekly Behavior Note dated 1/29/2022, revealed no documentation in the following sections: Behaviors Noted, Safety, Observed Behaviors, Behavior Management Intervention, Outcome of Interventions, Behavior Triggers, and Frequency of Behaviors. Review of a Progress Note dated 2/14/2022 at 4:37 PM, revealed .res is having episodes of exit seeking behavior, going to doors and pushing on them trying to get them open, gets angry when you tell her they are locked .walks off or sits down in chair close to doors . Review of a Weekly Behavior Note dated 2/19/2022, revealed .Behaviors Noted .no . There was no documentation of the potential for elopement, wandering, and anxiety behaviors. Review of a Progress Note dated 2/20/2022 at 5:17 PM, revealed .res was anxious this am [morning] trying to get out front door . Review of a Weekly Behavior Note dated 2/25/2022, revealed .Behaviors Noted .no . There was no documentation of the potential for elopement, wandering, and anxiety behaviors. Review of a Progress Note dated 3/21/2022 at 9:56 PM, revealed .Resident exit seeking, was assisted down sidewalk by cna [Certified Nursing Assistant] and reentered by back door . Review of the facility investigation dated 3/23/2022, and provided to the survey team on 3/24/2022, revealed .Monday 21 March 2022 [3.21/2022]. [Named Resident #11] had been visiting with her daughter in room #2 .daughter left at 5:45pm [5:45 PM] [Named Resident #11] at approximately 645pm [6:45 PM] was exit seeking .kept stating she was looking to go home to take care of the boys .came to the Administrator office and sat down .watching for her family .She got up to leave admin [Administrator] office, [Named MDS Coordinator] was standing in the entryway, [Named Resident #11] pushed the door and it opened, she stepped out onto the front door step .[Named MDS Coordinator] .got a hold of her arm to keep her from going outside .hollered for [Licensed Practical Nurse (LPN) #5] to come help .[Named CNA #2] .walked up to the door .assisted [Named Resident #11] down the stairs and walked her down the side walk and up to the back door [North Hall Exit Door outside of the Director of Nursing (DON) Office] .[Named Resident #11] was tired, so she sat in a geri [geriatric] chair at the end of the hall where [Named CNA #2] and [LPN #4] were working. [Named Resident #11] got out the door and no one was aware where she was. She was found sitting on the back patio [outside of the North Hall Exit Door] drinking a [named beverage] . Review of an Incident Reporting System report dated 3/24/2022, revealed .Date of Occurrence .3/21/2022 .Time of Occurrence .7:20 PM .Resident sitting in chair at end of hall by exit door. Resident exited door, without supervision, to sit at picnic table outside. Staff was unaware that resident was outside. When she was not in chair staff began to look for her .No injuries noted .3/23/2022 Medical Director .notified of incident .3/23/2022 One on one supervision implemented for resident. Annual Survey team is here for our annual and is investigating . Review of the medical record, revealed a Head-to-Toe Nursing Assessment was not completed and vital signs were not obtained after Resident #11 eloped from the facility on 3/21/2022. Review of a Weekly Behavior Note dated 3/25/2022, revealed .Behaviors noted .no .Observed Behaviors .Potential for elopement .Wandering .Restless . The Weekly Behavior Note documented Resident #11 had no behaviors and then documented Resident #11 had potential for elopement, wandering, and restless behaviors. Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 seated in her chair eating dinner, appeared to have periods of confusion, and a wander guard was observed on her left ankle. Observation in the resident's room on 3/22/2022 at 8:18 AM and 3/23/2022 at 8:42 AM, revealed Resident #11 appeared confused and a wander guard was observed on her left ankle. Observation in the facility parking lot on 3/23/2022 at 11:35 AM and 8:00 PM, 3/24/2022 at 7:50 AM and 1:40 PM, 3/25/2022 at 7:30 AM, 12:10 PM, 3:49 PM, and 7:55 PM, 3/26/2022 at 8:00 AM, 12:38 PM, 3/27/2022 at 11:00 AM and 8:00 PM, and 3/28/2022 at 10:00 AM and 10:45 PM, revealed the gate which led from the ramp at the North Hall Exit Door to the sidewalk, and the gate which led from the sidewalk to the parking lot, both were wide open. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed Resident #11 eloped from the facility on 3/21/2022. CNA #3 confirmed she entered the facility for her shift at 6:23 PM. CNA #3 stated, .I was trying to come in .she [Resident #11] wanted out the front door, we tried to get her back .she wouldn't come back .she sat down with [Named Administrator] in the office .[Named CNA #2] took her for a walk and sat her down in a seat by the back door .I seen [saw] her sitting down there .went to take care of another patient .they asked if I had seen her .we went looking for her .went out the front door to make sure she didn't get out the front .walked all the way around to [Named DON] office [North Hall Exit Door] and she was sitting on the patio .I cannot tell you [how she got out the door] .still wonder that . CNA #3 confirmed she was not asked to write a statement after Resident #11 eloped from the facility unsupervised and stated, .usually they'll have us all write a statement .anyone who was involved or knew about it . CNA #3 confirmed that there was not a lock on the gate which led from the handicap ramp to the sidewalk behind the facility, or on the gate which led from the sidewalk to the back parking lot. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed that when she came to work on 3/21/2022, Resident #11 was on the front doorstep with the MDS Coordinator and LPN #5. CNA #2 stated, .She was wanting to go out and look for her car .I just put my stuff down, walked with her down the steps and around the building .walked down where the big white tree was blooming .she was tired .walked her up the ramp to the door where the DON's office is and sat her on the chair there . CNA #2 confirmed she left Resident #11 on a chair inside the facility, beside the North Hall Exit Door, and outside the DON's office. CNA #2 stated, .[Named LPN #4] started her med [medication] pass .she [Resident #11] wanted to sit there .I went on up and clocked in .pulled my snacks .doorbell rang, I went to the door and it was the granddaughter [of Resident #11] .she said where is she [Resident #11] .looked [down the hall at the chair where she had left Resident #11] and she wasn't there. We went down to her room and she wasn't there .I told the granddaughter I had left her in that chair [beside the North hall Exit Door] .went down the side door in the lobby [door from the Dining Room out to the smoking patio] and when I got back there by the office [DON office] she was sitting in a chair outside [on the back patio] .[Named Administrator] asked me where she was .I said she's sitting out there on the patio .I didn't hear an alarm .[Named Administrator] called maintenance and asked them to check the alarms on the doors . CNA #2 confirmed she had not been asked to write a statement regarding the incident of elopement and staff did not conduct a building inspection to ensure no other wandering residents had gotten out of the facility. During an interview on 3/23/2022 at 2:43 PM, General Maintenance Staff #1 confirmed the Administrator called him on 3/21/2022, at approximately 7:00 PM, and notified him that the North Hall Exit Door wasn't working properly. General Maintenance Staff #1 confirmed the door mechanically malfunctioned, that it was not making full contact, which would make the door easier to open, and no one was posted to monitor the door when he arrived for the repair. During a telephone interview on 3/23/2022 at 5:35 PM, LPN #4 confirmed that on the evening of 3/21/2022, Resident #11 was exit-seeking, so CNA #2 walked with her outside, down the sidewalk, and around to the back door by the DON's office. Resident #11 was tired after the walk outside, so she sat down and rested in a chair beside the North Hall Exit Door. LPN #4 confirmed she entered Resident #41's room and Resident #11 was left alone. LPN #4 stated, .She was sitting there .I was passing my meds [medications] .went into [Named Resident #41's] room .took his temp [temperature], checked his oxygen [saturation level], and gave his nighttime medicine . LPN #4 confirmed she was in the room 5-6 minutes. LPN #4 confirmed that Resident #11 was not in the chair when she exited Resident #41's room and stated, .looked down the hall to my left and looked out the door and she was outside at the picnic table . LPN #4 stated, .She walked out the door .didn't alarm, or lock . LPN #4 confirmed Resident #11 sat in a chair at the picnic table on the back patio by herself. LPN #4 stated, .When I went out to get her the door just opened. LPN #4 confirmed the DON was not in the facility when the incident occurred, but the Administrator was there. LPN #4 confirmed that she was asked to write her statement regarding this incident on 3/23/2022, 2 days following the incident of elopement. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed that on the evening of 3/21/2022, Resident #11 was exit-seeking. The Administrator stated, .[Named Resident #11] was starting to get anxious .sat in my office a little while .got up from my office, pushed the door [Front Lobby Door], it opened and [Named MDS Coordinator] went out with her .on the steps and couldn't get her back in. [Named CNA #2] was walking up and walked [Named Resident #11] down the stairs and around the building .towards the parking lot .went back in my office .one of the girls said she was sitting in a chair in front of the DON office and now they couldn't find her .so we looked .they told me she was sitting on the back porch [patio outside the North Hall Exit Door] . The Administrator confirmed that after the resident was found she called maintenance to come check the North Hall Door to see if there was problem with the door. The Administrator confirmed maintenance came and repaired the door. The Administrator was asked what she told staff to do after Resident #11 eloped from the facility on 3/21/2022. The Administrator confirmed she did not begin her investigation into the incident of elopement, conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting, and notify the Medical Director until 3/23/2022, 2 days following the incident of elopement. The Administrator confirmed that no specific interventions were implemented until 3/23/2022. The Administrator stated, .Oh yes, we did watch that door .I don't have a log .[Named LPN #4 [watched the door] while passing medicines down that hall . The Administrator confirmed the door would not have been monitored while LPN #4 was in residents' rooms. The Administrator confirmed that when the doors were checked on 3/23/2022 the South Hall Exit Door, across from Resident #11's room, did not alarm and someone was stationed outside her room to monitor the door. The Administrator confirmed the facility staff should not have left Resident #11 sitting by the door alone. The Administrator stated, .we knew she was exit-seeking .we brought her in and sat her right in front of the door . The Administrator confirmed a head-to-toe assessment should have been conducted after Resident #11 was found and the physician should have been notified. The Administrator was asked why the physician was not notified after the incident of elopement. The Administrator stated, I didn't think of it. Observation in the resident's room on 3/24/2022 at 7:39 AM, revealed Resident #11 in bed with her eyes closed and her room dark. A staff member was posted outside her room. During an interview on 3/25/2022 at 6:45 PM, LPN #5 confirmed he was not asked to write a statement regarding Resident #11's incident of elopement until late in the afternoon on Wednesday, 3/23/2022. LPN #5 confirmed he did not obtain vital signs or perform a head-to-toe assessment when Resident #11 was brought back into the facility, after she eloped. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services confirmed he was not made aware that Resident #11 had eloped from the facility until Tuesday, 3/22/2022. During an interview on 3/26/2022 at 11:55 AM, the DON confirmed she was not notified until 3/22/2022, that Resident #11 had eloped from the facility on 3/21/2022. The DON was asked if the facility's Elopement policy was followed. The DON stated, No, ma'am. During an interview and observation on 3/27/2022 at 7:30 PM, LPN #4 identified the location where she first observed Resident #11 sitting in a chair at the picnic table, on the patio outside the facility. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed he was not made aware of the incident of elopement until the afternoon of 3/23/2022, and that he should have been made aware of the elopement the day it occurred. The CEO confirmed that the facility's chain of command consisted of the Administrator reporting to the Executive Director of Support Services and the Executive Director of Support Services reported to him. The CEO was aware that the Administrator had engaged the services of a Nurse Consultant but was not aware that an Acting Administrator had been retained. During an interview and observation on 3/28/2022 at 12:50 PM, the Maintenance Supervisor used a measuring wheel to measure the distance Resident #11 ambulated when she eloped from the facility on 3/21/2022. The measurements revealed the following: a. The distance from the threshold of the North Hall Exit Door of the facility, to the chair on the patio outside the facility, where Resident #11 was found, was 13 feet. b. The distance from the patio chair where Resident #11 was found, to the end of Ramp #1, the handicap ramp, on the North end of the facility, was 94 feet. c. The distance from the end of Ramp #1 to the parking lot was an additional 13 feet, for a total of 107 feet from the chair to the parking lot. d. The distance from the end of Ramp #1 to the driveway was 40 feet, for a total of 134 feet from the patio chair to the driveway. The Maintenance Supervisor confirmed the driveway was called the driveway in front of the nursing home. Review of the medical record, revealed a Fall Risk Evaluation was not completed when Resident #11 was admitted to the facility, per facility policy. Review of a Fall Risk Evaluation, dated 4/7/2021, revealed Resident #11 had 1 to 2 falls in the past 3 months. The Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. Review of a Fall Risk Evaluation, dated 7/7/2021 and 10/7/2021, revealed the Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. Review of a Progress Note dated 10/8/2021 at 9:23 AM, revealed .Resident questioned about fall 10/7/2021 .remembered falling and stated .I'm sore all over . There was no documentation of an Incident Report, that a fall investigation was completed, that staff statements were obtained, or interventions were implemented following Resident #11's fall on 10/7/2021. There was no documentation of the fall in the medical record. Review of a Fall Risk Evaluation, dated 1/7/2022, revealed the Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. The Fall Risk Evaluation documented the resident had no falls in the past 3 months. Review of the Care Plan revised 1/14/2022, revealed .The resident is at risk for falls d/t [due to] Gait/balance problems .Anticipate and meet The resident's needs .Apply Gripper socks before transfers and ambulation .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Bed Alarm while in bed .Ensure that The resident is wearing appropriate footwear .when ambulating . Review of an Incident Report dated 3/10/2022, revealed .When CNA opened door to resident's room, she was lying on her back nude in the floor .called nurse for assistance. Resident was alert but confused which is her normal baseline .Noted resident to have a small skin tear on Lt [left] elbow and wrist displaced & [and] painful. Resident has a large hematoma [collection of blood under the skin] on Lt occipital [back of the head] area .Predisposing Situation Factors .Improper Footwear .Ambulating without Assist . Review of the facility investigation dated 3/10/2022 at 11:58 AM, revealed .Resident was not utilizing walker for ambulation and had no shoes/socks on feet at time of fall .returned from ER [emergency room ] at approx. [approximately] 4pm [4:00 PM] with fracture of the ulnar and radial bones (L) [left] arm in sling .3/11/22 [2022] .transported to [Named Orthopedic Clinic] .able to do a close [closed] reduction of fracture and applied splint . The facility investigation did not contain statements from staff working that shift, documentation that neurochecks were performed before Resident #11 went to the ER or after she returned to the facility, or interventions to prevent further falls from occurring. Review of a radiology report dated 3/10/2022 at 12:43 PM, revealed Resident #11 had a .Comminuted [multiple breaks] intra-articular [fracture that affects the wrist joint] distal radius and a comminuted transverse [perpendicular to the shaft or long part of the bone] distal ulnar fracture .Moderate posttraumatic soft tissue [CONDITION(S)] about the left wrist . Review of a radiology report dated 3/10/2022 at 12:23 PM, revealed Resident #11 had a computed tomography (CT) scan of the head which identified a left occipital scalp hematoma and no acute intracranial findings. No fall intervention was put into place until 3 days after the fall with major injury. Observation in the resident's room on 3/21/2022 at 9:53 AM, revealed Resident #11 in bed with her eyes closed, dressed, and appeared clean and well-groomed. Resident #11 was noted to have a cast on her left arm from mid upper arm to fingers with bruises noted to fingers below cast. During an interview on 3/25/2022 at 3:27 PM, the DON confirmed there was not a fall investigation and interventions were not implemented for Resident #11's fall on 10/7/2021. The DON stated, .There was not because I did not know that a fall had occurred . The DON confirmed there was only an incident report and a summary statement she had typed up related to Resident #11's fall on 3/10/2022. The DON stated, .This represents the entire investigation . The DON confirmed that staff statements were not obtained, neuro checks were not documented, and no new interventions were implemented to prevent further falls, after Resident #11's fall on 10/7/2021. The DON confirmed she would expect to see additional fall interventions implemented for a resident who was at high risk for falls. The DON stated, .I would try to move them closer to the desk [Nurses' Station] .more frequent checks from staffing . Resident #11's room was at the far end of the South Hall, away from the Nurses' Station and in close proximity to the South Hall Exit Door. The DON confirmed that due to Resident #11's severe cognitive impairment, reminders to use the call light would not be an effective intervention. The DON stated, .she would not remember that. During an interview on 3/25/2022 at 6:06 PM, the DON confirmed neuro checks should have been performed after Resident #11's fall with a head injury and radial and ulnar fractures on 3/10/2022. The facility's failure to investigate Resident #11's fall on 10/7/2021 and implement appropriate fall interventions, resulted in Actual Harm when Resident #11 fell and sustained a fracture of the right radius and ulna bones on 3/10/2022. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Muscle Wasting and Atrophy, Depressive Disorder, Dementia, [CONDITION(S)], [CONDITION(S)], Malignant Neoplasm of Bronchus and Lung, and Metabolic [CONDITION(S)]. Review of a Fall Risk Evaluation, dated 10/7/2021, revealed Resident #10 had multiple falls in the last 3 months. The Fall Risk Evaluation did not have a score to determine whether Resident #10 was at low, moderate, or high risk for falls. Review of the Care Plan dated 10/13/2021, revealed .resident is at risk for falls r/t [related to] Gait/balance problems, hx [history] of falls .2 person transfer at all times .Gait belt for all transfers .staff reeducated on need of gait belt for transfers with resident .Staff to monitor resident every 30 min [minutes] and document . Review of a Fall Risk Evaluation, dated 1/6/2022, revealed Resident #10 had multiple falls in the last 3 months. The Fall Risk Evaluation did not have a score to determine whether Resident #10 was at low, mo[TRUNCATED]

