Every finding on record at Haywood Post Acute

Based on policy review, Director of Maintenance job description, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when elevated hot water temperatures were measured. On 4/28/2025 dangerous elevated hot water temperatures ranging from 128 degrees Fahrenheit (F) to 135 degrees Fahrenheit (F) were found in 6 of 76 (Resident #4, #15, #36, #58 #62, and #66) resident rooms, some with shared bathrooms. The findings include: 1. Review of the facility policy titled, Water Temperatures, Safety of, dated 12/2024, revealed .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heater that service resident rooms, bathrooms .shall be set to temperatures of no more than 115 degrees F .or the maximum allowable temperature per state regulation. Maintenance staff are responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch (hot enough to be painful or cause reddening of the skin .] staff will report this finding to the immediate supervisor . Review of the undated Maintenance Director job description revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner .Ensure that supplies, equipment, etc are maintained to provide a safe and comfortable environment . 2. Resident #4, #15, and #62 shared a bathroom. a. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Psychosis, Depression, Anxiety, and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #4 was severely cognitively impaired. Resident was dependent on staff to perform ADLs. b. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Alzheimer's Disease, Anxiety, and Psychotic Disorders. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated Resident #15 was severely cognitively impaired. c. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Diabetes, Depression and Delusional Disorders. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #62 was severely cognitively impaired. Resident was moderate assistance with toileting, supervision assistance needed for transfers, and dependent with bathing. Resident has wandering behaviors, and on oxygen. d. Observation in the Resident's shared bathroom on 4/28/2025 at 10:12 AM, the water temperature was checked using a calibrated thermometer with the temperature 134 degrees F. 3. Residents #36, #58, and #66 shared a bathroom. a. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Dementia, Depression, Anxiety, and Cerebral Ischemia. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, which indicated Resident #36 was severely cognitively impaired. Resident was independent with ADLs and ambulating. b. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Delusional Disorders, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #58 was severely cognitively impaired. Resident was independent with toileting, transfers, and ambulation. c. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Dementia, Depression, and Hypertension. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 5 which indicated Resident #66 was severely cognitively impaired. Resident required supervision assistance of staff needed with toileting and ambulation. d. Observation in the Resident's shared bathroom on 4/28/2025 at 10:09 AM, the water temperature was checked using a calibrated thermometer with the water temperature 128 degrees F. 4. Observation and interview on 4/28/2025 at 11:34 AM, the Maintenance Director performed a water temperature check with a digital thermometer of resident's shared bathrooms in the Memory Care Unit revealed the following: a. The temperature of Residents #36, #58, and #66's shared bathroom was 135 degrees F. b. The temperature of Residents # 4, #15, and #62 shared bathroom was 133 degrees F. c. The temperature of the boiler was set at 140 degrees F that feeds the 300 Hall and the Memory Care Unit rooms. The Maintenance Director did not confirm who turned the temperature up. 5. The Maintenance Director confirmed that the water in the resident's shared bathrooms were too hot and the boiler should be set at 110-115 degrees F. During an interview on 4/28/2025 at 12:09 PM, CNA H confirmed that the water was hot this morning when preparing bath water for a resident. CNA H confirmed that today was the first time she had noticed the hot water. Observation and interview on 4/28/2025 at 3:25 PM, the Maintenance Director confirmed that the boiler temperature was turned down to 122 degrees F. Review of the [named company] invoice dated 4/28/2025, revealed .system needs several check valves on system mixing valves need to rebuilt. Found shuttle in the main mixing valve to be stuck .able to adjust smaller mixing valve to hold 108 degrees [F] at rooms . During an interview on 4/28/2025 at 3:52 PM, the Maintenance Director confirmed that he was unable to provide documentation of water temperature checks from 4/7/2025 through 4/11/2025. During an interview on 4/29/2025 at 7:49 AM, the Administrator confirmed that water temperatures should be checked weekly and should be within appropriate range. There was no evidence the water had been hot prior to 4/28/2025, no evidence of burns, and the facility took immediate actions to correct the hot water temperatures.

Based on the policy review, medical record review, and interview, the facility failed to resubmit a Preadmission Screening and Resident Review PASRR after the resident had the addition of a new antipsychotic medication for 1 (Resident #23) of 1 sampled resident reviewed for PASRR. The findings include: 1. Review of the facility's policy titled, PASRR (Pre-Admission Screening & Resident Review, undated, revealed, .individuals identified with MD [mental disorder] or ID [intellectual disability ] are evaluated and receive care and services in the most integrated setting appropriate to their needs .A positive PASRR Level 1 screen necessitates an in-depth evaluation of the individual .Known as a Level II PASRR .PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses which included Bipolar Disorder (a mental health condition that causes extreme mood swings), Current Episode Depressed (a state of general unhappiness), Severe, Psychotic Features (loss of some contact with reality), Anxiety Disorder (excessive fear of or apprehension about real or perceived threats), Unspecified, and Other specified Depressive Episodes (depressed mood, feeling sad, irritable, empty). Review of the facility document titled, Level I Form Pre-Admission Screening and Resident Review, for Resident #23 dated 10/3/2021, revealed, .DIAGNOSIS .Schizophrenia (Current Diagnosis) .Schizoaffective Disorder (Current Diagnosis) .Major depression (Current Diagnosis) .Bipolar Disorder (manic depression) (Current Diagnosis) .Anxiety Disorder (Current Diagnosis) .Depression - mild or situational (Current Diagnosis) .PSYCHOTROPIC MEDICATIONS .Seroquel .Clonazepam .Paxil .Depakote .Abilify .A Level II evaluation is not required and this Level 1 is approved with a Level 1 No Status Change .Should there be an exacerbation related to mental illness .a status change should be submitted .for further evaluation . Review of the facility document titled, Notice of PASRR Level 1 Screen Outcome, for Resident #23 dated 10/4/2021, revealed, .Your Level 1 screen .is accurate and remains active .Should you have a change in symptoms, diagnosis or medication related to a serious mental illness (SMI), intellectual/developmental disability (IDD), or related condition (RC) . a new Level 1 screen will need to be submitted. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Active diagnoses Active diagnoses Anxiety Disorder, Depression, Bipolar Disorder, and Schizophrenia (schizoaffective and schizophreniform disorders). Medication received Antipsychotics. Review of the Care Plan for Resident #23 revised on 2/26/2025, revealed, .has aggressive behaviors r/t [related to] Depression and Bipolar Disorder .Can be inappropriate with female staff, visitors, and residents .taking Anti-Psychotic medications r/t Behavior management, Disease Process .Interventions .Administer Anti-Psychotic medications as ordered by physician. Monitor for side effects and effectiveness Q [every] - SHIFT .Initiated 12/17/2024 . Review of the quarterly MDS dated [DATE], revealed Resident #23 had a BIMS score of 6 which indicated severe cognitive impairment. Active diagnoses Anxiety Disorder, Depression, and Bipolar Disorder. Medications received Antipsychotic and Antianxiety. Review of the Medication Review Report for Resident #23 dated 4/11/2025, revealed, a medication order date of 8/7/2024, for Haloperidol 2 mg tablet give 2 tablets orally three times a day related to Bipolar Disorder Current Episode Depressed, Severe with Psychotic Features. Review of the medical record revealed no documentation that a PASRR had been resubmitted for Resident #23 after the addition of a new antipsychotic medication Haloperidol on 8/7/2024, for Bipolar Disorder Current Episode Depressed, Severe with Psychotic Features. Resident #23's last PASRR was dated 10/4/2021. During an interview on 4/29/2025 at 4:17 PM, the Admissions Coordinator stated in January 2025 she was responsible for resident PASRR's. The Admissions Coordinator was asked when a resident is put on a new psychotropic medication should a new PASRR be done? The Admissions Coordinator stated, That is what I have been told. The Admissions Coordinator was asked if Resident #23 had a PASRR completed since the one dated 10/4/2021? The Admissions Coordinator stated Not that I had seen. I have to do his [Resident #23]. There are quite a few that I am working on. The Admissions Coordinator was asked should a new PASRR have been completed prior to now for Resident #23? The Admissions Coordinator stated, Yes, Ma'am.