Based on facility investigation, policy review, medical record review, observation, and interview, the facility failed to timely and thoroughly investigate an incident of neglect and elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering and elopement. The facility's failure to timely and thoroughly investigate an incident of elopement and neglect, resulted in Immediate Jeopardy when Resident #11, a confused and vulnerable resident, eloped through an unlocked exit door on the North Hall, walked outside the facility unsupervised, and sat down in a chair near the facility's parking lot and driveway. Resident #11 was unsupervised outside the facility for approximately 5-6 minutes and traveled approximately 13 feet from the facility's North Hall Exit Door. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:06 PM, in the Board Room. The facility was cited an Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and a severity of J, which is Substandard Quality of Care. The facility was previously cited an Immediate Jeopardy at F-610 at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, for F-610 was received on 3/25/2022 at 2:48 PM. The corrective actions were validated onsite by the surveyors on 3/27/2022 and 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, revised 7/2017, revealed .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following data, as applicable, shall be included on the Report of Incident/Accident form .The date and time the accident or incident took place .nature of the injury/illness .bruise, fall, nausea .circumstances surrounding the accident or incident .Where the accident or incident took place .name(s) of witnesses and their accounts of the accident or incident .The injured person's account of the accident or incident .time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions .date/time the injured person's family was notified and by whom .condition of the injured person, including his/her vital signs .disposition of the injured .transferred to hospital, put to bed, sent home .Any corrective action taken .Follow-up information .Other pertinent data as necessary or required .signature and title of the person completing the report .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services [DON] within 24 hours of the incident or accident . The facility's policy titled, Abuse, Neglect, Misappropriation of Funds Protocol, dated 4/2019, revealed .The facility has a zero tolerance policy for abuse, involuntary seclusion, neglect and misappropriation of resident property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Investigation process .The individual conducting the investigation will, as a minimum .Review the completed Resident Abuse Report .Review the resident's medical record to determine events leading up to the incident .Interview with person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident .The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports Note: a copy of such reports must be attached to the Resident Abuse Investigation Report.The results of the investigation will be recorded on the Resident Abuse Investigation Report .The investigator will give a copy of the completed Resident Abuse Investigation Report to the Administrator within 2 working days of the reported incident .The Administrator will inform the resident and his/her representative .of the results of the investigation and corrective action taken within 3 days of the completion of the investigation . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 was eating dinner seated in her chair, appeared to have periods of confusion, and a wander guard was observed on her left ankle. The facility's investigation provided to the surveyors on 3/23/2022 at 7:45 PM, included: a. 1 undated handwritten statement by the Minimum Data Set (MDS) Coordinator, revealed .On Monday evening March 21, 2022 I was at the door of administrators office talking with her [Administrator], when [Named Resident #11] came by me and opened up the door, at this time I got a hold of her [Resident #11's] arm to encourage her to come in, but she refused. While pleading with her, I called for [Named Licensed Practical Nurse (LPN) #5] to assist me. He came to door and tried to convince her to come inside to talk. She still refused, then [Named Certified Nursing Assistant (CNA) #2] came up side walk to come in door. She took [Named Resident #11] for a walk around the building. At this time I was no longer needed, and clocked out and went home. This episode occurred around 6:30-7:00 [PM] . b. 1 undated handwritten statement by LPN #4, revealed .On Monday night [3/21/2022] [Named Resident #11] attempted to go out the front door CNA [Certified Nursing Assistant] .met her at the door when she was coming in and took resident for a walk around the nursing home and they came in through the back door .[Named Resident #11] wanted to rest so she [Resident #11] sat in a chair at the end of the hall. When I was doing my med [medication] pass I seen [saw] her [Resident #11] sitting in the chair resting so I went in to [Named Resident #41's] room to give medication and when I came out she [Resident #11] wasn't sitting there anymore. She had went [gone] out the back door without alarm going off and was sitting at the picnic table right outside the door . c. 1 handwritten statement by LPN #5 dated 3/23/2022, revealed .This is an [a] statement for an incident that took place on Mon. [Monday] March 21, 2022. I was passing by front entrance when I saw [Named MDS Coordinator] standing in threshold of main entrance with resident [Named Resident #11] I went to assit [assist]. As we were trying to coax her [Resident #11] back thru [through] door [Named CNA #2] walked up and suggested she walk with her to keep her calm, they walked from main entrance to back door by DON [Director of Nursing] office. I went down to back entrance and CNA and resident came in and resident sit [sat] on chair at end of hall she said she was tired. I went back up hall but in a few minutes was motioned back down hall resident was sitting on bench outside of the door . d. 1 Ad Hoc QAPI [Quality Assurance and Performance Improvement] meeting note dated 3/23/2022 at 3:30 PM, revealed .Monday, 21 March 2022 [3/21/2022]. [Named Resident #11] .was exit seeking .[Named Resident #11] got out the door and no one was aware of where she was. She was found sitting on the back patio . The facility's investigation of the elopement of Resident #11 on 3/21/2022 did not include interviews/statements from other staff working on the day of the elopement, did not include interviews/statements from staff working on previous shifts, did not include a full assessment of the resident after the elopement, did not include elopement or skin assessments of other residents, did not include documentation that all the doors were checked to be assured they could not be opened by the residents, and did not include interviews with the maintenance department staff regarding the security of the doors. The facility failed to provide a thorough and timely investigation of Resident #11's elopement. The investigation was not started until 3/23/2022, 2 days after the resident eloped from the facility. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed she was the CNA assigned to provide care for Resident #11 on Monday, 3/21/2022. She confirmed Resident #11 eloped and she did not know she was out of the building. She confirmed she had not been asked to write a statement about the elopement. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed she worked Monday, 3/21/2022 and confirmed she saw Resident #11 trying to get out the front door. CNA #2 stated, .I just put my stuff down, walked her down the steps and around the building .walked her up the ramp to the door where the DON's office is and sat her on the chair .inside .[Named LPN #4] started her med [medication] pass on that hall .I went on up and got clocked in .I pulled my snacks up .doorbell rang, I went to the door and it was the granddaughter [Resident #11's granddaughter] .we went to the hall and she [Resident #11] wasn't there .we went to her room and she wasn't there . She confirmed the staff started looking for Resident #11. CNA #2 confirmed she had not been asked to write a statement at that time. Observation on the Skilled 1 Hall on 3/23/2022 at 2:30 PM, revealed the double exit doors to the outside courtyard were not locked and opened easily. Outside the doors was an open courtyard that led to 3 steep stairwells. During a telephone interview on 3/23/2022 at 5:35 PM, LPN #4 was asked about the elopement incident that occurred on Monday, 3/21/2022 and stated, .When we got there, she was trying to get out the front door. One of the CNAs and nurses was talking to her by the door. The CNA walked with her outside. She walked her down the sidewalk and they came in the back door by the DON's office. When she came back in, she was tired, so she sat down and rested. She was sitting there for a few minutes. I was passing meds [medications]. I went into [Named Resident #41's] room .took his temp [temperature], checked hid oxygen [saturation level], and gave his nighttime medication .when I came out, she was not sitting in the chair anymore. She had gone out and was sitting there at the picnic table. LPN #4 confirmed she had been in Resident #41's room for 5 to 6 minutes. LPN #4 stated, .I looked down the hall to my left and looked out the door and she [Resident #11] was outside at the picnic table. She was sitting there by herself. The door was not locked .the doors opened for me . During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 was found outside the facility, unsupervised, on Monday 3/21/2022. She stated, .I called the on-call maintenance man to come in to check the doors to see if it was a door problem and he did come and said he fixed it. The Administrator confirmed she did not know what was wrong with the doors. She stated, I don't remember, other than he said he fixed it. The Administrator was asked if she obtained statements from staff. She stated, .from some of the staff, not all . She was asked when she obtained the statements. The Administrator stated, Today [3/23/2022]. She confirmed she also had the exit doors checked and held a QAPI meeting today. The Administrator confirmed she had someone watching Resident #11's door and stated, .it [the monitoring of Resident #11's door] started today . The Administrator was asked what the facility put in place after the elopement to keep all residents in the facility safe. The Administrator stated, .just keep an eye on her [Resident #11], there were no immediate things put in place at that time . The Administrator confirmed the nursing staff should have assessed the resident for injuries and checked her vital signs at that time. The Administrator confirmed the double exit doors on the Skilled 1 Hall were broken, no one was monitoring them at this time, and she was not aware until today that they were broken. During an interview on 3/25/2022 at 6:24 PM, LPN #4 read her statement and signed it. She confirmed Resident #11 had eloped on 3/21/2022. LPN #4 was asked when the Administrator asked her for a statement. She stated, It was Wednesday, the 23rd [3/23/2022]. LPN #4 was asked who she reported the elopement to. LPN #4 confirmed she reported the elopement to the Administrator on 3/21/2022, right after it happened. During an interview on 3/25/2022 at 6:45 PM, LPN #5 confirmed his statement and signed it. He confirmed Resident #11 had eloped on 3/21/2022, and he had assisted her back to her room. LPN #5 confirmed he was not asked to write a statement about the incident until Wednesday, 3/23/2022, at approximately 5:00 PM to 6:00 PM. LPN #5 was asked if the Administrator was present when the elopement occurred. He stated, Yes. LPN #5 confirmed he administered Resident #11's medications but did not complete a head-to-toe assessment or obtain vital signs after the elopement. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services was asked if a full inspection of the facility was done to check all the wandering residents and the doors. He stated, .I found out Tuesday [3/22/2022] from [Named Administrator]. I don't know if all the doors were checked. The courtyard doors [the double exit doors on the Skilled 1 Hall] have been broken for a while .the first time we were aware of the doors was when y'all told us .It was not on the door list . During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she was not made aware of Resident #11's elopement on Monday, 3/21/2022. The DON confirmed she was notified of the elopement on Tuesday, 3/22/2022, by the Administrator. The DON was asked what she did when she was made aware. The DON stated, I just said okay . Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed LPN #4 confirmed the location on the patio outside the North Hall Exit Door, where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor used a measuring wheel to measure the distance from the North Hall Exit Door to the chair where Resident #11 was found. The distance measured approximately 13 feet. Refer to F-600, F-609, and F-689. The facility verified the Removal Plan by: 1. On 3/24/2022, the Healthcare Consultant conducted a one-on-one training with the Administrator reviewing the Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting, investigation of potential instances requiring reporting to the State Incident Reporting System. The surveyors reviewed the training and interviewed the Administrator. 2. The Administrator completed the investigation of the elopement and entered the information into the State Incident Reporting System related to the elopement of Resident #11 on 3/24/2022. The surveyors reviewed the completed investigation and interviewed the Administrator. 3. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect, and Misappropriation of Property policy with approval of the Quality Assurance Committee members and the Medical Director on 3/24/2022. The surveyors reviewed the Abuse, Neglect and Misappropriation of Property policy and interviewed the Administrator and Healthcare Consultant. 4. On 3/23/2022, the Administrator obtained statements from all staff working on 3/21/2022, 7:00 PM to 7:00 AM, concerning the elopement incident of Resident #11. The surveyors reviewed the statements and interviewed the staff to confirm their statements. 5. Wander Risk Assessments were completed on all current residents by the DON, Assistant Director of Nursing (ADON) and/or Charge Nurses on 3/24/2022. The surveyors reviewed the assessments and interviewed the DON and ADON. 6. The DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), LPNs, and CNAs) on the Revised Abuse, Neglect, and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System (IRS), wandering residents, and caring for residents with a wander guard on 3/24/2022. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the training, in-service sign-in sheets, and interviewed nursing staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed the Care Plans of exit seeking residents and interviewed the MDS Coordinator. 8. The MDS Coordinator reviewed the weekly Behavior documentation to ensure behaviors are captured and care planned appropriately on 3/24/2022 . The surveyors reviewed the weekly Behavior documentation and the Care Plans and interviewed the MDS Coordinator. 9. The Administrator will question management staff at daily Stand-Up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily Stand-Up meetings beginning 3/25/2022. The surveyors interviewed the management staff and the Administrator. 10. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and /or misappropriation of property for completion of the investigation and reporting to state agency, for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the Quality Assurance and Performance Improvement (QAPI) committee deems satisfactory compliance has been achieved. The surveyors interviewed the Executive Director of Support Services and the Healthcare Consultant. 11. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified, beginning 3/25/2022. This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 12. The DON and/or Assistant Director of Nursing (ADON) will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect Policy, caring for residents with wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors interviewed the DON and ADON. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to report an incident of neglect and elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering and elopement. The facility's failure to report an incident of elopement and neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #11, a cognitively impaired, vulnerable resident, eloped through an unlocked exit door on the North Hall, walked outside the facility unsupervised, and sat down in a chair near the facility's parking lot and driveway. Resident #11 was unsupervised and without staff awareness for approximately 5-6 minutes, and the distance the resident traveled was approximately 13 feet from the North Hall Exit Door. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:06 PM, in the Board Room. The facility was cited an Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 3/25/2022 at 2:48 PM. The corrective actions were validated onsite by the surveyors on 3/27/2022 and 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, .Abuse, Neglect, Misappropriation of Funds Protocol, revised 4/2019, revealed .Reporting Protocols .Neglect is the failure of the facility, its [it's] employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Staff members and persons affiliated with this facility shall not knowingly .fail to report an incident of mistreatment or other offense .or withhold information to reporting agencies .The results of the investigation findings are to be reported in 5 working days .Serious Bodily Injury .2 Hour Limit .All others .Within 24 Hours .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .and others as may be required by state or local laws, within five (5) working days of the reported incident . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Progress Notes dated 3/21/2022, revealed .Resident exit seeking, was assisted down sidewalk by cna [Certified Nursing Assistant] and reentered by back door . During the Entrance Conference on 3/21/2022 at 9:05 AM, the Administrator denied having any reportable incidents that had not been investigated by the State Survey Agency. Review of Resident #11's Elopement Occurrence dated 3/21/2022 and documented on 3/23/2022, revealed .Resident .had gotten outside and was found sitting on back patio .she had been sitting at the end of the hall in a .chair resting from walking w/a [with a] CNA [Certified Nursing Assistant] .Resident exited the building .without supervision .Was out for a short period of time . Review of an undated Witness Statement revealed Licensed Practical Nurse (LPN) #4 documented in her statement, .When I was doing my med [medication] pass I seen [saw] her [Resident #11] sitting in the chair resting so I went in to [Named Resident #41's] room to give medication .when I came out she wasn't sitting there anymore. She had went [gone] out the back door without alarm going off and was sitting at the picnic table .outside . During a telephone interview on 3/23/2022 at 4:50 PM, 2 days after the elopement, the Administrator's Office was called from the telephone in the Board Room and the Administrator was asked again if the facility had any reportable events or incidents for the team to review. The Administrator stated, No .something from 2019 . The Administrator called the team right back and stated she had found one from October and would bring it. The Administrator did not report the incident of elopement to the State Survey Team when asked about reportable incidents. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 had eloped on 3/21/2022. The Administrator was asked if she had notified the State or any other entity. She stated, No, Ma'am, I did not. The Administrator was asked if the incident of elopement should have been reported. She stated, Yes, immediately. Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #4 identified the location on the patio where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor measured the distance from the North Hall Exit Door to the marked area where Resident #11 was found after she eloped. The distance measured approximately 13 feet. During an interview on 3/28/2022 on 10:14 AM, the Chief Executive Officer (CEO) was asked when he was informed of the elopement. He stated, .I found out about that on Wednesday [3/23/2022], brought to my attention probably around 3:00 [3:00 PM] in the afternoon . The CEO was asked if he should have been informed of the elopement on Monday night after it happened. The CEO stated, I do, and I think that you all should have . Refer to F-600, F-610, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. On 3/23/2022, the Administrator obtained statements from all staff working on 3/21/2022 concerning the elopement incident of Resident #11. The surveyors reviewed copies of the statements, interviewed the Administrator, the staff, and had staff read and sign their statements. 2. On 3/24/2022, the Healthcare Consultant conducted a one-on-one training with the Administrator reviewing the Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting and investigation of potential instances that required reporting to the State Incident Reporting System. The surveyors reviewed the training and interviewed the Administrator. 3. The Administrator completed an investigation of the elopement and entered the information into the State Incident Reporting System concerning the elopement of Resident #11 on 3/24/2022. The surveyors reviewed the completed investigation and interviewed the Administrator. 4. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect, and Misappropriation of Property policy with the approval of the Quality Assurance Committee members and Medical Director on 3/24/2022. The surveyors reviewed the Abuse, Neglect and Misappropriation of Property policy and interviewed the Administrator and Healthcare Consultant. 5. On 3/24/2022, Wander Risk Assessments were completed on all current residents by the DON, Assistant Director of Nursing (ADON) and/or Charge Nurses. The surveyors reviewed the assessments and interviewed the DON and ADON. 6. On 3/24/2022, the DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), LPNs, and CNAs) on the Revised Abuse, Neglect, and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System (IRS), wandering residents, and caring for residents with a wander guard. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the training, in-service sign-in sheets, and interviewed nursing staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed the Care Plans of exit seeking residents and interviewed the MDS Coordinator. 8. The MDS Coordinator reviewed the weekly Behavior documentation to ensure behaviors are captured and care planned appropriately on 3/24/2022 . The surveyors reviewed the weekly Behavior documentation and the Care Plans and interviewed the MDS Coordinator. 9. The Administrator will question management staff at daily Stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily Stand-up meetings beginning 3/25/2022. The surveyors interviewed the management staff and the Administrator. 10. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and /or misappropriation of property for completion of investigation and reporting to state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the Quality Assurance and Performance Improvement (QAPI) committee deems satisfactory compliance has been achieved. The surveyors interviewed the Executive Director of Support Services and the Healthcare Consultant. 11. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified, beginning 3/25/2022 . This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 12. The DON and/or ADON will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to the Abuse/Neglect Policy, caring for residents with a wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors reviewed the sign-in sheets and interviewed the DON and nursing staff. The facility's noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility investigation, policy review, medical record review, observation, and interview, the facility neglected to provide adequate supervision to a cognitively impaired, vulnerable resident with a history of wandering and exit-seeking behaviors for 1 of 5 sampled residents (Resident #11) reviewed at risk for wandering and elopement. Resident #11 exited the facility without staff supervision or staff knowledge through an unlocked door and was found approximately 5-6 minutes later, sitting in a chair at a picnic table on the back patio, approximately 13 feet from the door of the facility, and approximately 147 feet from the driveway beside the nursing home. A Certified Nursing Assistant brought the resident back into the facility and left her alone in a chair beside an exit door even though the resident had demonstrated exit seeking behavior prior to this occurrence. The facility's failure resulted in Immediate Jeopardy for Resident #11. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:03 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at F-610 on 5/30/2020 related to a resident elopement. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/25/2022 at 3:26 PM, and was validated onsite by the surveyors on 3/27/2022 through 3/28/2022, through policy review, medical record review, review of education records, auditing tools, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, ABUSE, dated 3/2017, revealed .The facility has a zero tolerance policy for abuse .neglect .Neglect is the failure of the facility, its [it's] employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility's policy titled, Resident Elopement, dated 1/2021, revealed .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .the nurse will .provide the resident with 1:1 [one on one] or other level of supervision . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Wandering Risk assessment dated [DATE], revealed Resident #11 was assessed to be a moderate risk of wandering, with a known history of wandering. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and the resident wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Care Plan revised 1/14/2022, revealed .The resident is an elopement risk/wanderer .Monitor .every shift for wandering/exit seeking behavior . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .may apply wanderguard [wander guard] bracelet to lower extremity .monitor .every shift for wandering/exit seeking behaviors . Review of the Progress Notes dated 2/14/2022 at 4:37 PM, revealed Resident #11 exhibited episodes of exit-seeking behavior, pushed on exit doors in an attempt to leave the facility, and sat in a chair close to the exit doors. Review of the Progress Notes dated 2/20/2022 at 5:17 PM, revealed Resident #11 was anxious and tried to get out of the facility door that morning. Review of the Progress Notes dated 3/21/2022 at 9:56 PM, revealed .Resident exit seeking . Review of Resident #11's Elopement Occurrence dated 3/21/2022 (documented on 3/23/2022), revealed .Resident .had gotten outside and was found sitting on back patio .she had been sitting at the end of the hall in a .chair resting from walking w/a [with a] CNA [Certified Nursing Assistant] .Resident exited the building .without supervision .Was out for a short period of time . Observation in the resident's room on 3/21/2022 at 9:53 AM, revealed Resident #11 in bed with her eyes closed, dressed appropriately, and appeared clean and well-groomed. Resident was noted to have a cast on her left arm from mid upper arm to fingers with bruises noted to fingers below the cast. Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 eating dinner in her room, wearing a wander guard on her left ankle, appeared to be confused, and mumbled unintelligibly. Observation in the resident's room on 3/22/2022 at 8:18 AM and 3/23/2022 at 8:42 AM, revealed Resident #11 appeared to be confused and a wander guard was observed on her left ankle. Review of the facility investigation dated 3/23/2022, revealed .[Named Resident #11] at approximately 645pm [6:45 PM] was exit seeking .kept stating she was looking to go home .She came to the Administrator office and sat down looking out the window .She got up to leave admin [Administrator] office, [Named MDS Coordinator] was standing in the entry way, [Named Resident #11] pushed the door and it opened, she stepped out onto the front door step .[Named MDS Coordinator] .got a hold of her arm .[Named Resident #11] did not want to come back in .[Named CNA #2] walked up to the door .assisted [Named Resident #11] down the stairs and walked her down the side walk and up to the back door [North Hall Exit Door outside of the Director of Nursing's (DON) Office] .[Named Resident #11] was tired .sat in a .chair at the end of the hall .[Named Resident #11] got out the door and no one was aware of where she was .was found sitting on the back patio [outside of the North Hall Exit Door] .Potential for Improvement .Resident should have had one on one monitoring when she came in after walking outside the building with [Named CNA #2] .Log of increased monitoring should have been utilized .Currently collecting statements from staff that were working that evening . Observation in the facility parking lot on 3/23/2022 at 11:35 AM and 8:00 PM, 3/24/2022 at 7:50 AM and 1:40 PM, 3/25/2022 at 7:30 AM, 12:10 PM, 3:49 PM, and 7:55 PM, 3/26/2022 at 8:00 AM and 12:38 PM, 3/27/2022 at 11:00 AM and 8:00 PM, and 3/28/2022 at 10:00 AM and 10:45 PM, revealed the gate which led from the ramp of the North Hall Exit Door to the sidewalk, and the gate which led from the sidewalk to the parking lot, both stood wide open. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed Resident #11 often exhibited exit-seeking behaviors and that she eloped from the facility on the evening of 3/21/2022, shortly after her shift began. CNA #3 stated, .[Named CNA #2] took her for a walk and sat her down in a seat by the back door .I seen [saw] her sitting down there .went to take care of another patient .they asked if I had seen her .we went looking for her .she was sitting on the patio . CNA #3 confirmed she did not hear Resident #11's wander guard alarm when she left the facility. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed that on the evening of 3/21/2022, when she arrived at work, Resident #11 was standing on the front doorsteps with the MDS Coordinator and LPN #5. CNA #2 stated, .She [Resident #11] was wanting to go out and look for her car .I just put my stuff down, walked with her down the steps and around the building .said she was tired, wanted a seat with a cushion on it, walked her up the ramp to the door where the DON's office is and sat her on the chair [inside the facility beside the North Hall Exit Door] .[Named LPN #4] started her med [medication] pass on that hall .I let her [Resident #11] sit there, went on up and got clocked in .started for the night .pulled my snacks [bedtime residents' snacks] .doorbell rang .it was the granddaughter [Resident #11's granddaughter] .we looked and she [Resident #11] wasn't there [where CNA #2 left her beside the exit door] .I went down to the room .[Resident #11] wasn't in her room .I told the granddaughter that I had left her in that chair .[Named CNA #2] went out the side door .when I got to the back [patio outside the facility] .by the [DON] office door [at the North Hall Exit Door] she was sitting in a chair there [outside the facility on the back patio] . During an interview on 3/23/2022 at 2:43 PM, General Maintenance Staff #1 confirmed he was on call on Monday, 3/21/2022 and received a call that the North Hall Exit Door was not working properly. He confirmed that one of the magnets had dropped down and was not making full contact which would cause the door to open more easily. He stated, .I tightened the bolt . He confirmed there was no one at the door, monitoring the door when he arrived to repair it, and the door had mechanically malfunctioned. During a telephone interview on 3/23/2022 at 5:35 PM, Licensed Practical Nurse (LPN) #4 confirmed CNA #2 took Resident #11 outside to walk around the facility and brought her back in the facility through the North Hall Exit Door beside the DON's office. LPN #4 stated, .[Named Resident #11] was tired .sat in the chair there and rested [beside the exit door] .I .went into [Named Resident #41's] room .when I came out [of Resident #41's room], she was not sitting in the chair anymore .she had walked out [the North Hall Exit Door] .she sat at the picnic table .I hollered for [Named LPN #5] . LPN #4 confirmed that she was in Resident #41's room for approximately 5-6 minutes and stated, .took his temp [temperature], checked his oxygen [saturation level], gave his nighttime medicine . LPN #4 confirmed she did not hear the North Hall Exit Door alarm and when she pushed on the door it was not locked, and opened immediately. LPN #4 stated, .[Named Administrator] was there [when the incident occurred] . LPN #4 confirmed Resident #11 was outside the facility, unsupervised, and without staff's knowledge. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 eloped from the facility on the evening of 3/21/2022. The Administrator stated, .One of the girls said [Named Resident #11] was sitting in a .chair in front of the DON office [beside the North Hall Exit Door] . The Administrator confirmed she was then told Resident #11 was not in the chair where staff had left her. The Administrator stated, .I looked .they called and said she was on the back porch [back patio outside of the facility] . The Administrator confirmed staff had left Resident #11 unsupervised in the chair beside the North Hall Exit Door, shortly after she exhibited exit-seeking and wandering behaviors, and attempted to leave the facility. The Administrator confirmed that facility staff should not have left Resident #11 unsupervised near an exit door after she had exhibited wandering and exit-seeking behaviors. Observation in the resident's room on 3/24/2022 at 7:39 AM, revealed Resident #11 rested in the bed with her eyes closed and her room darkened. A staff member was posted outside her room. Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #4 identified the location on the patio where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor measured the distance from the North Hall Exit Door to the marked area where Resident #11 was found after she eloped. The distance measured approximately 13 feet. Refer to F-609, F-610, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. The Administrator requested the maintenance staff check the exit door outside the DON office for proper locking and maintenance repaired the door on 3/21/2022 at 7:30 PM. The surveyors interviewed the maintenance staff and observed the doors to ensure they functioned properly. 2. The Administrator requested the Maintenance Director to check all the exit doors in the facility for proper locking mechanism and functionality of the wander guard on 3/23/2022. The surveyors interviewed the Maintenance Director and observed the doors to ensure they functioned properly. 3. The Maintenance Director requested an outside vendor to come in and repair the door at the end of the East Hall and the door by the MDS office. This repair was begun on 3/24/2022. The Maintenance Staff will check all locking doors daily until all repairs have been completed. The surveyors interviewed Maintenance Staff and reviewed door logs. 4. The DON and Assistant Director of Nursing (ADON) conducted an in-service with the Nursing staff (Registered Nurses (RNs), LPNs, and CNAs) on the revised Abuse, Neglect and Misappropriation of Funds Policy, including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring 2 hour reporting requirement versus the type of incident requiring a 24 hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System, wandering residents, and caring for residents with wander guard. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors interviewed the DON, ADON, and nursing staff on all shifts, reviewed the in-service education, the in-service sign-in logs, and the Post Tests. 5. The Administrator and the Executive Director of Support Services completed the Elopement drill on 3/24/2022 at 6:30 PM and completed the newly developed Evaluation Form. The surveyors reviewed the Elopement Drill sign-in sheet and interviewed staff on all shifts. 6. Wander Risk Assessments were completed on all current residents by the DON, ADON, and/or Charge Nurses. The surveyors reviewed the assessments and interviewed staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed all residents' Care Plans and interviewed the MDS Coordinator and the Healthcare Consultant. 8. On 3/24/2022, the MDS Coordinator reviewed the Weekly Behavior Documentation to ensure behaviors are captured and care planned appropriately. The surveyors reviewed the medical records and interviewed the MDS Coordinator. 9. The Administrator and Executive Director of Support Services completed the Elopement drill on 3/24/2022 at 6:30 PM and completed the newly developed Missing Resident Evaluation Form. The surveyors reviewed the Elopement Drill sign-in sheet, Missing Resident Evaluation Form, and interviewed staff on all shifts. 10. On 3/24/2022, the Administrator and Executive Director of Support Services posted pictures of wandering residents at each Nurses' Station, the hospital Nurses' Station on each floor, Emergency Department, Front Door Registration and in the Maintenance Department. The surveyors observed the pictures posted at the various facility locations and interviewed staff. 11. Beginning on 3/23/2022, Maintenance increased exit door checks for proper locking mechanisms and functionality of the wander guard alarm system from monthly to weekly checks. The surveyors reviewed the door logs and interviewed Maintenance Staff. 12. An outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/Plan of Correction at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, Chief Executive Officer (CEO), the full Quality Assurance and Performance Improvement (QAPI) committee and to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 13. The outside Healthcare Consultant will report findings to the Governing Body, the full QAPI committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 14. Beginning 3/25/2022, the Administrator will question management staff at daily stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily stand-up meetings. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 15. Beginning 3/25/2022, the Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and/or misappropriation of property for completion of investigation and reporting to the state agency for accuracy and completion, per policy. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 16. Beginning 3/25/2022, the MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified. This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 17. Beginning 3/24/2022, the DON and/or the ADON will initiate a QAPI program related to review of any Abuse, Neglect and Misappropriation of Property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect Policy, caring for residents with wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors interviewed the DON and ADON. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, and interview, the facility Administration failed to administer the facility in a manner that ensured supervision, oversight, and provision of a safe environment for Resident #11 who was assessed to be at risk for wandering and failed to thoroughly and timely investigate and report an incident of elopement for Resident #11. The facility Administration failed to conduct a thorough and timely investigation and follow care planned interventions related to falls when Resident #10 fell and suffered a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). Facility Administration failed to administer the facility in a manner that provided a safe and secure environment for the residents, when they failed to ensure doors were secured, failed to provide supervision of wandering residents, failed to ensure a thorough and timely investigation was conducted, and failed to report an elopement for Resident #11. These failures resulted in Immediate Jeopardy (IJ) for Resident #11, a cognitively impaired resident with a history of exit-seeking behaviors, when she exited the facility without staff knowledge, and the facility was unaware of Resident #11's location for 5 to 6 minutes after a staff member had previously brought the resident back into the building and left the resident unattended. The facility's failure to ensure staff followed the Care Plan for use of a gait belt to prevent falls and to complete an incident report and investigation resulted in Actual Harm when Resident #10 fell and suffered a fracture of the right hand and when Resident #11 fell and suffered a fracture of the left radial and ulnar bones. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Acting Administrator was notified of the Immediate Jeopardy on 3/27/2022 at 5:39 PM, in the Board Room. The facility was cited an Immediate Jeopardy F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-600, F-609, F-610 and F-689 at a scope and a severity of J, which is Substandard Quality of Care. The facility was previously cited F-610, F-689, F-835, and F-867, at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy was removed onsite and existed from 3/21/2022 through 3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/28/2022 at 4:47 PM. The corrective actions were validated onsite by the surveyors on 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Administrator, revised 5/2013, revealed .A licensed administrator shall be responsible for the day-to-day functions of the facility .The administrator shall be a licensed nursing home administrator in this state and is responsible for .Managing the day-to-day functions of the facility .Ensuring that each resident's right to fair and equitable treatment, self-determination, individual privacy, property and civil rights including the right to lodge a complaint, are strictly enforced .Implementing established resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations, and guidelines .Serving as liaison to the governing board medical staff and other professional and supervisory staff .In the absence of the administrator, the Director of Nursing or designee is authorized to act in the administrator's behalf . Review of the facility's Administrator job description dated 7/10/2017, revealed .Provides leadership for the Nursing Home; plans, organizes, and supervises nursing home staff and resources. Oversees all activities of a nursing home in accordance with established policies and federal and state guidelines .Recommends and leads changes to improve the nursing home .Reports to the CEO and/or designee .KNOWLEDGE .Quality/Safety Standards .Healthcare Laws and Regulatory Agency Standards .The ability to effectively lead others in achieving essential duties .BEHAVIOR .Core Values/Standards of Conduct .Abuse and Neglect .JOB SPECIFIC CORE COMPETENCIES .Nursing Home Management .Knowledge of nursing home administrative practices, aging, and long-term care, gerontology and aging and health behavior .ESSENTIAL FUNCTIONS .Ensures department employees are accountable and adheres to all [Named Facility] policies and procedures, government laws and regulatory agency standards .Provides training of staff to maintain high standards of quality patient care .Provides leadership and supervises nursing home staff .Investigates and resolves staff issues .Promotes efficiency and effectiveness of job responsibilities .Maintains a quality conscious workforce . Review of the facility's Director of Nursing job description dated 7/10/2017, revealed .The Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources .to enable each resident to attain or maintain the highest practical, physical, mental, and psychosocial well-being .Reports to the Facility Administrator .Supervisory Responsibilities: Nurses and clinical staff .CORE COMPETENCIES .Communications .Healthcare Laws and Regulatory Agency Standards .ABILITIES .ability to effectively lead others in achieving essential duties .ability to effectively converse and actively listen to others concerning [Named Facility] matters .JOB SPECIFIC CORE COMPETENCIES .Abuse and Neglect .Knowledge of long-term care management, policies, personnel management .Knowledge of current federal and state laws and regulations that apply to the practice of nursing in a long-term care setting .strong organizational .skills and the ability to prioritize responsibilities .Ability to define problems, collect data, establish facts, and draw valid conclusions .ESSENTIAL FUNCTIONS .Directs and conducts the day-to-day activities of the nursing home in accordance with established policies. Implements changes to improve nursing home and reviews ongoing activities. Communicates directly with residents, families, medical staff, nursing staff, interdisciplinary team members, and Department Heads to coordinate care and services, promote participation in care plans, and maintain a high quality of care and life for residents. Collaborates with other departments, medical professionals, consultants and organizations including government agencies .to develop, support and coordinate resident care .Develops, maintains, and implements nursing policies and procedures that conform to current standard of nursing practice .while maintaining compliance with state and federal laws and regulations .Communicates and interprets policies and procedures to nursing staff, and monitors staff practices and implementation .daily or weekly management team meetings to discuss resident status .resident complaints or concerns .Evaluates the work performance of all nursing personnel .Ensures delivery of compassionate quality care .Exercises overall supervision of resident assessment and care plans .Reviews 24-hour report from every unit daily to monitor and ensure effective responses to .unexplained injuries, falls, behavioral episodes .Monitors complaint reports daily .for allegations of potential abuse or neglect .participates in these investigations .OTHER DUTIES .Creates, procures and implements ongoing education for staff members . During an interview on 3/23/2022 at 4:50 PM, the Administrator confirmed the last reportable or incident was 11/2019 and 10/2021. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed she had an unusual incident of elopement to occur on 3/21/2022 and staff searched for the resident before the resident was located sitting outside on the back patio. The Administrator confirmed she called General Maintenance Staff #1 to come check the North Hall Exit Door, after Resident #11 was found outside the door, which did not alarm or lock down, although she wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). The Administrator confirmed the door was fixed and the doors have been an ongoing problem. The Administrator confirmed she did not start the investigation, have staff to write statements, and notify the Medical Director, until today (3/23/2022). During the interview with the Administrator on 3/23/2022 at 6:39 PM the Administrator was asked what interventions were implemented after the elopement to ensure the safety of the residents. The Administrator stated, .other than just them keeping a close eye on her there were no specific interventions put into place .before today . The Administrator was asked if the North Hall Exit Door was monitored until General Maintenance Staff #1 arrived. The Administrator stated, We did watch the door, I don't have it on a log .As Licensed Practical Nurse [LPN] #4 was passing the meds [medications] .If she was in a room there would not have been [anyone monitoring the door] . The Administrator confirmed that when the doors were checked today, the locking mechanism on the South Hall Exit Door, across from Resident #11's room, was repaired but the door would not alarm today. The Administrator stated, .That's why someone is sitting outside her room . The Administrator confirmed she was just made aware that the 2 doors on the Skilled 1 Hall opened to an outside courtyard which had 3 sets of steep steps. The Administrator stated, .I was on the phone with maintenance .didn't know if I needed to station someone . The Administrator stated, .Right now nobody is [monitoring those doors] but I'll be watching until he [General Maintenance Staff #1] gets here . The Administrator was asked what problems she identified from the investigation of the elopement incident. The Administrator stated, To me one of the biggest problems, we knew she was exit-seeking .we brought her in and set her right in front of the door .should have brought her back to sit with me .we should not have left her alone in front of the door . The Administrator confirmed she did not notify the State or any other entity of Resident #11's elopement from the facility, but the incident should have been reported immediately. The Administrator confirmed staff should have performed a head-to-toe assessment and obtained vital signs, after Resident #11's elopement from the facility. During an interview on 3/24/2022 at 1:20 PM, the Director of Nursing (DON) confirmed the plan of care for gait belt use had not been followed when Resident #10 fell on [DATE] and suffered a right-hand fracture. Education was done with all staff on 10/2021 and re-education was done with two staff members after the fall on 3/6/2022 resulting in a right-hand fracture. No incident report or investigation was done at the time of the resident's fall. The incident report was completed on 3/8/2022, 2 days after the fall with major injury occurred. The DON confirmed she was notified of the fall on 3/7/2022 and started her investigation at that time. During an interview on 3/25/2022 at 3:29 PM, the DON confirmed an investigation was not conducted on Resident #11's fall on 10/7/2021 and fall interventions were not implemented. The DON stated, .I didn't know a fall happened . The DON confirmed that neurochecks were not documented for Resident #11's fall with major injury on 3/10/2022, fall interventions were not implemented after the fall, and staff statements were not obtained. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services confirmed he was not made aware of the elopement until Tuesday, 3/22/2022, by the Administrator. During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she was notified of Resident #11's elopement on 3/22/2022, by the Administrator. The DON confirmed the Administrator did not report the elopement. The DON confirmed she did not investigate Resident #11's elopement. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed he was notified of the elopement on Wednesday, 3/23/2022. The CEO was asked if he should have been notified of the elopement on Monday, after it occurred. The CEO stated, I certainly do, and I think you guys [State Survey Team] should have been too .given the fact you guys were in the house it's puzzling . The CEO confirmed he had notified the Board about Resident #11's elopement but had not notified them of the IJ. The CEO confirmed he approved the Nurse Consultant that the Administrator consulted but was not aware there was an Acting Administrator on board. During an interview on 3/28/2022 at 5:55 PM, the Healthcare Consultant stated, .She [the Administrator] pretty much knew she should have reported .She knew the 2-hour part and it was just the decision part that was not right . Refer to F-600, F-609, F-610, F-689, and F-867. The surveyors verified the Removal Plan by: 1. The Nursing Home Administrator hired a Healthcare Consultant to also evaluate policies and procedures, investigations of accidents/incidents for any improvements, and to work with the Administrator and DON to ensure compliance with regulations, effective 3/24/2022. This was verified by the surveyors through interviews with the Acting Administrator and Nurse Consultant. 2. The Maintenance Director requested an outside vendor to come in and repair the door at the end of the East Hall and the door by the MDS Office. This repair was begun on 3/24/2022. The Maintenance staff will check all locking doors daily until all repairs have been completed and more often if necessary. This was verified by the surveyors through interview with the Maintenance Director, Acting Administrator, and Nurse Consultant. 3. The Administrator requested the maintenance staff to check the exit door outside the DON Office for proper locking, repaired, and checked all exit doors in the facility for proper locking mechanism and functionality of the wander guard on 3/21/2022. This was verified by the surveyors through review of the door logs and interview with the Maintenance Director. 4. The DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)) on Revised Abuse, Neglect and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State IRS, wandering residents, and Caring for Residents with Wander guards on 3/24/2022. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. This was verified by the surveyors through the in-service education provided, Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. The Administrator and Executive Director of Support Services completed the Elopement drill and completed the newly developed evaluation form on 3/24/2022. This was verified by the surveyors through review of the evaluation form and interview with the nursing staff and Administration. 6. Wander Risk Assessments were completed on all current residents by the DON, ADON and/or Charge Nurses on 3/24/2022. This was verified by the surveyors through record review, review of the assessments, and interviews with staff and administration. 7. The Healthcare Consultant conducted a one-on-one training with the Administrator reviewing Abuse, Neglect and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting, investigation of potential instances requiring reporting to the State Incident Reporting System on 3/24/2022. This was verified by the surveyors through interview with the Acting Administrator and Nurse Consultant. 8. The Administrator completed the investigation of the elopement and entered the information into the State IRS concerning the elopement of Resident #11 on 3/24/2022. This was verified by the surveyors through interview with the Acting Administrator and Nurse Consultant. 9. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect & Misappropriation of Property policy with approval of the Quality Assurance committee members and Medical Director. This was verified by the surveyors through review of the policy and interview with the Acting Administrator and Nurse Consultant. 10. On 3/23/2022, the Administrator obtained a statement from all staff working on 3/21/2022, 7:00 PM to 7:00 AM, concerning the elopement incident of Resident #11. This was verified by the surveyors through investigation review, and interview with staff and the Administrator. 11. The Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. This was verified by the surveyors through record review, review of the Care Plans of exit seeking residents, and interview with the Healthcare Consultant and MDS Coordinator. 12. The MDS Coordinator reviewed weekly Behavior Documentation and all orders and documentation for the past 24 hours to ensure behaviors and medication or incidents were captured, and care planned appropriately on 3/24/2022. This was verified by the surveyors through record review and interview with the MDS Coordinator. 13. The Administrator and Executive Director of Support Services posted pictures of wandering residents at each Nurses' Station, hospital Nurses' Station on each floor, Emergency Department, Front Door Registration and in the Maintenance Department on 3/24/0222. This was verified by the surveyors through observation of the pictures posted, staff and the Healthcare Consultant interviews. 17. Beginning 3/24/2022, an Outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/Plan of Correction (AOC/POC) beginning 3/24/2022. Monitoring will consist of implementation of the AOC/POC at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, CEO, the full Quality Assurance Performance Improvement (QAPI) committee and to determine if the issues have been resolved or if the QAPI initiative should continue. This was verified by the surveyors through interview with the acting Administrator and the Healthcare Consultant. 18. The Healthcare Consultant will report findings to the Governing Body, the full QAPI committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. This was verified by the surveyors through interview with the Acting Administrator and the Healthcare Consultant. 19. The Administrator will question management staff at Daily Stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months, beginning 3/25/2022. The Administrator will acknowledge this questioning in the minutes of the Daily Stand-Up meetings. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 20. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and/or misappropriation of property for completion of investigation and reporting to state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until QAPI committee deems satisfactory compliance has been achieved. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 21. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified beginning 3/25/2022. This will continue for 3 months or until QAPI committee deems satisfactory compliance has been achieved. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 22. The Director of Nursing and/or Assistant Director of Nursing will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum of a review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued beginning 3/24/2022. One hundred percent (%) of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect policy, Caring for Residents with a Wander Guard, and Missing Residents. This was verified by the surveyors through review of the QAPI meeting, interview with the QAPI members, Acting Administrator and the Healthcare Consultant. 23. The Director of Maintenance will conduct monthly elopement/missing resident drills for 3 months, with at least one on night shift beginning 3/24/2022. Re-education will be conducted at the time of the drill if corrective action is needed. This was verified by the surveyors through staff interview and review of in-service sign in sheets, and interviews with the Acting Administrator, Healthcare Consultant, and Director of Maintenance. 24. The DON and the MDS Coordinator will review the Care Plan of all new residents who score high on their Elopement Assessment and/or are identified to be a potential for elopement for appropriate interventions on the Care Plan beginning 3/24/2022. This review of the Care Plan will continue for 6 weeks until 100 % compliance with the facility policy. This was verified by the surveyors through record review and interview with the DON and the MDS Coordinator. 25. The Administrator and Healthcare Consultant developed a competency checklist for nursing staff on caring for resident with wander guards on 3/24/2022. This Competency will be done following the in-service conducted with all nursing staff (RNs, LPNs, CNAs) with a completion date of 3/24/2022. This was verified by the surveyors through review of check list, interviews with staff on all shifts, Acting Administrator and Healthcare Consultant. 26. The Nursing Home Administrator hired a Healthcare Consultant to also evaluate policies and procedures, investigations of accidents/incidents for any improvements, and to work with the Administrator and DON to ensure compliance with regulations on 3/24/2022. This was verified by the surveyors through interview with the acting Administrator and Nurse Consultant. 27. The Interdisciplinary Team (IDT) will review all incidents from the past 24 hours daily Monday through Friday at the Morning Stand Up meeting; Weekend incidents will be reviewed on Mondays and incidents on Holidays will be reviewed on the next business day, effective 3/29/2022. The team will ensure immediate interventions were placed at the time of the incident and the intervention is appropriate and adequate. The IDT will ensure the Plan of Care is updated to reflect any new interventions and/or recommendations. This will be done indefinitely. All Incidents will be reviewed in QAPI monthly for trending and tracking. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Employee Time Punch Reports, Employee Screening Logs, observation, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 19 of 90 staff members (Patient Care Advocate #1, Certified Nursing Assistant (CNA) #2, #5, and #6, Registered Nurse (RN) #3, Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN) #3, #6, #8, #9, and #10, Certified Dietary Manager (CDM) and Dietary Staff #1, #2, #5, #8, #9, #10, and #13) failed to complete screenings for prevention and detection of COVID-19 prior to reporting to work on 9 of 10 days (3/5/2022, 3/7/2022, 3/8/2022, 3/9/2022, 3/10/2022, 3/11/2022, 3/12/2022, 3/13/2022 and 3/14/2022) reviewed; and when 1 of 1 nurse (LPN #7) failed to follow infection control practices during suprapubic catheter care for 1 of 1 sampled resident (Resident #14) observed. This had the potential to affect the 41 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options .include .individual screening on arrival at the facility .before entering the facility . Review of the Employee Time Punch Reports and Employee Screening Logs from 3/5/2022 to 3/14/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 3/5/3022 - CNA #5 b. 3/7/2022 - MDS Coordinator, LPN #6 #8 c. 3/8/2022 - CNA #6, LPN #6, #8, and #9 d. 3/9/2022 - CNA #5, LPN #6 and #8 e. 3/10/2022 - CNA #5, LPN #6, #8, and #10 f. 3/11/2022 - CNA #2, LPN #8 and #10, and Patient Care Advocate g. 3/12/2022 - CNA #6, RN #3, CDM, Dietary Staff #1, #2, #5, #8, and #13 h. 3/13/2022 - CNA #2 and #6, LPN #9, CDM, Dietary Staff #1, #2, #5, #8, and #13 I. 3/14/2022 - LPN #3, CDM, Dietary Staff #9 and #10 During an interview on 3/24/2022 at 3:59 PM, the Administrator confirmed all staff should be screened for COVID-19 upon entering the facility and prior to beginning work. The facility's policy titled, Hand Decontamination - Indications for Handwashing and Hand Antisepsis, revised 3/2017, revealed .Hand hygiene is the primary mode to prevent the spread of pathogens .Decontaminate hands .Before having direct contact with patients .If moving from a contaminated body site to a clean-body site during patient care .After removing gloves . Observation during suprapubic catheter care in Resident #14's room on 3/23/2022, revealed LPN #7 performed hand hygiene and donned gloves. She obtained a stack of gauze and soaked them with warm tap water and soap. She opened a white trash bag and placed it on the bed. She removed the old suprapubic catheter dressing using her gloved left hand and discarded the old dressing in the trash bag. She removed the left glove and placed it in the trash bag. LPN #7 did not perform hand hygiene and donned another glove to the left hand. She used the right gloved hand to clean the suprapubic catheter site with the gauze soaked with soap and water. LPN #7 began cleaning at the middle of the catheter tubing and wiped downward toward the suprapubic stoma and used the same gauze to clean around the stoma site. She removed the left glove, did not perform hand hygiene, and sprayed a clean gauze with Normal Saline and wiped around the stoma using the right gloved hand. She then placed a clean drain gauze around the suprapubic stoma and catheter using the right gloved hand. She did not change gloves or perform hand hygiene between wiping around the stoma and placing the clean drain sponge around the stoma and catheter. She removed her gloves and performed hand hygiene. She then took a pair of scissors from her pocket, cut a piece of tape, applied the tape to the drain sponge, and placed the scissors back in her pocket without cleaning them. During an interview on 3/26/2022 at 2:40 PM, the Director of Nursing (DON) confirmed when cleaning a suprapubic catheter, the catheter should be cleaned beginning at the stoma and up the tubing, away from the stoma site. She confirmed the nurse should have discarded the gauze used to clean the tubing, obtained new gauze with soap and water, and used the new gauze to clean around the stoma. The DON confirmed nurses should change both gloves, perform hand hygiene, and don new gloves between touching contaminated areas and clean areas. The DON confirmed the scissors should have been cleaned before and after cutting the tape and applying it to the dressing.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by 1 of 1 dietary staff (Dietary Staff #1) failed to remove gloves and perform hand hygiene during the dishwashing procedure, 10 wet-nested trays, the Certified Dietary Manager (CDM) placed a food thermometer into sanitizing solution and then placed it into the resident food to check the food temperature, 2 dented cans in the canned food supply, staff food was in 1 of 2 Resident Nutrition Refrigerators (Skilled 1 Hall Resident Nutrition Refrigerator), and staff failed to log the temperatures 2 times a day for 1 of 2 Resident Nutrition Refrigerators (Skilled 1 Hall Resident Nutrition Refrigerator). The facility had a census of 41 with 41 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, .Food Serving and Display, revised 6/2021, revealed, .All food while being displayed and served to patients, staff, and guests shall be protected against contamination .All food .shall be protected against contamination. This includes protection from dust, flies, roaches, rodents, or other vermin .or any other source of contamination . Review of the facility's policy titled, .Sanitation of Foodservice Equipment, revised 3/2022, revealed, .Purpose .To provide clean sanitary dishes and containers for patients .All china, trays, and flatware are air dried .Always wash your hands before you touch clean dishes . Review of the facility's policy titled, .Food Storage, revised 6/2021, revealed, .The temperature of all cool storage facilities should be checked and logged on the appropriate form daily with deviations from the norm [normal] reported and action recommended or taken recorded .Any damaged or leaking cans are removed from the storage area, and discarded, or returned for credit . Review of the facility's policy titled, .Nourishment Refrigerator Monitoring, revised 3/2020, revealed, .Nourishment refrigerators are intended for patient's food only. No employee food, multiple use condiments, or medications are allowed in patient nourishment refrigerators .Record temperature every shift, utilizing the Nourishment Refrigerator Monitoring Record . Observation in the Kitchen on 3/21/2022 at 9:15 AM, revealed Dietary Staff #1 was on the dirty side of the dishmachine, scrubbing pots and pans that had been used to prepare the food. Dietary Staff #1 went to the clean side of the dishmachine and removed clean pots and pans from the dish racks wearing the same gloves she wore while scrubbing the used pots and pans. Dietary Staff #1 returned to the dirty side of the dishmachine and continued to scrub the dirty pots and pans. She used a squeegee to remove the excess water, removed her gloves and went to the clean side and unloaded clean pans. Dietary Staff #1 did not perform hand hygiene before unloading the clean pans. Observation in the Kitchen on 3/22/2022 at 11:00 AM, revealed 10 wet nested trays on the serving line. During an interview on 3/22/2022 at 11:20 AM, the CDM confirmed trays should not be wet nested and began to dry them with a towel. Observation in the Kitchen on 3/22/2022 at 11:25 AM, revealed the CDM obtained a red container of solution and confirmed the solution was the sanitizing solution, used to wipe the food preparation areas. She placed the thermometer into the sanitizing solution and then placed it immediately into the pureed corn to check the temperature. During an interview on 3/22/2022 at 11:37 AM, the CDM confirmed she should not use a thermometer that had been placed in sanitizing solution directly into resident's food to check the food temperature. She removed the pureed corn from the line and discarded it. Observation in the dry storage area on 3/25/2022 at 10:15 AM, revealed a dented 6 pound can of mandarins and a dented 6 pound can of peaches in the dry storage canned goods supply. During an interview on 3/25/2022 at 10:16 AM, the CDM confirmed the cans were dented and should not be in the canned goods supply. The CDM stated, .I didn't see those .I didn't have my glasses on . During an interview on 3/27/2022 at 12:28 PM, the CDM confirmed the wet nested trays should not have been dried with a dish towel; they should have been air-dried on racks. She confirmed dietary staff should remove their gloves, perform hand hygiene, and don new gloves when moving from the dirty area of the dishmachine to the clean area to put away clean dishes and cookware. Observation in the Skilled 1 Hall Nutrition Room on 3/27/2022 at 2:00 PM, revealed the Resident Nutrition Refrigerator's Freezer contained 3 frozen dinners and a hot pocket that were not labeled. Observation in the Skilled 1 Hall Nutrition Room on 3/27/2022 at 2:02 PM, revealed the Refrigerator Temperature Log for March 2022 had only been completed one time a day for 4 of 27 days (3/3/2022, 3/11/2022, 3/21/2022, and 3/25/2022). During an interview on 3/27/2022 at 2:05 PM, Licensed Practical Nurse (LPN) #1 confirmed the frozen dinners belonged to staff. LPN #1 was asked if staff food should be in the Resident Nutrition Refrigerator. She stated, .No. During an interview on 3/27/2022 at 3:18 PM, the CDM confirmed staff should not put personal food in the Resident Nutrition Refrigerator. The CDM confirmed refrigerator temperatures should be logged on the Refrigerator Temperature Log twice a day by nursing staff.

Based on medical record review and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 7 of 20 sampled residents (Resident #2, #9, #10, #14, #21, #25, and #28) reviewed for Advance Directives. The findings include: Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of Resident #2's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission or was informed of her right to develop one. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #9 had a BIMS score of 3, which indicated severe cognitive impairment. Review of Resident #9's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative were provided written information regarding her right to formulate an Advance Directive upon admission or informed of the right to develop one. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #10 had a BIMS score of 15, which indicated she was cognitively intact. Review of Resident #10's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative were informed upon admission of the right to develop one or provided written information regarding her right to develop an Advance Directive. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE], revealed Resident #14 had a BIMS score of 15, which indicated intact cognition. Review of Resident #14's medical record, revealed there was no Advance Directive present and there was no documentation the resident or his legal representative were informed of or provided written information regarding his right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #21 had a BIMS score of 15, which indicated intact cognition. Review of Resident #21's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative were informed of or provided written information regarding her right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #25 had a BIMS score of 15, which indicated intact cognition. Review of Resident #25's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed of or provided written information regarding her right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE], revealed Resident #28 had a BIMS score of 15, which indicated intact cognition. Review of Resident #28's medical record, revealed there was no Advance Directive present and there was no documentation the resident or his legal representative was informed of or provided written information regarding his right to formulate an Advance Directive upon admission. During an interview on 3/26/2022 at 12:13 PM, the Nurse Consultant confirmed there was no documentation Resident #2, #9, #10, #14, #21, #25, and #28 or their legal representatives were informed of or provided written information regarding their right to formulate an Advance Directive upon admission. The Nurse Consultant stated The Advance Directives have to say Yes or No that they have or do not have an Advance Directive .Their packet needs to be updated .

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 5 sampled residents (Resident #1) reviewed with wandering/exit seeking behaviors which resulted in Immediate Jeopardy when Resident #1 exited the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Hospital Administrator, Director of Nursing (DON), and Staffing Coordinator were notified of the Immediate Jeopardy (IJ) on 5/28/2020 at 3:30 PM in the Administrator's office. F-610 was cited at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 5/19/2020 through 5/29/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/29/2020 at 4:44 PM, and was validated onsite by the surveyor on 5/30/2020 through review of assessments, policies related to wandering and exit seeking behavior, in-service training records and staff interviews. The findings include: Review of the facility's Accidents and Incidents-Investigating and Recording, policy revised 6/2015, showed, .All accidents or incidents occurring on our premises must be investigated .Investigative Action: .The nurse responsible for resident care of the hall and/or the nurse supervisor must conduct an immediate investigation of the accident or incident .The following data, as it may apply, must be included on the Incident Report Form .the circumstances surrounding the accident or incident . Review of the facility's Quality Assurance Performance Improvement Program, policy revised 5/2018, showed, .evaluating all systems and processes, identifying problems that have occurred or that potentially might result from the facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum data Set (MDS) assessment dated [DATE], showed Resident #1 scored a 5 on the Basic Interview of Mental Status (BIMS) scale, which indicated the resident was severely cognitively impaired for decision making. Review of Resident #1's Wandering Risk assessment dated [DATE], showed a score of 12, which indicated the resident was at high risk for wandering. Review of Resident #1's Care Plan dated 11/7/2019 and updated 5/14/2020, showed the resident was to have an intact wanderguard (a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors) at all times. This intervention was initiated 5/14/2020. Review of Resident #1's Nurse's Note dated 5/19/2020 at 7:12 PM showed .ER (emergency room staff) phoned stating they had an elderly lady in their parking lot with a mask on .concerned she was a nursing home resident. CNA (Certified Nursing Assistant) notified nurse that resident was in ER parking lot. Nurse and CNA went to the ER to verify resident. Upon arrival resident was sitting in a visitor's car. Nurse and CNA assisted resident out of car and walked her back to Nursing Home. Head to toe assessment performed, no injuries noted. Notified DON and DON notified Administrator. Nurse notified daughter and attempted to notify MD (Medical Doctor), unable to get and awaiting response. Staff one on one care with resident as soon as returned to facility . Review of Resident #1's Nurse's Note dated 5/19/2020 at 7:39 PM, showed .MD returned phone call and made aware of resident incident . Review of the facility's investigation of the elopement of Resident #1 showed the facilty reviewed the statements obtained from the staff on duty at the time of the elopement and the completed incident report. There was not any further investigation conducted to determine the circumstances of Resident #1's elopement. During a telephone interview on 5/27/2020 at 10:27 AM, LPN #1 stated, .That day (5/19/2020) I worked 7 AM-7 PM (7:00 AM-7:00 PM) and she (Resident #1) did fine (no wandering behaviors). I was asked by the other shift nurse to remove the zip tie someone had used to strap the wanderguard on her (Resident #1) ankle. I cut it off to replace it but did not have a band because the bands were on order and were to come in the next day. I left her (Resident #1) and went to look for something like a ribbon to put the wanderguard on with .I left her (Resident #1) lying in the bed in her room and walked down the hall to the other resident's room and asked if she had a ribbon .and I asked if I could cut the ribbon off the balloon and use it .and I left to go get scissors. I don't remember what time, I know I had already started med (medication) pass and I start that at 4:30 PM .I heard the CNA yell for me. She (CNA #1) had taken a phone call from the ER saying they thought one of our residents was out in the front parking lot of the hospital .The CNA and I went to the ER by way of outside our front door and around the building to the front ER parking lot. A woman, not a hospital employee said I have her in my car So the CNA and I went to the car and got Ms. (Resident #1) and walked her back to the facility. Once back to the facility I did a head to toe assessment and she had no injuries and I placed the wanderguard on her using the ribbon because the bands were not available . Review of the facility's video system footage showed that on 5/19/2020 at 5:40 PM, Resident #1 exited the nursing home at 5:40 PM at the annex door (which had a wanderguard system at the door) leading into the acute care hospital medical surgical unit. This door had a wanderguard sensor. Resident #1 was ambulating without any assistive device and there was no wanderguard bracelet present on either ankle. She ambulated through the hospital, and exited out the front door of the hospital into the parking lot at 5:45 PM. The video showed the nursing home staff leaving the nursing home front door at 5:50 PM. The 2 staff members escorted Resident #1 from the front parking lot to the nursing home at 5:59 PM. During an interview on 5/27/2020 at 3:05 PM, the DON/Interim Administrator confirmed a thorough investigation was not conducted and stated, .I assumed it was the band cut off and she (Resident #1) was left unattended .I thought (it) was because we didn't replace the band correctly and all other steps were in place .the more I look at this wanderguard incident the process is broken .there also is nothing in place to decide when you put a wanderguard on a resident . The DON/Interim Administrator stated the investigation did not include a review of the video system and stated, .we assumed she went out of the front door of the nursing home . After viewing the video with the surveyor, the DON/Interim Administrator stated, .We had no idea she got out of the facility through the Annex door into the hospital, then out the front door of the hospital . The facility failed to ensure a thorough and complete investigation was conducted when Resident #1, a cognitively impaired resident with known exit seeking behaviors exited the building to the adjacent acute care hospital parking lot, which resulted in an Immediate Jeopardy for Resident #1. The surveyor verified the Removal Plan by: 1. The DON/Interim Administrator developed a policy regarding investigation of resident elopement, to include reviewing the video evidence to establish a timeline and means of exit. This was confirmed by policy review and interviews on 5/30/2020. 2. The DON/Interim Administrator conducted staff, resident and bystander interviews to obtain statements regarding the incident, notification of medical director, Chief Executive Officer (CEO), Administrator, DON, resident family and Primary Care Physician (PCP). This was confirmed by policy review on 5/30/2020. 3. The DON/Interim Administrator and/or designee educated all licensed staff on conducting a thorough investigation of an incident of elopement. This was confirmed by review of in-service sign in sheets and interviews with staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 4. The DON/Interim Administrator or designee educated all licensed staff and CNAs on the Resident Elopement policy and Care of Residents at Risk for Wandering policy dated 5/2020. The licensed staff were educated on the wandering risk assessment to be completed quarterly, the orders for the wanderguard system, the assessment of placement of the wanderguard band, expiration date documentation, and functioning of the wanderguard band. Staff will not be allowed to work until they receive the in-service education. The surveyor reviewed the in-service sign in sheets and interviewed staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 5. The DON/Interim Administrator will moderate ad hoc Quality Assurance Performance Improvement meetings to establish root cause analysis to determine contributing factors, as well as the main factors leading to the elopement incidents. This was confirmed by interviews on 5/30/2020. 6. The DON enrolled in a Six Sigma Root Cause Analysis online training course which teaches how to thoroughly investigate an incidents. This was confirmed by documentation of the online enrollment and interview of the DON/Interim Administrator on 5/30/2020. Noncompliance of F-610 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 5 sampled residents (Resident #1 and #2) reviewed with wandering/exit seeking behaviors. Resident #1 was a cognitively impaired, vulnerable residents with wandering/exit seeking behaviors and eloped from the facility which resulted in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Hospital Administrator, Director of Nursing (DON), and Staffing Coordinator were notified of the Immediate Jeopardy (IJ) on 5/28/2020 at 3:30 PM in the Administrator's office. F-689 was cited at a scope and severity of J which is Substandard Quality of Care. The IJ was effective from 5/19/2020 to 5/29/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/29/2020 at 4:44 PM, and was validated onsite by the surveyor on 5/30/2020 through review of assessments, policies related to wandering and exit seeking behavior, in-service training records and staff interviews. The findings include: 1. Review of the facility's policy and procedure manual showed no documentation of a policy for management of residents with wandering and/or exit seeking behavior. During an interview on 5/27/2020 at 9:15 AM, the DON/Interim Administrator stated the facility did not have any policies on monitoring the care of residents with wandering or exit seeking behaviors. The facility had no policies or procedures to implement based on the results of a wandering risk assessment. Review of the facility's Accidents and Incidents-Investigating and Recording, policy revised 6/2015, showed, .All accidents or incidents occurring on our premises must be investigated .Investigative Action: .The nurse responsible for resident care of the hall and/or the nurse supervisor must conduct an immediate investigation of the accident or incident .The following data, as it may apply, must be included on the Incident Report Form .the circumstances surrounding the accident or incident . Review of the facility's investigation of the elopement of Resident #1 showed the facilty reviewed the statements obtained from the staff on duty at the time of the elopement and the completed incident report. Review of the DON job description dated 7/10/2017 showed, .monitors complaint reports daily for allegations of potential abuse or neglect .and participates in these investigations . 2. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Wandering Risk assessment dated [DATE], showed a score of 12, which indicated the resident was at high risk for wandering. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was assessed to have a Basic Interview of Mental Status (BIMS) of 5, which indicated the resident had severe cognitive impairment. The resident needed limited assistance with walking, and required an assistive device as needed. Review of Resident #1's Care Plan dated 11/7/2019 and updated on 5/14/2020 showed Resident #1 was an elopement risk related to a history of wandering and a [DIAGNOSES REDACTED]. Staff were to document wandering behavior and attempted diversional interventions in the behavior log and to identify the pattern of wandering, purposeful, aimless, or elopement activity and to intervene as appropriate. The Care Plan also showed the resident should have a wanderguard on her at all times. Review of Resident #1's Medication Administration Record (MAR) dated May 2020 showed no documentation of validating a wanderguard (a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors) was in place or functioning from 5/14/2020 - 5/26/2020. There was no assessment of a wanderguard in place or functioning in the Nurse's notes dated 5/14/2020 - 5/19/2020 or 5/21/2020 - 5/26/2020. During a telephone interview on 5/27/2020 at 3:10 PM, LPN #1 stated, .I didn't document wanderguard checks on (Resident #1) . During an interview on 5/27/2020 at 10:00 AM Licensed Practical Nurse (LPN) #2 was asked how nursing determines a resident needs a wanderguard. She stated, .You just know by experience . During an interview on 5/27/2020 at 2:20 PM, the DON/Interim Administrator stated, .No, we don't have any policy or procedure for residents at risk (of) wandering or elopement .No, we don't have a process in place once the wander risk assessment is completed and based on that score what the intervention would be in regard to wanderguard placement or not . Medical Record review documented the following episodes of impaired cognitive status, wandering, and exit seeking behaviors displayed by Resident #1: a. A Nurse's Note dated 5/14/2020 at 2:40 AM, showed .resident continued to be agitated at start of this shift, being very persistent about leaving the facility . b. A Nurse's Note dated 5/16/2020 at 3:17 PM, showed .wandering around packing up things and wanting to leave . c. A Nurse's Note dated 5/17/2020 at 9:29 AM, showed .mania, aggression, [MEDICAL CONDITION], says we are trying to kill her, refusing po (given orally) meds, going room to room, trying to go out all the doors, one on one not working . d. A Nurse's Note dated 5/17/2020 at 11:21 PM, showed .resident remains very confused and anxious, unable to redirect, distract or console, repeatedly speaks about going home . e. A Nurse's Note dated 5/19/2020 at 7:12 PM, showed .ER (emergency room staff) phoned stating they had an elderly lady in their parking lot with a mask on, concerned she was a nursing home resident. CNA (Certified Nursing Assistant) notified nurse that resident was in ER parking lot. Nurse and CNA went to the ER to verify resident. Upon arrival resident was sitting in a visitor's car. Nurse and CNA assisted resident out of car and walked her back to Nursing Home. Head to toe assessment performed, no injuries noted. Notified DON and DON notified Administrator. Nurse notified daughter and attempted