Based on policy review, medical record review, observation, and interview, the facility failed to perform practices to prevent the potential spread of infections during medication administration when 1 of 5 (Licensed Practical Nurse (LPN) D ) nurses failed to perform hand hygiene and failed to clean a multi-use vial prior to use, and when 1 of 5 (LPN E ) Nurse failed to clean reusable equipment after use. The findings include: 1. Review of the facility policy titled, Insulin Administration, dated 2001, revealed .Steps in the Procedure (Insulin Injections via Syringe) .Disinfect the top of the vial with an alcohol wipe . Review of the facility policy, titled, Handwashing/Hand Hygiene, dated 2001, revealed .This facility considers hand hygiene to be the primary means to prevent the spread of healthcare-associated infections .Hand hygiene is indicated .immediately after glove removal . Review of the facility policy, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2019, revealed .Resident-care equipment, including reusable items .will be cleaned and disinfected .Reusable items are cleaned and disinfected between residents . 2. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Diabetes. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was unable to be assessed due to rarely/never understood. Review of the Physician Orders revealed NovoLOG Injection Solution [used to lower blood glucose] Inject as per sliding scale .140 - 180 = 3 units . During observation on 4/29/2025 at 11:19 AM, LPN D withdrew insulin from a multi-use vial without cleaning the vial, administered the injection, removed gloves and did not perform hand hygiene. 3. Review of medical record revealed Resident #47 was admitted on [DATE], with diagnoses including Gastrostomy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was unable to be assessed due to rarely/never being understood Review of the Physician Orders dated 2/12/2025, revealed . Check placement of enteral/peg tube [a feeding tube inserted directly into the stomach through the abdominal wall] per auscultation and aspiration every day and evening shift Check tube placement before initiation of formula, medication administration . Observation on 4/30/2025 at 11:30 AM, revealed LPN E verified peg placement by auscultation with stethoscope, administered peg medications, exited room, signed out medications, and did not clean stethoscope. During an interview on 5/1/2025 at 8:34 AM, the Director of Nursing (DON) confirmed that multi use vials should be cleaned before use. The DON was asked if hand hygiene should be performed after removing gloves. The DON stated, Yes. The DON was asked if a stethoscope should be cleaned after use on resident. The DON stated, It should have been cleaned, yes ma'am.

Based on facility policy review, medical record review, and interview, the facility failed to ensure the medical record was accurately documented related to antipsychotic medications for 2 of 5 (Resident #4 and #22) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility's policy titled, Physician's Services, dated 2/2025, revealed .The medical care of each resident is supervised by a licensed physician .Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician .nurse practitioner .Supervising the medical care of the residents includes .overseeing a relevant plan of care for the resident . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Psychosis, Depression, Anxiety, and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #4 was severely cognitively impaired. Resident #4 was dependent on staff to perform Activities of Daily Living (ADLs). Resident #4 was taking antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Review of Physician's Order dated 11/7/2024, revealed Risperidone [an atypical antipsychotic medication used to treat mental health conditions] TAB [tablet] 0.5MG [milligram] .Give 1 tablet orally at bedtime related to delusional disorders . Review of the Physician's Order dated 1/6/2025, revealed RisperDAL [Brand name] Tablet 0.5 MG (risperiDONE [Generic name]) Give 1 tablet by mouth at bedtime . Review of the Medication Administration Record (MAR) dated 1/2025, revealed that Resident #4 received Risperdal 0.5mg and Risperidone 0.5mg on 1/6/2025 through 1/31/2025 at 9:00 PM, resulting in a duplication of the medication dosage. Review of the MAR dated 2/2025, revealed that Resident #4 received Risperdal 0.5mg and Risperidone 0.5mg on 2/1/2025 through 2/28/2025 at 9:00 PM, resulting in a duplication of the medication dosage. Review of the MAR dated 3/2025, revealed that Resident #4 received Risperdal 0.5mg and Risperidone 0.5mg on 3/1/2025 through 3/31/2025 at 9:00 PM, resulting in a duplication of the medication dosage. Review of the MAR dated 4/2025, revealed that Resident #4 received Risperdal 0.5mg and Risperidone 0.5mg on 4/1/2025 through 4/12/2025 at 9:00 PM, resulting in a duplication of the medication dosage. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Dementia, Post Traumatic Stress Disorder, Anxiety, Depression and Psychotic Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #22 was severely cognitively impaired. Resident #22 was taking Antipsychotics, Antidepressants, Antiplatelet, and Anticonvulsants medications. Review of the MAR dated 2/2025 revealed that Resident #22 received Quetiapine (Generic name-used for the treatment of schizophrenia, bipolar disorder, and major depressive disorder) 100 MG and Seroquel (Brand name for Quetiapine) 100 MG at 9:00 PM on 2/27/2025 and 2/28/2025, resulting in a duplication of the medication dosage. Review of the Pharmacist's Report to Nursing .Medication Regimen reviews performed between 03/10/2025 and 3/13/2025 . revealed .There are 2 orders for QUETIAPINE TAB 100MG TAKE ONE TAB BY MOUTH AT BEDTIME. One order is quetiapine 100mg hs [hours of sleep] (generic name) and one order for Seroquel 100 mg hs (brand name) which are the same medication .Would you please discontinue one order . Review of the MAR dated 3/2025 revealed Resident #22 received Quetiapine 100 MG and Seroquel 100 MG on 3/1/2025 through 3/31/2025 at 9:00 PM, resulting in a duplication of the medication dosage. Review of the MAR dated 4/2025 revealed Resident #22 received Quetiapine 100 MG and Seroquel 100 MG on 4/1/2025 through 4/17/2025 at 9:00 PM, resulting in a duplication of the medication dosage. Review of the Order Recap Report, dated April 30, 2025, revealed .SEROquel Oral Tablet 100 mg .Discontinued 4/18/2025 .Reason .duplicate order . During an interview on 4/30/2025 at 1:33 PM, the Director of Nursing (DON) confirmed these were duplicate orders and the Nurse Practitioner (NP) had been notified.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 3 of 57 (Residents #16, #57, and #281) resident occupied rooms and when expired medications were found in 1 of 8 (South 2 Medication Storage Room) Medication Storage Areas. The findings include: 1.Review of the facility policy titled, Medication Labeling and Storage, dated 2001, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access .multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date . 2. Review of the medical revealed Resident #16 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including Rash and other nonspecific Skin Eruption, Bipolar Disorder, Anxiety, Chronic Pain and Major Depressive Disorder. Review of the Medication Review Report dated 4/4/2025, revealed .Betamethasone Valerate External Cream [used to reduce redness and selling of the skin] 0.1% [percent] .Hydrocortisone External Cream 2.5% [used to reduce redness and selling of the skin] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #16 was cognitively intact. During a random observation in the Resident's room on 4/28/2025 at 9:06 AM, revealed a clear medication cup with white cream in it and a tongue depressor in it. During an interview on 4/28/205 at 9:53 AM, LPN F confirmed the medications in the cup were hydrocortisone cream and betamethasone. LPN F stated, .it should not be at the bedside, the treatment nurse leaves it . During an interview on 5/1/2025 at 8:24 AM, the Director of Nursing (DON) confirmed that medications should not be left at bedside unattended. 3. Review of medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Hypertension, and Dependence on Renal Dialysis. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #57 was cognitively intact and was assessed for dialysis. During an observation in Resident #57's room on 4/28/2025 at 8:35 AM, revealed a clear medication cup with several pills in it. Resident grabbed them up and stated he was getting ready to go to dialysis. During an interview on 4/28/2025 at 8:36 AM, LPN B was asked if Resident #57 was assessed to self-administer medications. LPN B stated, No he is not. LPN B confirmed that medications should not have been left in the Resident's room unsecured and unattended. 4. Review of medical record revealed Resident #281 was admitted on [DATE], with diagnoses including Chronic Kidney Disease, Intestinal Obstruction, Diabetes, and Heart Failure. Review of the admission MDS assessment dated [DATE], revealed the assessment was still in progress. Review of Progress Note dated 4/23/2025, revealed .Skin/Wound Note .Head to toe skin assessment completed at this time. Resident has no skin issues at this time . Review of the April 2025 Physician Orders revealed Resident #281 did not have an order for any type of wound cream. Observations in Resident #281's room on 4/28/2025 at 8:31 AM and at 2:18 PM, revealed a tube of triad hydrophilic wound dressing cream laying on the bed. 5. Observation in the South 2 Medication Storage Room on 4/29/2025 at 3:36 PM, revealed promethegan (medication to treat nausea and vomiting)12.5 mg (milligrams) suppositories with an expiration date of 12/2024. During an interview on 4/29/2025 at 3:38 PM, RN C confirmed expired medications should not be in the medication storage rooms. During an interview on 5/1/2025 at 8:24 AM, the DON confirmed that medications should not be left at bedside unattended. The DON confirmed that expired medications should not be left in medication storage areas.

Based on facility policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering for 1 of 1 (Resident #54) sampled residents reviewed for ADLs. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 2021, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care .including .assistance with .hygiene (bathing, dressing, grooming, and oral care . 2. Review of medical record revealed Resident #54 was admitted on [DATE] with diagnoses including Epilepsy, Diabetes, and Contracture of Left and Right Lower Legs. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #54 was cognitively intact. Resident #54 required substantial/maximum assist with showers/baths. Review of the Care Plan dated 1/17/2024, revealed .updated 4/29/2025 .Resident prefers to take showers at HS [hour or sleep/bedtime] .Assist resident with showers at HS .Bathing Bath/Shower resident 3xweek/prn [as needed] as tolerated/desired alternating days with sponge baths if resident prefers. Date Initiated: 01/24/2025 . Review of Bathing Sheets for February 2025 revealed that Resident #54 did not receive a shower on any days in February. Review of Bathing Sheets for March 2025 revealed that Resident #54 did not receive a shower on any days in March. Review of Bathing Sheets for April 2025 revealed that Resident #54 did not receive a shower on any days in April. During an interview on 4/28/2025 at 10:17 AM, Resident #54 stated, I feel like they give other people care before me. Resident #54 was asked how often he gets showers. Resident #54 stated, I have been here for three years, and I have had one shower. During an interview on 4/29/2025 at 8:10 AM, Certified Nursing Assistant (CNA) A stated that 200 Hall odd rooms get showers on Tuesday, Thursday, and Saturday. During an interview on 5/1/2025 at 8:24 AM, the Director of Nursing (DON) was asked if a resident prefers showers and is care planned for showers 3 times a week, should the resident be getting showers 3 times a week. The DON stated, Yes ma'am.