to notify Medical Doctor (MD), unable to get and awaiting response. Staff one on one care with resident as soon as returned to facility . f. A Nurse's Note dated 5/19/2020 at 7:39 PM, showed .MD returned phone call and made aware of resident incident . Based on the National Weather Service records, the recorded high temperature for Savannah TN on 5/19/2020 (the day of the elopement) was 68 degrees Fahrenheit. Review of the facility's video camera showed Resident #1 exited the front of the hospital. There were large puddles of liquid in the parking lot as if it had been raining prior to the resident's elopement. The acute care hospital is located on a very busy 4 lane highway. Across the street from the front of the acute care hospital is a strip mall. A grocery store was across this busy highway in the strip mall. During a telephone interview on 5/27/2020 at 10:27 AM, LPN #1 stated, .She (Resident #1) roams the building ambulating sometimes with her walker. We encourage her to use the walker. That day (5/19/2020) I worked 7 AM-7 PM and she did fine (no wandering behaviors). I was asked by the other shift nurse to remove the zip tie someone had used to strap the wanderguard on her (Resident #1) ankle. I cut it off to replace it but did not have a band because the bands were on order and were to come in the next day. I left her (Resident #1) and went to look for something like a ribbon to put the wanderguard on with. I remembered a resident who likes to do crafts possibly had a ribbon. I left her (Resident #1) lying in the bed in her room and walked down the hall to the other resident's room and asked if she had a ribbon. She did; attached to a balloon and I asked if I could cut the ribbon off the balloon and use it. She said yes, and I left to go get scissors. I don't remember what time, I know I had already started med (medication) pass and I start that at 4:30 PM. While I was looking for scissors, I heard the CNA yell for me. She (CNA #1) had taken a phone call from the ER (staff) saying they thought one of our residents was out in the front parking lot of the hospital. I did not know who it was at that time. The CNA and I went to the ER by way of outside our front door and around the building to the front ER parking lot. A woman, not a hospital employee said 'I have her in my car and I told her I would take her to (the named grocery store across the four lane highway)'. So the CNA and I went to the car and got Ms. (Resident #1) and walked her back to the facility. Once back to the facility I did a head to toe assessment and she had no injuries and I placed the wanderguard on her using the ribbon because the bands were not available . During an interview on 5/27/2020 at 10:50 AM, CNA #1 stated, .I worked 7 AM-7 PM that day and don't know the exact time I got the call from the ER but I was picking up supper trays on the front hall, at approximately 5:40 PM. I got (LPN #1) and we went outside and walked to the front of the hospital to the ER entrance and saw a lady who had her (Resident #1) in her car. She (Resident #1) had on black shoes with a strap, no wanderguard, a personal gown like a house dress, her purse, and baby doll. She had no injuries that I could see. She (Resident #1) said she was going to the (the named grocery store across the four lane highway) and was catching a ride with the lady. We had to coach her to walk back with us and then come back in the facility . On 5/27/2020 the facility's video camera system footage dated 5/19/2020 was reviewed. The footage showed Resident #1 exited the nursing home at the annex door which had a wanderguard system on the door into the acute care hospital's medical surgical unit at 5:40 PM on 5/19/2020. She was wearing a house dress with an unbuttoned blouse over the dress, black shoes with a strap, carrying a baby doll, purse and jacket type object, and ambulating without any assistive device. There was no wanderguard bracelet present on either ankle. She ambulated through the acute care hospital medical surgical unit, turned left by the nurse's station, continued down the long hall past the Administration office into the main lobby and out the front door of the acute care hospital into the parking lot at 5:45 PM. The video footage review also showed the 2 nursing home staff members leaving the nursing home front door at 5:50 PM. The outside video footage review showed Resident #1 being escorted from the front parking lot to the Nursing home at 5:59 PM by the 2 staff members. During an interview on 5/27/2020 at 11:01 AM, CNA #2 stated, .She (Resident #1) tries to get out .She sometimes says she wants to go home and sometimes she says she wants to go to (the named grocery store) and for someone to give her a ride .I try to redirect her and sometimes it doesn't work . During an interview on 5/27/2020 at 3:05 PM, the DON/Interim Administrator was asked if the investigation included a review of the video system footage . He stated, .No .We assumed she went out of the front door of the nursing home . After viewing the video with the surveyor, the DON/Interim Administrator stated, .We had no idea she got out of the facility through the Annex door into the hospital then out the front door of the hospital . During an interview on 5/27/2020 at 9:15 AM, the DON/Interim Administrator stated, .the wanderguard supplies are kept in my office .the staffing coordinator is responsible for ordering the supplies and keeping them stocked . When asked who had a key to his office to access the supplies if needed at night or on weekends, he stated, .the charge nurse . During an interview on 5/27/2020 at 9:42 AM, the day shift Charge Nurse stated, .No, I don't have a key to the DON's office .I would have to call Annex (hospital) and get them to bring the master key to let me in his office to get the supplies . During an interview on 5/27/2020 at 9:59 AM, LPN #2 stated, .The wanderguard supplies are kept in the DON office .we would have to call Annex for the master key to get in his office . During an interview on 5/27/2020 at 3:05 PM, the DON/Interim Administrator confirmed the facility's action plan due to the incident. He stated, .I didn't do a thorough investigation .I assumed it was the band cut off and she (Resident #1) was left unattended .I thought was because we didn't replace the band correctly and all other steps were in place .I see now the steps were not in place .The more I look at this wanderguard the process is broken .there also is nothing in place to decide when you put a wanderguard on a resident . During an interview on 5/27/2020 at 12:30 PM, the DON/Interim Administrator was asked how often the doors with wanderguard alarm systems were checked and who had the responsibility for checking the doors to be certain they would alarm. The DON/Interim Administrator stated, .We have 6 exit doors that have the wanderguard alarm system .No one is checking all those doors for functioning properly on a routine basis .Nursing just hears the alarm if a resident gets too close, but can't say if all 6 doors are checked .I guess someone should be doing that . During an interview on 5/28/2020 at 8:53 AM, the Director of Maintenance was asked who had the responsibility for monitoring the doors that had the wanderguard alert system to assure the doors were functioning properly. The Director of Maintenance stated, .the nursing staff does that . During an interview on 5/28/2020 at 9:32 AM, the Maintenance Supervisor who had the direct responsibility for maintaining the nursing home was asked how the wanderguard doors were monitored to be certain the doors would activate if a resident wearing a wanderguard band was close to the door. The Maintenance Supervisor stated, .I don't check them .the nursing staff checks the wanderguards . Observations in Resident #1's room on 5/27/2020 at 9:42 AM, showed Resident #1 had a wanderguard band on her right ankle. During an interview on 5/27/2020 at 9:59 AM, LPN #2, #3 and #4 were asked if the wanderguard band had an expiration date. All 3 stated they were not aware the wanderguard device had an expiration date. The facility failed to ensure a safe environment, failed to supervise Resident #1, and placed Resident #1 in Immediate Jeopardy (IJ). Resident #1 was cognitively impaired and had prior wandering and exit seeking behaviors. The staff was notified by telephone by the emergency room (ER) personnel that a visitor had found Resident #1 wandering in the front parking lot of the hospital and placed Resident #1 in her car. The emergency room parking lot was located in the front of the hospital, approximately 75 yards from the nursing home. The hospital is located on a busy 4 lane major highway. This resulted in an IJ for Resident #1. 3. Medical Record review showed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] documented the resident scored a BIMS of 3 which indicated the resident had severe cognitive impairment. Review of Resident #2's MAR and Nurse's Notes dated March, April and May 2020, showed no documentation of an assessment that a wanderguard was in place on this resident or functioning. Review of Resident #2's Wandering Risk assessment dated [DATE], showed a score of 14, which indicated the resident was at high risk for wandering. Observations in Resident #2's room on 5/27/2020 at 9:45 AM showed Resident #2 had a wanderguard band on the right ankle. Observations on 5/27/2020 - 5/30/2020 showed Resident #2 seated in a wheel chair, self propelling throughout the halls. She self propelled herself to the front door and north door beside the DON's office and activated the wanderguard alarm system. During an interview on 5/27/2020 at 3:10 PM, LPN #1 stated, .She (Resident #2) has had her wanderguard I know in place since March 2020 before COVID .No, I never documented she had it on or that I checked it .but she would make the alarm go off . During an interview on 5/27/2020 at 1:00 PM, the DON/Interim Administrator stated, .That is the only wandering risk assessment we have on her (Resident #2). They are to be done quarterly, every 3 months, should have had one March/April .that will be in my policy . The surveyor verified the Removal Plan by: 1. Wanderguard supplies are placed in marked storage containers behind the Nurse's station on the Skilled 1 Unit in a cabinet above the sink and behind the Nurse's station on the Skilled 2 Unit. The wanderguard inventory sheet was posted on the cabinet door where the supplies are kept. A minimum threshold of supplies are to be maintained and assessed weekly. Each storage container contained wanderguard replacements and bands. This was confirmed by observation and interview of staff on the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 2. A review of the records for the 3 of 3 residents that are currently wearing wanderguard bands showed orders written for the devices, the MARs were updated for the wanderguards to be assessed every shift for placement, the correct bands were in place, the skin integrity assessments were completed, and the expiration dates of the wanderguard devices were checked. This was confirmed by record review and interview of staff on both the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 3. A review of the records for the 3 of 3 residents that are currently wearing wanderguard bands showed the functioning of the wanderguard devices were assessed daily. This was confirmed by record review and interview of staff on both the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 4. Review of the wanderguard tracking system showed the expiration dates were documented and the process is to review it on a monthly basis. This was confirmed by record review and interview on 5/30/2020. 5. The DON/Interim Administrator developed a policy regarding resident elopement, which included the investigation process such as obtaining video evidence to establish a timeline and means of exit, conducting staff, resident and bystander statements regarding the incident. The policy includes the notification of the Medical Director, Chief Executive Officer, Administrator, DON, resident family and Primary Care Physician. This was confirmed by policy review on 5/30/2020. 6. The DON/Interim Administrator and/or designee educated all licensed staff and CNAs on the Resident Elopement policy and Care of Residents at Risk for Wandering policy dated 5/2020. The licensed staff were educated on wandering risk assessment to be completed quarterly, orders to be obtained for use of the wanderguard system, assessment of placement, assessment of skin integrity, expiration date documentation, and functioning of the wanderguard band. Those staff unable to attend the in-services will not be allowed to work until they receive the training. The surveyor reviewed the in-service sign in sheets and interviewed staff on the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM on 5/30/2020. 7. The DON/Interim Administrator and Maintenance Supervisor established that all doors with the wanderguard sensor are functioning properly and developed a log to maintain compliance with monthly checks. This was confirmed by record review and interview of staff on 5/30/2020. 8. The DON/Interim Administrator will moderate ad hoc Quality Assurance Performance Improvement meetings to determine the contributing factors and perform a root cause analysis to determine the main factor that led to elopement incidents. This was confirmed by interviews on 5/30/2020. 9. The DON/Interim Administrator developed procedure guidelines for changing the wanderguard band on residents. If the alarm or band needs to be changed for any reason on a resident, the supplies will be collected prior to removing the alarm/band that is on the resident. If the resident's wanderguard is removed and the staff member needs to leave the resident for any reason, another staff member will stay one on one with the resident until the original staff member returns to complete the replacement of the wanderguard band. The surveyor reviewed the in-service sign in sheets and interviewed staff on the 7:00 AM-7:00 PM and the 7:00 PM-7:00 AM on 5/30/2020. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on the job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopement, and conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting when the resident eloped from the facility. Administration's failure to ensure a safe environment placed 1 of 5 sampled residents (Resident #1) in Immediate Jeopardy (IJ) when the resident, a cognitively impaired resident with wandering and exit seeking behaviors, exited the facility and was located by a visitor in the front parking lot of the adjacent acute care hospital. The front parking lot of the acute care hospital is on a busy 4 lane highway. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Hospital Administrator, Director of Nursing (DON), and Staffing Coordinator were notified of the Immediate Jeopardy (IJ) on 5/28/2020 at 3:30 PM in the Administrator's office. The facility was cited F-610, F-689, F-835, and F-867 at a scope and severity of J. F-610 and F-689 are Substandard Quality of Care. The Immediate Jeopardy was effective from 5/19/2020 through 5/29/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/29/2020 at 4:44 PM. The Removal Plan was validated onsite by the surveyor on 5/30/2020 through review of assessments, policies related to wandering and exit seeking behavior, in-service training records and staff interviews. The findings include: 1. Review of the facility's Nursing Home Administrator job description dated 7/10/2017 showed, .provides leadership for the Nursing Home; plans, organizes, and supervises nursing home staff and resources. Oversees all activities of a nursing home in accordance with established policies and federal and state guidelines .administers, directs and coordinates the business .recommends and leads changes to improve the nursing home .ensures department employees are accountable and adheres to all HMC (Named Medical Center) policies and procedures, government laws, and regulatory agency standards .provides for training of staff to maintain high standards of quality patient care .provides leadership and supervises nursing home staff and resources . Review of the facility's DON job description dated 7/10/2017 showed, .assumes authority, responsibility, and accountability for the delivery of nursing services in the facility .in collaboration with facility Administration, allocates department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practical, physical, mental, and psychosocial well-being .directs and conducts the day-to-day activities of the nursing home in accordance with established policies .implements changes to improve nursing home and reviews ongoing activities .communicates directly with residents, families, medical staff, nursing staff, interdisciplinary team members, and department heads to coordinate care and services, promote participation in care plans, and maintain a high quality of care and life for residents .develops, maintains, and implements nursing policies and procedures that conform to current standards of nursing practice, facility philosophy, and operational policies while maintaining compliance with state and federal laws and regulations .communicates and interprets policies and procedures to nursing staff, and monitors staff practices and implementation .ensures delivery of [MEDICATION NAME] quality care and nursing supervision .demonstrates knowledge of and application of key clinical quality indicators, and proactively monitors and implements systems to achieve and/or surpass company thresholds .exercises overall supervision of resident assessments and care plans .reviews 24-hour report from every unit daily to monitor and ensure timely, effective responses to significant changes in condition, transfers, and discharges, use of restraints, unexplained injuries, falls, behavioral episodes, and medication errors . During an interview on 5/27/2020 at 9:15 AM, the DON/Interim Administrator stated, .I received a