Based on policy review, medical record review, facility investigation, and interview, the facility failed to ensure effective fall interventions were in place to prevent injury, and failed to complete neuro checks for 2 of 3 (Resident #23 and #73) sampled residents reviewed for accidents. The facility's failure to implement effective fall interventions when Resident #23 fell and sustained a closed fracture (broken bone) of right distal femur (large upper bone of the leg) resulted in actual harm. The findings include: 1. Review of the facility's policy titled, Fall Risk-Fall Prevention, dated 4/20/2023, revealed Purpose: To provide a coordinated system to identify Residents at risk for falls and develop an individualized interdisciplinary plan of care to reduce the risk of falls and subsequent injury .Implement interventions, including adequate supervision, consistent with a Resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of a fall .Monitor for effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice .Residents with a BIMS [Brief Interview for Mental Status] of 13 or greater [indicates no cognitive impairment] may be educated on the use of the call light system and reminded to ask for assistance . Review of the facility's policy titled, Neurological Exam, dated 11/28/2023, revealed .Neuro assessments shall be performed for 72 hours .Neuro-checks shall be initiated when there is an unobserved fall and the residents [resident's] BIMS is less than 13 . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses that included Dementia, Schizoaffective Disorder, Seizures, Mood Disorder, Anxiety, and Depression. Review of the Care Plan dated 1/17/2023-1/17/2024, revealed .At Risk for Falls R/T [related to] self ambulatory, unsteady gait, poor safety awareness .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [named Resident #23] to call for assistance before moving from bed-to-chair and from chair-to-bed .has exhibited Wandering Behavior potential for elopement .Patient transferred to Memory Care Unit for safety and to prevent potential elopement .Redirect [named Resident #23] behavior/activity when wandering is observed .Provide orientation to facility layout and room as needed .Redirect when wandering .Monitor resident's location to ensure safety . Further review of the 1/17/2023-1/17/2024 care plan revealed, .Provide diversional activities .[Named Resident #23] is receiving antipsychotic drugs on a regular basis secondary to impulse control disorder .Remind [Named Resident #23] that BEHAVIOR is not appropriate .Remove from situation; allow time to calm down . The care plan to remind a severely cognitively impaired resident to use ambulation and transfer assist devices and remind the resident to call for assistance was inappropriate. Review of the Nurses' Note dated 4/8/2023, revealed Res. [Resident #23] alert, verbal, able to make some needs known. Ambulatory in hallway with walker. Res trying to take food from meal cart. Tried to take water from nurse's hand. Walked up on nurse twice in aggressive manner, but no threat or physical action taken. Res. was upset that 'everybody else gets medicine'. Repeatedly attempting to enter female res. room. Redirected res. [Resident #23] each time, but continues to come back to that door and trying to enter . The facility failed to follow its policy to use education on use of call lights remind to ask for assistance for residents with a BIMS score of 13 or greater and to modify interventions as necessary. The facility failed to implement effective interventions when continued redirection for wandering into other residents' room was ineffective. Review of the Nurses' Note dated 4/9/2023, revealed Res. [Resident #23] repeatedly entering female [resident's] room. Angry and aggressively approaching nurse when told not to enter room. Verbal insults to this nurse when instructed not to enter room. Review of the Nurses' Note dated 5/16/2023, revealed Res. [Resident #23] pacing most of the day with walker. Rare exit seeking noted. Repeatedly entering rooms of female res [residents] sometimes when they were in the rooms and sometimes when they were out, despite being told not to enter. Res [Resident #23] on the constant lookout for any kind of food item or drink that he can find. Trying to take other res food from tray. Repeatedly trying to get into trash can to look at it . Review of the Nurses' Note dated 8/6/2023, revealed Res. [Resident #23] continues to wander the halls, entering other res [residents] rooms at will. Unable to redirect. Res [Resident #23] continues to steal snacks, food, and drink from med cart, other residents, food cart, or any item he can find. Res [Resident #23] cannot stop this behavior. It is every day, as long as he is awake he is wandering and searching for food items. When given food or drink, he may or may not consume it, but will always attempt to take food or drink item that is left unsecured. Review of the Nurses' Note dated 8/20/2023, revealed Res [Resident #23] awake, up ambulating in hallway with walker. Going into female res [residents'] rooms. Instructed to not enter any room but his own. Res [Resident #23] verbalized understanding, reminded frequently and continued to enter other rooms. At present sitting in chair in his room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a BIMS score of 2, which indicated severe cognitive impairment. The facility failed to follow its policy to use education on use of call lights remind to ask for assistance for residents with a BIMS score of 13 or greater and to modify interventions as necessary. Resident #23 had a BIMS of 2, which indicated severe cognitive impairment, and did not have a BIMS of greater than 13 per facility policy. The facility failed to implement effective interventions/modify when continued redirection for wandering into other residents' room was ineffective. Review of the facility's FALL RISK assessment dated [DATE], revealed a score of 18, which indicated moderate risk. Review of the facility's OCCURANCE INVESTIGATION INTERVIEW, dated 11/7/2023, revealed .FALL .WITNESSED [by Resident #71] .I heard [Named Resident #71] yell Get out of my room. [Named Resident #23] stated he fell .Resident fell on his R [right] side .He was walking with his walker .Resident told not to go in another resident room . Review of the facility's Interdisciplinary Team Occurrence Investigation Worksheet dated 11/7/2023, revealed Transferred to Hospital .No .STEPS IMPLEMENTED TO PREVENT RECURRENCE .[Named Resident #23] will be redirected to his hall and will not go into [named Resident #71's] room . Resident #23 ambulated with a walker and would attempt to enter Resident #71's room. Resident #71 often stood in her doorway and did not want anyone coming into her room. On 11/7/2023 Resident #23 attempted to enter Resident #71's room and she grabbed Resident #23's walker to turn him around causing Resident #23 to fall. Resident #23 was transferred to the hospital where he was admitted for a right femur fracture. Resident #23 had a surgical repair for the right fractured femur. Resident #23 was readmitted to the facility on [DATE]. Review of the discharge MDS assessment (with return anticipated) dated 11/7/2023, revealed Resident #23 had short term memory problems, was moderately cognitively impaired, made poor decisions, and required cues/supervision. Review of the Nurses' Note dated 11/13/2023, revealed .The resident [Resident #23] returned from hospital due to Right hip fracture .The resident received a hemiarthroplasty [partial hip replacement] and is now stable . Review of the Care Plan dated 11/20/2023, revealed .at risk for complications related to Right Femur Fracture .Call light available and answered promptly . Review of the Care Plan dated 12/15/2023, revealed .[Resident #23] At risk for mood swings related to .has diagnoses of depression and impulse disorder . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #23 had a BIMS of 2, which indicated severe cognitive impairment, wandering behavior occurred daily, no falls were documented, and the resident received antipsychotic, antidepressant, and antiplatelet medications. Review of the Care Plan dated 1/17/2024 - Present, revealed .At Risk for Falls R/T self ambulatory, unsteady gait, poor safety awareness .Provide patient with extra snacks b/t [between] meals to reduce/limit wandering and taking food .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [named Resident #23] to call for assistance before moving from bed-to-chair and from chair-to-bed .has exhibited Wandering Behavior at times .Memory Care Unit. Ensure all doors alarms/locks are armed to reduce the risk of [named Resident #23] leaving secure area .Redirect [named Resident #23] behavior/activity when wandering is observed .Provide orientation to facility layout and room as needed .Redirect when wandering . The facility failed to follow its policy to use education on use of call lights remind to ask for assistance for residents with a BIMS score of 13 or greater and to modify interventions as necessary. Resident #23 had a BIMS of 2, which indicated severe cognitive impairment, and did not have a BIMS of greater than 13 per facility policy. The facility failed to implement effective interventions/modify when continued redirection for wandering into other residents' room was ineffective. Review of the quarterly MDS dated [DATE], revealed Resident #23 had a BIMS of 2, which indicated severe cognitive impairment. During an interview on 4/24/2024 at 4:33 PM, CNA G was asked about Resident #23. CNA G stated, [Named Resident #23] has been in [the memory] unit a long time. He ambulated with his walker all the time and he would steal food wherever he found it. He would wander into all the residents' rooms, male and female. Now [after the fractured femur] he has to use [his] wheelchair due to lack of strength. He goes to showers and is total dependent for all ADLs [Activities of Daily Living] except eating. He would not participate in therapy, so he does not receive therapy at this time . During an interview on 4/26/24 at 10:15 AM, the Director of Rehabilitation was asked about Resident #23. Director stated, He was ambulating in [the] Memory Care unit with his walker. He was picked up post traumatic fall [with a fracture]. His dementia is worse now since [his] fall. Some get scared after a fall .used to be able to reason with to get him [Resident #23] to do things in therapy back in 2022. After his fall he [Resident #23] just would not participate in therapy or restorative .[Resident #23] had a doctor visit with ortho [Orthopedic doctor that performs surgery on bones] and the doctor seemed pleased with his progress of getting around in his wheelchair . During an interview on 4/26/2024 at 10:30 AM, CNA H was asked about Resident #23. CNA H stated, He is used to going in the rooms of other residents and pilfering their stuff and eating their food. He knows what he is doing because he laughs and said 'I know' when you redirect him. When you ask why [are] you doing that he would say 'I don't know.' I didn't take him to [the] main dining room because he won't stay and he be [is] constantly rolling back here. He won't go all the way to [Named Resident #71's] room he turns around at the nurse station. He won't go to [Named Resident #8's] room either because she curses like a sailor. He continues going into other residents' room in his wheelchair. His sister is aware of his roaming here because she [has] seen him doing it. I stand him up with the standing lift but we can't get him to walk. When elderly persons falls, they get scared .We just try to redirect him, but he laughed [laughs]. He snatched a cookie from a female resident that was eating a cookie. She turned around and started cursing him and he gave it back. His interventions was to redirect and provide extra food/snacks . During an interview on 4/26/2024 at 2:41 PM, the Director of Nursing (DON) was asked, Would you expect other interventions besides being redirected for Resident #23 since he continued to wander. The DON stated, I would do other interventions if there had been an injury, or maybe MDS [coordinator] could do other interventions. He didn't mean no harm to anyone. He was just looking for food or something. He is in [a] wheelchair and still going into resident rooms . The facility's failure to ensure effective interventions were implemented resulted in an actual harm when Resident #23 sustained a fall with a right femur fracture. 3. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, Fracture Left Femur, Acute Respiratory Failure, Diabetes, and Panic Disorder. Review of the Care plan dated 2/15/2024, revealed .At Risk For Falls R/T [related to] weakness, poor endurance, functional decline .All Staff .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .provide the Resident and/or Resident Representative with education regarding strategies to reduce the risk for falls .Remind [Named Resident #73] to call for assistance before moving from bed-to-chair and from chair-to-bed .Respond promptly to calls for assist to the toilet .Short-term memory impaired-unable to recall after 5 minutes .Re-orient to time, location, events, and activities as needed .Use cues to enhance participation in self-care .Report any decline in ability to participate/perform ADL care . The facility failed to follow its policy to use education on use of call lights remind to ask for assistance for residents with a BIMS score of 13 or greater and to modify interventions as necessary. Resident #73 had a BIMS of 12, which indicated moderate cognitive impairment, and did not have a BIMS of greater than 13 per facility policy. Review of the admission MDS dated [DATE], revealed Resident #73 had a BIMS score of 12, which indicated moderate cognitive impairment with no behaviors identified and required partial to moderate assistance with most activities of daily living (ADLs). Review of Nurse's Notes dated 2/15/2024, revealed Resident arrived to the facility by ambulance and escorted in by paramedics. She is alert and oriented [AAO] X [times] 3 upon arrival and with a lot of anxiety. She has been on the call light every 5-10 minutes. She has been very restless. She is on oxygen at 2L [liters]. She has a bruise on both eyes and 5 stitches over her right eye that can be removed on 2/18. She is still very weak, incontinent, and is a fall risk. Review of Nurse's Notes dated 2/22/2024, revealed Found resident on the floor, in her room on her left side facing the door. Unknown what resident was doing and she was unable to state what she was doing. She states she did not hit her head and there are no visible injuries but resident states her left hip hurts. While laying [lying] in bed resident cannot lay on her back or move her left leg without complaining of pain. MD [Medical Doctor] notified and order received for hip x-rays. Resident is her own RP [Responsible Party] with a BIMs of 12. Neuros not initiated . During an interview on 4/26/2024 at 2:53 PM, the DON was asked should neuro checks have been done with an unwitnessed fall and a BIMS of 12. The DON stated, Yes ma'am.

Based on policy review, review of the IV (Intravenous) Medication Administration skills check off form, observation and interview, the facility failed to ensure infection control practices were followed during IV medication administration when 1 of 2 nurses (LPN (Licensed Practical Nurse) E) failed to clean an administration port prior to administration of IV medications and fluids and when 3 of 10 staff members (CNA C, CNA D, and the Life Enrichment Coordinator) failed to perform hand hygiene during dining. The findings include: 1. Review of the facility policy titled, Medication Administration, revised 8/4/2023, revealed .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order. While administering medications the nurse shall observe the 8 Rights of Medication Administration .IV Medication/Fluids .Follow infection precautions and related techniques to minimize the risk of contamination .Adhere to accepted professional standards of practice for preparation, insertion, administration, maintenance, and discontinuance of IV medications/fluids . Review of the document [Named Company] .IV Medication Administration check off form, revealed .Perform another vigorous scrub of [with] antiseptic pad for at least 5 seconds and allow to dry. Attach the syringe or tubing [with medication] to the site . Review of the facility policy titled, Hand Hygiene, dated 3/28/2024, revealed .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Staff shall assist residents as needed and encourage them to perform hand hygiene procedures to prevent the spread of infection .Hand hygiene is indicated and shall be performed under the conditions listed .before and after eating .between resident contacts .after handling contaminated objects . 2. Review of medical record revealed Resident #383 was admitted to the facility on [DATE], with diagnoses of Sepsis, Cerebrovascular Disease, Anemia, Diabetes, IVABT (intravenous antibiotic) for ESBL (Extended spectrum beta-lactamase) in blood. Review of the Care Plan dated 4/16/2024, revealed Risk for UTI (Urinary Tract Infection) and IV and sepsis addressed. ADLs (Activities of Daily Living) addressed, Patient planning to return home . Review of the signed Physician's Orders dated 4/19/2024, revealed: 4/16/2023 INVANZ POWDER FOR INJECTION (Antibiotic to treat infection) . 1gm (gram)/ (per) NS (Normal Saline) 100ml (Milliliter) Every 1 Day for 12 Days. 4/16/2023 Pre-Filled Normal Saline (sterile solution containing sodium chloride) 0.9 % (percent) injection syringe 2 Times Daily 10 ml IV. 4/16/2024 Heplock flush (used to keep IV catheters open and flowing freely) Flush PICC (peripherally inserted central catheter) with 5 ml Heparin after flushing with normal saline every day. Review of the Medication Administration Record (MAR) date April 2024, revealed: 4/23/2024 Sodium Chloride IV PIGGYBACK 1000ML BAG 15 ml/hr (hour) Observation during medication administration on 4/23/2024 at 10:28 AM, revealed LPN E disconnected the PICC tubing, clamped PICC line and laid the PICC tubing on the bed. LPN E administered the Heparin flush into the PICC line without cleaning the PICC line. During an interview on 4/26/2024 at 11:15 AM the DON (Director of Nursing) confirmed that you should not flush a port that is lying on the bed with Heparin without cleaning it. The DON confirmed that you should not connect an IV tubing to the port without cleaning the port. 3. Observation in Resident #52's room on 4/22/2024 at 12:08 PM, revealed CNA C dropped a straw on the floor, picked it up and did not perform hand hygiene, then opened the condiments for Resident #52. Observation in Resident #32's room on 4/22/2024 at 12:09 PM, revealed CNA C entered the room without performing hand hygiene, set up tray, and opened condiments. Observation in Resident #57's room on 4/22/2024 at 12:11 PM, revealed CNA C entered the room, set up tray and did not perform hand hygiene. Observation in Resident #27's room on 4/22/2024 at 12:13 PM, revealed CNA C entered the room, placed tray on over bed table, repositioned resident, moved the covers, set up tray and opened condiments. She did not perform hand hygiene after repositioning resident. Observation in the dining room on 4/22/2024 at 12:21 PM, revealed the Life Enrichment Coordinator served tray to resident and did not perform hand hygiene. Observation in the dining room on 4/22/2024 at 12:24 PM, revealed the Life Enrichment Coordinator got the tray from meal cart, served resident, set up the tray, went and got another tray. Hand hygiene was not performed. Observation in Resident #10's room on 4/23/2024 at 5:57 PM, revealed CNA D entered room and set up tray, moved the table closer, used bare hand to pick up resident's bread and placed tuna on the bread. Hand hygiene was not performed. During an interview on 4/26/2024 at 3:36 PM, the DON confirmed that staff should not touch residents' food with bare hands and hand sanitizer should be done between residents and if hands are visibly soiled or contaminated hand washing should be performed. Facility staff failed to perform proper infection control during medication administration and failed to practice proper hand hygiene during dining.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the prescribed physician orders for oxygen for 1of 4 (Resident #74) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility's policy titled, Oxygen Concentrator and Oxygen Storage, dated 12/1/2022, revealed .Oxygen should be administered only under orders of the attending physician .Obtain physician's orders for the rate of flow and route administration of oxygen .Turn the unit on to the desired flow rate . Review of the facility's policy titled, Medication Administration, dated 8/4/2023, revealed .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order .Check that the medication dose matches the dosage ordered .Review the EMAR [electronic medication administration record] to identify the medication to be administered .Administer medications as ordered . 2. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Dysphagia, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Review of a Physicians' Order dated 2/23/2024, revealed .Apply O2 [oxygen] at 2 L/min [liters per minute] per nasal cannula as needed for dyspnea .sats lower than 88% . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated he had severe cognitive impairment. Shortness of breath when laid flat and received oxygen. Observation in the resident's room on 4/22/2024 at 10:10 AM, 4/23/2024 at 5:31 PM, 4/25/2024 at 8:05 AM and 9:47 AM, revealed Resident #74's oxygen was set at a level of 4 liters per minute. During an interview on 4/25/2024 at 11:07 AM, LPN B was asked what Resident #74's oxygen should be set on. LPN B confirmed the correct oxygen level was 2 L/min according to the doctor's order. During an interview on 4/25/2024 at 11:11 AM in Resident #74's room, LPN B looked at Resident #74's oxygen concentrator and confirmed the rate was set at the incorrect level of 4 L/min and changed it to the correct level of 2 L/min. LPN B confirmed that according to the doctor's orders, Resident #74's oxygen should not have been set to 4 L/min. During an interview on 4/26/2024 at 3:10 PM, the DON confirmed that staff should follow physician's orders.