phone call from (Licensed Practical Nurse (LPN) #1) at 6:02 PM that she went to replace (Resident #1's) wanderguard band and she cut it off, but didn't bring a replacement with her .she left the resident to get supplies and while she was gone, the ER (Emergency Department staff) notified our staff there was an elderly lady in the parking lot asking for a ride to (Named local grocery store) .the LPN was still looking for a (wanderguard) band when the call came in .the LPN and CNA (Certified Nursing Assistant) went and got (Resident #1) and brought her back to the facility .she had no injuries .we thought she had walked out the front door of the nursing home . During an interview on 5/27/2020 at 12:30 PM, the DON/Interim Administrator was asked who was responsible for checking the wanderguard bands, the doors with wanderguard sensors, and how often all the doors with wanderguard alarm systems are checked. The DON/Interim Administrator stated, .We have 6 exit doors that have the wanderguard alarm system .No one is checking all those doors for functioning properly on a routine basis .Nursing just hears the alarm if a resident gets to close, but can't say if all six doors are checked .I guess someone should be doing that . During an interview on 5/27/2020 at 2:20 PM, the DON/Interim Administrator was asked if the facility had a policy and procedure for wandering/elopement and the DON/Interim Administrator stated, .No, we don't have any policy or procedure for residents at risk of wandering or elopement .No, we don't have a process in place once the wander risk assessment is completed and based on that score what the intervention would be in regard to wanderguard placement or not . During an interview on 5/27/2020 at 3:05 PM, the DON/Interim Administrator stated, .I didn't do a thorough investigation .I assumed it was the (wanderguard) band cut off and she (Resident #1) was left unattended .I thought was because we didn't replace the band correctly and all other steps were in place .I see now the steps were not in place .The more I look at this wanderguard the process is broken . During an interview on 5/28/2020 at 8:53 AM, the Director of Maintenance was asked about the monitoring of the security system of the wanderguards and he stated, .the nursing staff does that . During an interview on 5/28/2020 at 9:32 AM, the Maintenance Supervisor was asked how wanderguard doors are monitored and he stated, .I don't check them .the nursing staff checks the wanderguards . The surveyor verified the Removal Plan by: 1. The DON/Interim Administrator developed a policy regarding resident elopement to include the investigation process such as obtaining video evidence to establish a timeline and means of exit, conducting staff, resident and bystander interview statements regarding the incident, notification of the Medical Director, Chief Executive Officer (CEO), Administrator, DON, resident family and Primary Care Physician (PCP). This was confirmed by policy review on 5/30/2020. 2. The wanderguard supplies were placed in marked storage containers behind the Nurse's station on the Skilled 1 Unit in a cabinet above the sink and behind the Nurse's station on the Skilled 2 Unit. The wanderguard inventory sheet is posted on the cabinet door where the wanderguard supplies are maintained. The minimum threshold of supplies are to be maintained and assessed weekly. Each storage container contained wanderguard replacements and bands. This was confirmed by observation and interview of the DON/Interim Administrator and staff on the 7:00 AM-7:00 PM and the 7:00 PM-7:00 AM shifts on 5/30/2020. 3. The DON/Interim Administrator, Maintenance Director and Supervisor established proper function of all the wanderguard exits with sensor alarms and developed a log to maintain compliance with the monthly checks. This was confirmed by record review and interview of the DON/Interim Administrator and staff on 5/30/2020. 4. The DON/Interim Administrator developed procedure guidelines for the changing of the wanderguard band or alarm. If the alarm or wanderguard band needs to be changed for any reason on a resident, the supplies will be collected prior to removing the previous alarm/band. If the resident's wanderguard is removed and the staff member needs to leave the resident for any reason, another staff member will stay one on one with the resident until the original staff member returns to complete task of attaching the wanderguard band. The surveyor reviewed the in-service sign in sheets and interviewed the DON/Interim Administrator and staff on the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 5. The DON/Interim Administrator and/or designee educated all licensed staff and CNAs on the Resident Elopement policy and Care of Residents at Risk for Wandering policy dated 5/2020. The licensed staff were educated on the wandering risk assessment to be completed quarterly, the orders for the wanderguard system, the assessment of placement, the assessment of skin integrity, the expiration date documentation and functioning of the wanderguard band. Staff unable to attend will not be allowed to work until they receive the in-service. The surveyor reviewed the in-service sign in sheets and interviewed the DON/Interim Administrator and staff on the 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, job description review and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program, the completion of a thorough investigation of an incident of elopement, and failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently in order to provide a safe environment for residents. The failure of the QAPI Committee to ensure systems and processes were in place and systems were consistently followed by staff and administration placed 1 of 5 sampled residents (Resident #1) in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, eloped from the facility into the adjacent acute care hospital and then into the hospital parking lot facing a busy four lane highway at the front of the acute care hospital. Resident #1 was found by a stranger in the front parking lot of the acute care hospital, placed the resident in her vehicle, and entered the acute care hospital to inquire about the resident. The facility was unaware the resident was missing from the facility until the emergency department at the acute care hospital contacted them. This resulted in an Immediate Jeopardy for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Hospital Administrator, Director of Nursing (DON), and Staffing Coordinator were notified of the Immediate Jeopardy (IJ) on 5/28/2020 at 3:30 PM in the Administrator's office. The facility was cited F-610, F-689, F-835 and F-867 at a scope and severity of J F-610 and F-689 are Substandard Quality of Care. The Immediate Jeopardy was effective from 5/19/2020 to 5/29/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/29/2020 at 4:44 PM, and the Removal Plan was validated onsite by the surveyor on 5/30/2020 through review of assessments, policies related to wandering and exit seeking behavior, in-service training records and staff interviews. The findings include: Review of the facility's Quality Assurance/Performance Improvement Committee policy dated 4/2020 showed, .The Quality Assurance Performance Improvement Committee (QAPI) shall serve as the final authority for implementing our facility's quality assessment and assurance programs .The QAPI Committee shall meet whenever necessary, but at least quarterly to assure that our quality assurance program is functional and meeting the needs of the facility . Review of the facility's Quality Assurance Performance Improvement Program policy dated 4/2020 showed, I. Introduction .The facility employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time. The facility's QAPI program is a collaborative and interdisciplinary approach. It is through this collaborative approach that the organization can plan, implement, and maintain an effective, ongoing, data-driven, systematic and facility-wide quality assurance and performance improvement program .IV. Objectives: Focus upon what is performed throughout the organization and how it will be performed .1. Organization and Design .B.4. Meets at least quarterly and more often if necessary . Review of the Administrator of Nursing Home job description dated 7/10/17 showed, Job Summary. Provides leadership for the nursing home staff and resources. Oversees all activities of a nursing home . Review of the Director of Nursing-Nursing Home job description dated 7/10/17 showed, Job Summary. The Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with facility administrator, allocates department resources in an efficient and economic manner .Ensures delivery of [MEDICATION NAME] quality care and nursing supervision . 2. During an interview on 5/27/2020 at 9:15 AM, the DON/Interim Administrator stated the facility did not have a policy on wandering or a policy on residents with exit seeking behaviors, or any policies/processes to be implemented based on the results of a wandering risk assessment. During an interview on 5/27/2020 at 2:30 PM, the DON/Interim Administrator stated, .Myself, the Administrator and the Staffing Coordinator talked about the incident and talked about an action plan .no, we did not contact the medical director . When asked if they had considered having an ad hoc (a meeting to obtain additional information if the need arises) QAPI meeting to discuss the unusual occurrence of the elopement, the DON/Interim Administrator stated, no. He further stated, they felt they had investigated the incident and it did not require any further investigation. The DON/Interim Administrator considered the investigation resolved and felt no necessity to convene an ad hoc QAPI meeting. The facility QAPI committee meets quarterly. The DON/Interim Administrator was unaware of when the next QAPI meeting would be held. The facility failed to convene an ad hoc QAPI meeting to discuss the occurrence of an elopement or obtain additional information in the eight days following the elopement. He acknowledged he is a member of the QAPI committee and attends the quarterly meetings. During a telephone interview on 5/27/2020 at 2:50 PM, the Medical Director stated, .No, I was not contacted about the elopement .my first awareness of what happened was 5/24/2020 when I was signing incident reports .there was no discussion .just what I read on the incident report was the information I read . During an interview on 5/27/2020 at 3:05 PM, the DON/Interim Administrator stated, .I didn't do a thorough investigation .I assumed it was the (wanderguard (a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors) band cut off and she (Resident #1) was left unattended .I thought it was because we didn't replace the band correctly and all other steps were in place .I see now the steps were not in place .The more I look at this wanderguard the process is broken .there also is nothing in place to decide when you put a wanderguard on a resident . The facility's QAPI Committee failed to identify the need for an ad hoc meeting to discuss the resident elopement, failed to investigate the elopement thoroughly, failed to analyze the situation, and evaluate possible regulatory concerns related to Resident #1's elopement from the facility to ensure the safety of the residents with wandering or exit seeking behaviors. Refer to F-610, F-689, and F-835. The surveyor verified the Removal Plan by: 1. The DON/Interim Administrator developed a policy regarding resident elopement, which included the investigation process such as obtaining video evidence to establish a timeline and means of exit, conducting staff, resident and bystander statements regarding incident; notification of medical director, Chief Executive Officer (CEO), Administrator, DON, resident family and Primary Care Physician (PCP). This was confirmed by policy review and interview with the DON/Interim Administrator on 5/30/2020. 2. The DON/Interim Administrator will moderate ad hoc QAPI meetings to discuss the results of the audits and establish a root cause analysis to determine the contributing factors, as well as the main factors which led to elopement incidents. This was confirmed by interview with the DON/Interim Administrator on 5/30/2020. 3. The DON/Interim Administrator developed procedure guidelines for the changing of the wanderguard band or alarm. If the alarm or band needs to be changed for any reason on a resident, the supplies should be gathered prior to removing previous alarm/band. If the resident's wanderguard is removed and the staff member needs to leave the resident for any reason, another staff member should stay one on one with the resident until original staff member returns to complete task. The surveyor reviewed the in-service sign in sheets and interviewed the DON/Interim Administrator and staff 7:00 AM-7:00 PM and 7:00 PM-7:00 AM on 5/30/2020. 4. The DON/Interim Administrator, Maintenance Director and Maintenance Supervisor established proper function of all wanderguard exits and developed a log to maintain compliance with the monthly checks. This was confirmed by record review and interview with the DON/Interim Administrator and staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 5. The DON/Interim Administrator reviewed 3 facility resident's records that currently had wanderguard bands and validated the orders were written for the device, the MARs were updated for the wanderguard to be assessed every shift for placement, the correct wanderguard band in place, a skin integrity assessment and expiration of the wanderguard device. This was confirmed by record review and interview with the DON/Interim Administrator and staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 6. The DON/Interim Administrator reviewed 3 facility resident's records that currently have wanderguard bands and validated the wanderguard device functioning was assessed daily. This was confirmed by record review and interview with the DON/Interim Administrator and staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. 7. The DON/Interim Administrator reviewed the wanderguard tracking system process of monitoring the expiration dates and process to review on a monthly basis. This was confirmed by record review and interview with the DON/Interim Administrator on 5/30/2020. 8. The DON/Interim Administrator and/or designee educated all licensed staff and CNAs on the Resident Elopement policy and Care of Residents at Risk for Wandering policy dated 5/2020. The licensed staff were educated on wandering risk assessments to be completed quarterly, orders for wanderguard system, assessment of placement, skin integrity, expiration date documentation and functioning of band. Staff will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed DON/interim Administrator and staff on 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM shifts on 5/30/2020. 9. The DON/Interim Administrator placed the wanderguard supplies in marked storage containers behind the Nurse's station on the Skilled 1 unit in a cabinet above the sink and behind the Nurse's station on the Skilled 2 Unit. Wanderguard inventory sheets were posted on the cabinet door where supplies are maintained. There will be a minimum threshold of supplies to be maintained and assessed weekly in these cabinets. Each storage container contained wanderguard replacements and bands. This was confirmed by observation and interview with the DON/Interim Administrator and staff on 7:00 AM-7:00 PM and 7:00 PM-7:00 AM shifts on 5/30/2020. Noncompliance of F-867 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, observation and interview, it was determined the facility failed to adequately manage pain for 1 of 2 (Resident #4) residents during a dressing change. Resident #4 had a physician's orders [REDACTED]. During a dressing change on 5/24/11 the facility failed to administer pain medication to manage Resident #4's pain, which resulted in actual harm to Resident #4. The findings included: Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. moderate amt (amount) serous drainage. area approx (approximately) 8 cm (centimeters) X (by) 5 cm X 1 cm. area pink c patches of slough around outer edges. No [DIAGNOSES REDACTED] peri (around) wound. No foul odor..." Review of the physician's orders [REDACTED]. Observations and an interview in Resident #4's room on 5/24/11 at 9:09 AM, Nurse #2 began the dressing change of Resident #4's right heel pressure ulcer. Nurse #2 asked Resident #4 if she had received pain medication. Resident #4 stated, "No." Nurse #2 removed the kerlix dressing with scissors and cleaned the skin around the wound with gauze and normal saline. Resident #4 grimaced, moaned, tensed and was breathing hard and fast. The surveyor asked Resident #4 to rate her pain on a 0 to 10 scale with 0 being no pain and 10 being the worse pain she ever felt. Resident #4 responded "a 9." Nurse #2 continued to apply the new dressing to Resident #4's right heel and secured with kerlix and tape. During an interview in the lobby on 5/24/11 at 2:30 PM, Nurse #2 was asked what she would do during a treatment if a resident was in pain. Nurse #2 responded, "...I would leave the room as soon as I could... I would wash my hands... and get them something for pain..." When asked about why she did not stop during Resident #4's dressing change to give her pain medication, Nurse #2 stated, "...It was my understanding that she had scheduled pain medication..." During an interview in the staff break room on 5/24/11 at 3:15 PM, the Director of Nursing (DON) was asked what was her expectation of pain management during a dressing change. The DON stated, "...if the resident is in pain, I would want her to have pain medication... I would stop (the dressing change) and get pain medication..." Resident #4 had a physician's orders [REDACTED]. During a dressing change on 5/24/11 the facility failed to administer pain medication to manage pain, which resulted in actual harm to Resident #4.