Based on policy review, observation and interview the facility failed to ensure medications were stored appropriately when staff (Registered Nurse (RN A) left 1 of 9 medication storage areas (100-400 hallway cart) unlocked, unattended, and out of line of site. The findings include: 1. Review of the Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy policy, revised 9/5/2023, revealed It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security .The medications shall be labeled in accordance with accepted professional Principals to include necessary instructions and expiration dates when applicable .All dugs and biologicals shall be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .Only authorized personnel shall have access to the keys to locked compartments . 2. Observation of the 100-400 Hall medication cart on 4/26/2024 at 11:20 AM, revealed the cart sitting in the 400 hallway next to the Nurse's office. RN A was asked to unlock the medication cart so the surveyor could observe contents, and was told that the surveyor would need her to stand with the cart during the observation. RN A unlocked the medication cart and stood with the surveyor to look through the large drawers, when the surveyor opened a small drawer containing medications, RN A walked away and went into the Nurse's office. The surveyor walked to the entrance of the office and observed RN A sitting at the desk out of view of the medication cart. 3. During an interview on 4/26/2024 at 11:20 AM, the Director of Nursing (DON) was asked, Should the medication cart be left unlocked and unattended. The DON stated, No, not if it is not in the line of sight. The facility failed to ensure that medications were stored properly.

Based on policy review, medical record review and interview, the facility failed to ensure a care plan meeting was scheduled and interventions implemented to ensure cognitively intact residents expressing sexual desires towards one another were care planned for their right to privacy and intimacy for 2 of 2 (Resident #31 and #61) cognitively intact residents expressing desires of intimacy with one another. The findings include: 1. Review of the facility's policy titled Sexual Expression of the Resident, revision date of 10/24/2022, revealed .It is the policy of this facility to respect all residents and their rights. This policy applies to individuals who exhibit intact cognitive decision-making capacity. Residents residing in the facility shall be allowed to express themselves in the way they prefer, given they have mental capacity to make informed decisions .Procedure .social service staff shall notify the interdisciplinary team .Residents with decisional capacity have the right to privacy, including private space for sexual expression .licensed independent practitioners shall be notified regarding residents participating in sexual activity for a clinical and cognitive evaluation to determine intact cognitive-decision-making-capacity and capacity to consent .Care plan meetings with the interdisciplinary team shall be scheduled as soon as possible for initial notification of the social service staff .Outcomes of the interdisciplinary team review shall be shared with the resident involved and documented in the plan of care .Based on the plan of care, intimacy and sexual expression shall be permitted if both parties consent .facility shall ensure the resident's right to privacy, including a private place for intimacy and/or sexual expression .Residents who express the desire to be sexually active shall receive education on the definition of abuse, sexual assault, and who to contact to report issues . 2. Review of medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Anxiety, Depression, Cognitive Communication Deficit, and Schizophrenia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #31 scored a Brief Interview for Mental Status (BIMS) of 14, which indicated the Resident was cognitively intact. Review of the Care Plan dated 9/29/2023, revealed Resident #31 expressed, physical behavior symptoms and public display of inappropriate behaviors directed at others at times. If sexual behavior is inappropriate or unwanted, staff should conduct frequent checks, including 1:1 during times when the sexual activity is a pattern. Behavior Symptoms .has verbal behavioral symptoms directed toward others .Openly expresses anger with others and physical sexual expression with staff and resident at times. Review of the Clinical Note dated 11/11/2023, revealed .[Resident #31] and a male resident [Resident #61] was sitting in the courtyard engaging in inappropriate behavior, residents were separated from the behavior. This nurse [licensed practical nurse (LPN I)] checked resident BIM score and resident has a score of 14 and voiced she gave consent for the inappropriate behavior. This nurse spoke with resident [Resident #31] with TX [treatment] nurse as witness this nurse [LPN I] informed [Resident #31] that public display of inappropriate behavior could not happen again. DON [Director of Nursing] was notified of inappropriate behavior with psych [psychiatric nurse practitioner] to be notified per DON. Review of the PSYCHIATRIC PERIODIC EVALUATION note for Resident #31 dated 11/21/2023, revealed .There were some inappropriate bx [behavior] between her and another male resident [Resident #61] in a public area .Notified resident that there could be no interactions like this in public . Review of the Clinical Note for Resident #31 dated 11/26/2023, revealed .[Resident #31] is also walking down the hall and going to other halls looking for male residents, resident [Resident #31]stating I'm [NAME] [horny] I want some [sex] .informed she [Resident #31] can not go looking for sexual desires .RP [Responsible Party] was informed . Review of the Clinical Notes for Resident #31 dated 1/29/2024, revealed .Patient [Resident #31] is very sexual. Patient likes to talk about it on the phone with people .Ombudsman was here .met with patient [Resident #31] about asking patients [residents] to have sex. One patient [Resident #61] in particular she had stated wanted to have sex with her [Resident #61] denied it and wants her [Resident #31] to stay away from him. This was also addressed with patient [Resident #31] .[Resident #31] also told if she wanted to talk about body parts and sex she could ask for the portable phone where those conversations could be kept private and not in the front dining room. Patient [Resident #31] stated that she understood .Family is aware of patient's [Resident #31] behaviors . Review of the quarterly MDS dated [DATE], revealed Resident #31 had a BIMS score of 15, which indicated she was cognitively intact. Review of the untitled document for Resident #31 dated 3/6/2024, revealed .F/u [follow up] inappropriate sexual behavior .seen today at request of facility staff for report of inappropriate sexual behavior .caught in front lobby touching each other [Resident #31 and Resident #61] sexually and kissing .Patient [Resident #31] has history of manipulating other residents inappropriately .PSYCH: judgment/insight impaired .Excessive sexual drive (disorder) . Review of the EDUCATION RECORD-RESIDENT OR FAMILY for Resident #31 dated 3/6/2024, revealed .CHECK THE APPROPRIATE REASON FOR THE EDUCATION .sexual express . [Resident #31] had stated that she wanted to be involved in sexual expression was informed it was to be in private location that we could provide. Patient [Resident #31] had been witnessed by staff members in public . During an interview on 4/25/2024 at 8:14 AM, the Nurse Practitioner (NP) stated staff went in front lobby to turn off the lights and Resident #31 and Resident #61 were in there alone, they both jumped up and Resident #61 ran. The NP stated, [Resident #31] is manipulative .[Resident #61] said that after the [NAME] he wasn't going to hide it, he liked her [Resident #31] . There was no documentation the Interdisciplinary team (IDT) had conducted a care plan meeting to ensure the Resident's Right to privacy and intimacy. 3. Review of the medical record revealed that Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory with Hypoxia, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #61 had a BIMS score of 15 which indicated the resident was cognitively intact. Review of the Care Plan entry dated 11/13/2023, revealed Resident #61 had inappropriate sexual behaviors at times, Record behaviors on Behavior Tracking Form. Monitor pattern of behavior (time of day), Remind [Resident #61] that behavior is not appropriate, remove from situation; allow time to calm down. Review of the Clinical Note for Resident #61 dated 11/11/2023, revealed Notified by CNA [Certified Nursing Assistant] that resident [Resident #61] was outside on public patio with his hand down female resident [Resident #31] pants, rubbing her between her legs. Both residents oriented and capable of making decisions. Stopped by CNA, as in a public area. Female's [Resident #31] charge nurse also made aware and said she was going to speak to female resident [Resident #31]. Let both residents know that if they choose to do anything private, they must be in private. Review of the Clinical Note dated 11/12/2023, revealed a Psychiatric Nurse Practitioner (NP) would be made aware of inappropriate behaviors between Resident #31 and Resident #61 in a public place. The Clinical note documented Resident #61 had voiced he had consent from Resident #31. Resident #61 was talked to by Charge Nurse and will be closely monitored by staff. Review of the Social Service Entry note dated 11/13/2023, revealed Quarterly [assessment] completed. [Resident #61] is alert and friendly . [Resident #61] is up with walker going around the facility at will . [Resident #61] enjoys going to acts [activities] [Resident #61] was caught recently having inappropriate touching with another oriented patient [Resident #31] in the courtyard. Explained to patient [Resident #61] about appropriate and inappropriate locations Resident #61] agreed. Social visits with patient [Resident #61]. Family comes and visits frequently. No DC [Discharge] plans as patient [Resident #61] requires level of care. Review of the quarterly MDS dated [DATE], revealed Resident #61 scored a BIMS of 15 which indicated that the resident was cognitively intact. There was no documentation the Interdisciplinary team (IDT) had conducted a care plan meeting to ensure the Resident's Right to privacy and intimacy. 4. During an interview on 4/24/2024 at 2:17 PM, the Psychiatric Nurse Practitioner NP was asked about Resident #31 and Resident #61. The Psychiatric NP stated [Resident #31] was wanting a private space for sexual contact with [Resident #61]. [Resident #61] wanted that at the start and changed his mind . During an interview on 4/25/2024 at 11:25 AM, the Director of Nursing (DON) was asked about the relationship between Resident #31 and Resident #61. The DON stated, They [Resident #31 and Resident #61] were in public fondling each other .reported to social worker . I called the psych [psychiatric] NP. She [The Psychiatric NP] said they [Resident #31 and Resident #61] were both consenting . [Resident #31] asked for a private room for encounters between her and [Resident #61]. [Resident #61] didn't ever come and ask for a private room. Psych [Psychiatric NP] said they [Resident #31 and Resident #61] are consenting adults and have to be provided a private place .

Based on facility policy review, medical record review, and interview, the facility failed to thoroughly investigate allegations of abuse for 2 of 20 residents (Residents #68, and #185) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled Abuse Prohibition Plan, dated 11/2/2023, revealed INVESTIGATION .The policy of this facility is that reports of abuse, neglect . are promptly and thoroughly investigated .The investigation shall begin immediately. The information gathered, and the findings/conclusion shall be provided to the Administrator .The investigation and conclusion .shall be reported to the State Agency .within 5 calendar days of the initial report of abuse, incident, or allegation .The individual conducting the investigation shall at a minimum .Review the completed allegation/incident documentation .Review the Resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .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 .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident .Witness reports shall be reduced to writing. Witnesses shall be required to write a statement and be interviewed by the Abuse Coordinator/designee. They shall review the interview, then sign and date it, attesting to its accuracy .Employees of this facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation have been reviewed by the Administrator .The results of the investigation shall be documented .The Administrator shall provide to the resident and his/her representative of the results of the investigation and corrective action taken as necessary .Investigation of Resident to Resident Altercation shall include .Whether the altercation was a willful action that results in physical injury, mental anguish, or mental pain .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .There may be some situations in which the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected. In these situations, it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident .The Administrator shall report the results of all investigations to the State Agency, within 5 working days of the allegation . 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including Seizures, Post-Traumatic Stress Disorder, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #68 had a BIMS score of 15, which indicated intact cognition. 3. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses including Anxiety, Depression, Seizures, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #185 had a BIMS score of 7, which indicated severe cognitive impairment. Review of a Nurse's Note dated 11/12/2023, revealed .Incident occurred on 11/11/2023 .[Named Resident #68] was involved in a physical altercation with another resident [Resident #185] in the 200 hallway, where he [Resident #68] struck another resident [Resident #185] in the back of the head, incident protocol was initiated .Resident [Resident #68] was immediately moved to another room .Resident [Resident #68] stated, I will do anything to get away from him.DON notified at the time of this incident. During an interview on 4/26/2024 at 11:24 AM, LPN J was asked about physical altercation between Resident #68 and Resident #185. LPN J stated, I saw [named Resident #68] wheeling himself from the adjoining bathroom .[named Resident #185] heard named resident [Resident #68] complaining and hit him on the back of his neck .I did an incident report and wrote it up .I'm not sure if statements were written. During an interview on 4/26/2024 at 1:56 PM, the Administrator was asked when an allegation of abuse should be reported. The Administrator stated, .when it is seen or heard .Once it's reported then we do an investigation .It was nothing to it he [Resident #68] just barely hit him [Resident #185]. He [Resident #185] didn't come tell me. If he [Resident #185] thought it was bad, I would have reported . The administrator was then asked if the abuse between Resident #68 and Resident #185 should have been investigated, she stated Yes. The facility failed to complete a thorough investigation for four allegations of abuse.

Based on facility policy review, medical record review, and interview, the facility failed to report allegations of abuse for 2 of 20 residents (Residents #68, and #185) sampled for abuse allegation investigations. The findings include: 1. Review of the facility's policy titled Abuse Prohibition Plan, dated 11/2/2023, revealed .The facility has a zero-tolerance policy for abuse .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Includes, but not limited to hitting, slapping, pinching, and kicking .It is the policy of this facility that abuse allegations .are reported per Federal and State Regulations and Law .If an incident of abuse or allegation of abuse is reported or discovered after hours, the Administrator or Director of Nursing must be notified immediately of such incident .Delayed reports of abuse incidents or allegations must be reported immediately to the Administrator or Director of Nursing, even though there is a time lapse since the incident occurred .The Administrator shall involve key leadership personnel as necessary to assist with reporting, investigation and follow up .The Medical Director, the Attending Physician, and the Long-Term Care Ombudsman shall be notified of the incident of abuse or allegation of abuse .The resident's family /representative shall be notified by the Administrator or designee of the report of an incident of abuse and that an investigation is being conducted .The facility shall ensure that alleged violations involving abuse, neglect, exploitation or mistreatment .are reported to the Tennessee Department of Health, Health Care Facilities Division and Adult Protective Services .All alleged violations are reported immediately, but not later than 2 hours after the allegation is made .The Administrator shall report the results of all investigations to the State Agency, within 5 days of the allegation . 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including Seizures, Osteomyelitis, Post-Traumatic Stress Disorder, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #68 had a BIMS score of 15, which indicated intact cognition. 3. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, Seizures, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #185 had a BIMS score of 7, which indicated severe cognitive impairment. Review of a Nurse's Note dated 11/12/2023, revealed .Incident occurred on 11/11/2023 .Resident [Resident #185] was involved in a physical altercation with another resident [Resident #68] in the 200 hallway, where he [Resident #185]struck another resident [Resident #68] in the back of the head, incident protocol was initiated. Head to toe assessment was completed, no injuries found. Resident [Resident #185] was immediately moved to another room, which resident [Resident #185] was in agreement to move. Resident [Resident #185] stated, I will do anything to get away from him. Family notified. Will continue to monitor. DON notified at the time of this incident. During an interview on 4/26/2024 at 11:24 AM, LPN J was asked about the incident with Resident #68 and Resident #185, LPN J stated, I saw [named Resident #68] wheeling himself from the adjoining bathroom. [Named Resident #68] was complaining of poop on the sink because [named Resident #185 ]had dementia and thought he could use the bathroom without help and would smear poop. [Named Resident #185] heard [named Resident #68] complaining and hit him on the back of his neck. We separated them and moved [named Resident #185] to another room the same day it happened, in the afternoon. I [LPN J] did an incident report and wrote it up and notified [named Resident #185's] family. [Named Resident #68] was on the phone with his family. We did a visual check of [named Resident #68] no injury noted. I'm not sure if statements were written. During an interview on 4/26/2024 at 1:56 PM, the Administrator was asked when an allegation of abuse should be reported. The Administrator stated, Reported when it is seen or heard .Once it's reported then we do an investigation, have to talk to both sides to see what happened, get statements from whoever was around. I have to report it to the state within 2 hours .After 5 days they send me something and I have to fill that out and send it back .If injured send out to hospital. Staff to Resident-Report immediately and staff has to be suspended for 3 days until investigation is finished. Then the Administrator was asked should all components of the abuse policy be completed. The Administrator stated, Yes. Then the Administrator was asked was this allegation reported to state. The Administrator stated, No, I talked with [named Resident #68] that same day. I asked him if he was hurt, and he said [named Resident #185] came up behind him and hit him in the head because he had talked with [Named Resident #68] that same day. I asked him if he was hurt. It was nothing to it he just barely hit him. He didn't come tell me. If he thought it was bad, I would have reported . The facility failed to report two allegations of abuse to the State Agency.

Based on policy review, medical record review, and interview the facility failed to ensure blood pressure medications were administered according to the physician ordered parameters for 1 of 5 (Resident #3) sampled residents reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, Medication Administration dated 11/2017 revealed, .Medications shall be administered .per the Physician's Signed Order .Check that the medication dose matches the dosage ordered .When applicable, medications shall be held for vital signs outside of the physicians' prescribed parameters . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Diabetes, Hypertension, Dementia and Anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the Physician Order Sheet February 2023 revealed, .Hydralazine [a blood pressure medication] 50mg [50 milligrams] 1 tab [tablet] by mouth three times daily .Systolic Blood Pressure [the top number on a blood pressure reading] < [less than] 140 Hold;Diastolic [Hold; Diastolic (the bottom number on a blood pressure reading)] Blood Pressure < 80 Hold . Review of the Medication Administration Record (MAR) dated November 2022 revealed Hydralazine was administered outside the physicians ordered parameters to hold for a systolic blood pressure less than 140 or a diastolic blood pressure less than 80 on the following dates with the following systolic and/or diastolic blood pressure recorded: 11/1/2022 at 7:00 PM systolic 133 11/3/2022 at 7:00 AM diastolic 66 11/4/2022 at 1:00 PM systolic 131 and diastolic 78 11/4/2022 at 7:00 PM systolic 122 and diastolic 76 11/5/2022 at 7:00 AM systolic 130 11/6/2022 at 7:00 PM systolic 138 and diastolic 74 11/9/2022 at 7:00 PM systolic 139 11/10/2022 at 7:00 PM systolic 131 and diastolic 76 11/11/2022 at 7:00 AM systolic 124 and diastolic 68 11/11/2022 at 1:00 PM systolic 133 11/14/2022 at 7:00 PM diastolic 76 11/16/2022 at 7:00 PM diastolic 76 11/17/2022 at 7:00 PM diastolic 76 11/21/2022 at 7:00 PM systolic 126 11/22/2022 at 7:00 PM systolic 135 11/24/2022 at 7:00 AM systolic 132 and diastolic 75 11/27/2022 at 7:00 PM diastolic 71 11/30/2022 at 7:00 PM diastolic 71 Review of the MAR dated December 2022 revealed Hydralazine was administered outside the physicians ordered parameters to hold for a systolic blood pressure less than 140 or a diastolic blood pressure less than 80 on the following dates with the following systolic and/or diastolic blood pressure recorded: 12/3/2022 at 7:00 PM systolic 134 12/4/2022 at 7:00 PM diastolic 79 12/5/2022 at 7:00 PM diastolic 78 12/6/2022 at 7:00 PM diastolic 76 12/8/2022 at 1:00 PM systolic 133 and diastolic 78 12/8/2022 at 7:00 PM systolic 133 12/9/2022 at 1:00 PM systolic 134 12/10/2022 at 7:00 PM diastolic 65 12/11/2022 at 7:00 PM diastolic 63 12/13/2022 at 7:00 PM systolic 136 12/14/2022 at 7:00 AM diastolic 72 12/14/2022 at 1:00 PM systolic 121 12/14/2022 at 7:00 PM systolic 134 and diastolic 78 12/15/2022 at 7:00 PM diastolic 78 12/16/2022 at 7:00 PM systolic 134 12/19/2022 at 7:00 PM systolic 136 and diastolic 72 12/20/2022 at 7:00 PM diastolic 76 12/21/2022 at 7:00 PM systolic 128 and diastolic 77 12/22/2022 at 7:00 PM systolic 132 12/23/2022 at 7:00 PM diastolic 73 12/24/2022 at 7:00 PM systolic 134 and diastolic 76 12/27/2022 at 7:00 PM systolic 129 12/28/2022 at 7:00 PM diastolic 78 12/29/2022 at 1:00PM diastolic 74 12/29/2022 at 7:00 PM diastolic 76 12/31/2022 at 7:00 PM diastolic 76 Review of the MAR dated January 2023 revealed Hydralazine was administered outside the physicians ordered parameters to hold for a systolic blood pressure less than 140 or a diastolic blood pressure less than 80 on the following dates with the following systolic and/or diastolic blood pressure recorded: 1/2/2023 at 7:00 PM diastolic 78 1/3/2023 at 7:00 PM diastolic 76 1/4/2023 at 7:00 PM diastolic 78 1/5/2023 at 7:00 PM systolic 128 and diastolic 74 1/6/2023 at 7:00 PM systolic 136 and diastolic 78 1/8/2023 at 7:00 PM systolic 138 and diastolic 78 1/9/2023 at 7:00 PM systolic 134 and diastolic 65 1/18/2023 at 7:00 PM diastolic 78 1/20/2023 at 7:00 PM diastolic 70 1/22/2023 at 7:00 PM systolic 132 and diastolic 73 1/24/2023 at 7:00 PM systolic 138 1/30/2023 at 7:00 PM diastolic 78 1/31/2023 at 7:00 PM diastolic 76 Review of the MAR dated February 2023 revealed Hydralazine was administered outside the physicians ordered parameters to hold for a systolic blood pressure less than 140 or a diastolic blood pressure less than 80 on the following dates with the following systolic and/or diastolic blood pressure recorded: 2/2/2023 at 7:00 PM systolic 135 and diastolic 79 2/3/2023 at 7:00 PM systolic 138 2/4/2023 at 7:00 PM diastolic 65 2/5/2023 at 7:00 PM systolic 136 and diastolic 67 2/6/2023 at 7:00 PM systolic 139 2/7/2023 at 7:00 PM systolic 139 2/8/2023 at 7:00 AM systolic 132 and diastolic 70 During an interview on 2/9/2023 at 10:17 AM, Licensed Practical Nurse (LPN) #2 was shown the order for Resident #3's Hydralazine and asked when should this medication be held. LPN #2 stated, Anytime her systolic blood pressure is less than 140 or her diastolic blood pressure is less than 80 .you just have to know your parameters. During an interview on 2/9/2023 at 1:00 PM, the Interim Director of Nursing (IDON) confirmed Hydralazine should not be given if the systolic blood pressure is less than 140 or if the diastolic blood pressure is less than 80.

Based on policy, medical record review, observation, and interview the facility failed to provide care and services for residents with enteral feeding tubes and feedings when 1 of 2 nurses (Licensed Practical Nurse (LPN) #1) was observed administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without auscultation prior to administration of medication for 1 of 2 sampled residents (Resident #38) observed during PEG medication administration and when staff failed to ensure the enteral feeding syringe and the flush solution were properly labeled for 1 of 2 sampled residents (Resident #66) reviewed with PEG tube feedings. The findings include: 1. Review of the facility's policy titled, Tube Feeding Management/Restore Eating Skills, revised 6/23/2022 revealed, .To ensure that staff providing care and services to the resident .feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care .Verify that the tube is functioning before beginning a feeding or administering medications .Check gastric residual volume .by aspiration .Auscultation . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Hypertension, Alzheimer's Disease, and Gastrostomy Status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 had severely impaired cognition, required extensive to total assistance with activities of daily living, and had a feeding tube. Review of the Physician Order Sheet dated 2/2023 revealed, .Check placement .of enteral tube per auscultation and aspiration . Observation in Resident #38's room on 2/7/2023 beginning at 5:20 PM, revealed LPN #1 prepared the medications, placed the liquid medication in cups for administration to Resident #38, gathered supplies, and entered the room without a stethoscope. LPN #1 aspirated and flushed the enteral feeding tube with 30 cubic centimeters (cc) of water, allowed water to flow by gravity and administration the medication. LPN #1 failed to auscultate to check placement before administration of the medication. During an interview on 2/9/2023 at 9:34 AM, the Interim Director of Nursing (IDON) was asked how placement is checked before administering medications through a PEG tube. The IDON stated, .you would auscultate . The IDON was asked is there anytime you would not auscultate. The IDON stated, No ma'am. 3. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses of Cancer, Malnutrition, Stenosis of Larynx, Dysphagia, Aphonia, and Tracheostomy. Review of a Physician Order dated 1/20/2023, revealed, .Continuous .Jevity 1.5 at 60 cc/hour with 50 cc/hour water auto flush .Two Times Daily . Review of a Physician Order dated 1/20/2023, revealed, .Change enteral syringe .Every One Day . Observation in Resident #66's room on 2/6/2023 at 9:44 AM, 3:27 PM, and 4:30 PM, revealed an enteral infusion of Jevity 1.5, without the resident's name, the date, the rate, or the time labeled on the formula bottle or water bottle. Resident #66's feeding syringe was not labeled. Observation in the resident's room on 2/8/2023 at 7:58 AM and 2:18 PM, revealed Resident #66 had an unlabeled clear tube feeding bag with a tan colored liquid infusing at 60 cubic centimeters per hour without the resident's name, date, rate, or time labeled, nor was there a label on the water bottle. Resident #66's feeding syringe was not labeled. During an interview on 2/9/2023 at 5:28 PM, the IDON confirmed that enteral feedings and water bags should be labeled with the resident's name, date, rate, and time, and the syringes should be dated.

Based on policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held at least quarterly for 1 of 10 (Resident #25) sampled residents reviewed for care plan meetings. The findings include: Review of the facility's policy titled Comprehensive Careplan, dated 10/24/2022 revealed, .Our resident person-centered plan of care includes .the comprehensive care plan shall be prepared by an interdisciplinary team, that includes .The resident and the resident's representative . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease, Dementia, Hypertension, Anxiety and Adult Failure to Thrive. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status score of 03, indicating the resident was severely cognitively impaired. During an interview on 2/6/2023 at 4:09 PM, a family member was asked if she participated in Care Plan meetings with the facility. The family member stated, No Ma'am, not any longer . The facility was unable to provide documentation that a care plan conference was held with Resident #25 or her representative after the completion of the 5/6/2022 assessment. During an interview on 2/7/2023 at 5:45 PM, the Interim Director of Nurses confirmed she was unable to provide documentation for a care plan conference meeting with resident and/or family.

Based on policy review, video camera footage review, Weather Website review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 4 sampled residents (Resident #1) reviewed for wandering/elopement, which resulted in Immediate Jeopardy for Resident #1. Resident #1, a cognitively impaired vulnerable resident eloped from the facility and was found by a non-staff member (motorist) walking in the road approximately 0.3 miles from the facility. The facility staff were unaware Resident #1 was missing for approximately 39 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Director of Operations, and the Regional Nurse Consultant were notified of the Immediate Jeopardy for F-689 on 4/21/2021 at 5:43 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 4/13/2021 through 4/16/2021. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors 4/19/2021 through 4/23/2021. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 3/2020, revealed, .residents environment remains as free of accident hazards as is possible; each resident receives adequate supervision .to prevent accidents .supervision is an intervention and a means of mitigating accident risk . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Seizures, Major Depressive Disorder, Alzheimer's Disease, Dementia, [CONDITION(S)] and Peripheral Vascular Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment for decision making. Resident #1 required glasses for adequate vision. Resident #1 required 1-person assistance for walking and 2-person physical assistance for transfers. Resident #1 was unsteady during transition and walking. Resident #1 used a cane for mobility. Review of the Quarterly Fall Scale dated 2/17/2021, revealed Resident #1 had an unsteady balance, wore glasses, had urge incontinence, and health conditions which contributed to a risk for falling. Review of the facility's video camera footage of the Lobby dated 4/13/2021, revealed the following: a. At 4:44 AM and 0 seconds, Resident #1 was standing in the foyer of the lobby with a walking cane, wearing blue-green lounge pants, a plaid long sleeve shirt, baseball hat, face mask and tennis shoes. b. At 4:45 AM and 44 seconds, a staff member walked by Resident #1 standing in the foyer. c. At 4:46 AM and 55 seconds, Resident #1 exited the facility through 2 unsecured doors located on the East side of the building, which is the main entrance of the building. Review of the facility's video camera footage of the Drive Through (East Side main entrance) dated 4/13/2021, revealed the following: a. At 4:46 AM and 56 seconds, Resident #1 exited the facility's main entrance doors. b. At 4:47 AM and 7 seconds, Resident #1 appeared to stumble. Review of the facility's video camera footage of the South East Front Parking Lot dated 4/13/2021, revealed the following: a. At 4:47 AM and 15 seconds, Resident #1 walked with a cane across the parking lot to the street. b. At 4:48 AM and 17 seconds, Resident #1 walked into the street and walked South on the street facing oncoming traffic. c. At 4:49 AM and 59 seconds, Resident #1 stopped walking and stood in the street. d. At 4:49 AM and 2 seconds, Resident #1 began walking across the street. e. At 4:49 AM and 14 seconds, Resident #1 crossed the 3-lane street, a busy heavily traveled street walking south and facing oncoming traffic. f. At 4:49 AM and 25 seconds, a vehicle was traveling South on the street and applied the brakes as it met Resident #1. g. At 4:51 AM and 57 seconds, Resident #1 walked South on the street until he was no longer visible on the video footage. There were 10 vehicles and 2 semi-trucks noted on the video that traveled north and south on the street and Resident #1 was not visible on the video camera footage. Review of the facility's video camera footage of the Drive Through (East Side main entrance) dated 4/13/2021, revealed the following: a. At 5:23 AM and 18 seconds, a vehicle arrived at the main entrance of the facility. A male exited the driver side of the vehicle and opened the facility's East main entrance exterior door. A female exited the passenger side of the vehicle and assisted Resident #1 out of the back seat of the vehicle. The driver motioned for someone to come to the door as the passenger assisted Resident #1 to the door and into the building. The video camera footage does not show a staff member or who the driver and passenger were talking to inside the facility. b. At 5:24 AM and 54 seconds, Resident #1 ambulated back in the facility's East main entrance. Review of the National Weather Service Records revealed, the temperature was 54-64 degrees Fahrenheit and the humidity level was 62% with passing clouds on 4/13/2021. Review of a Nurse's Event Note dated 4/13/2021, revealed the facility Administrator received a telephone call at approximately 8:15 AM. The caller reported to the Administrator that they had assisted a resident back to the facility at approximately 5:00 AM after seeing Resident #1 walking along the street near a convenience store located near the facility. The caller informed the Administrator that she and her husband noticed the resident, stopped, and talked with the resident inquiring where he was going. According to the caller, the resident stated he was on his way to work. The caller then inquired where the resident lived and the resident informed them that he lived at (Named Nursing Facility). The caller assisted the resident into her vehicle and returned him to the facility. The caller stated they assisted the resident into the facility and into the care of a nurse. Resident #1's vital signs were documented at 10:31 AM. Resident #1's Physician was notified on 4/13/2021 at 11:00 AM with new orders for laboratory tests and a Wanderguard (a mechanical ankle or wrist band tracking system that automatically locks the doors and alarms when the device is close to the door). Resident #1's Responsible Party (RP) was notified of the occurrence at 11:17 AM on 4/13/2021. Review of the Clinical Notes Event Report Follow up dated 4/13/2021 at 10:45 AM, documented by the Director of Nursing (DON), revealed, .head to toe assessment completed on patient [Resident #1] at this time . Observation of the (Named) Street on 4/19/2021 at 4:38 AM, revealed the street had a drop on both sides of the street of more than 3 feet into a large drainage ditch. The large drainage ditch was approximately 558 feet from the facility on the right side of the street. The drainage ditch was surrounded by large white rock and it was approximately 5-10 feet deep. On the right side of the road, there was an abandoned building with tires, wood and farm equipment and a gas station. The street inclined to a set of railroad tracks and the street declined past the railroad tracks. There were industrial buildings on both sides of the road. The posted speed limit was 40 miles per hour. The street had 2 lanes for traffic and a turning lane. There was a steep drop-off of approximately 10-15 feet on the left and right side of the road. During an interview on 4/19/2021 at 6:39 AM, Certified Nursing Assistant (CNA) #5, who was assigned to care for Resident #1 for the 6:00 PM-6:00 AM shift on 4/12/2021, stated, .I saw him getting out of the bed about 3:00-3:30 AM [on 4/13/2021] . During an interview on 4/19/2021 at 7:03 AM, Registered Nurse (RN) #1 stated, .I saw [Named Resident #4] down on the North 1 Hall walking unassisted .I told the resident [Resident #4] to stop .[Named Resident #1] was standing in the foyer hallway. He stopped and looked at me .he thought I was talking to him .I told him to go ahead .I passed by him and went down the hall to assist [Named Resident #4] .when I came back up the hall going back to TCU [Transitional Care Unit] Hall I saw a car pull up around 5:10-5:15 AM .a man opened the [first set] door and a lady was helping someone out of the car .I realized it was [Named Resident #1] .the lady said they found him down the street and figured he belonged here .took him [Resident #1] to his room .I didn't write a note about what happened .looked him over to make sure he was okay but did not complete a thorough assessment .didn't inform the DON until around 10:00 AM that morning when she called me to ask me about it [the elopement] . During an interview on 4/19/2021 at 12:00 PM, the Administrator confirmed he was notified at approximately 8:15 AM on 4/13/2021, by a non-staff member (the motorist) that she had picked up Resident #1 down the street, returned him to the facility and wanted to check to be sure the resident was unharmed. During a telephone interview on 4/19/2021 at 3:30 PM, the motorist confirmed that on 4/13/2021 between 4:45 AM and 5:00 AM, she and her husband were on their way to work when they crossed the railroad tracks on (Named Street). She stated, .We saw an elderly man [Resident #1] walking real slow with a cane in the road .we pulled up beside him, started talking to him .he said he was going to work .he finally told us he lived at [Named Nursing Facility] .while I was talking to the man, I had to get out of the car because there was a diesel truck traveling north on [Named Street] .I had to flag the diesel truck down, I was afraid the diesel truck was going to hit him .we got him in the car and took him to [Named Facility] .when we pulled up to the facility we didn't see anyone, got out of the car and then a staff member came to the door, she acted like it was her cat that had gotten out of the house, she didn't seem too concerned about him being out of the facility, she asked the resident [Resident #1] how he got out and laughed . The motorist confirmed the nurse assisted Resident #1 back into the facility. The motorist confirmed she called the facility that morning and talked to the Administrator about the incident because she was concerned about the resident. During an interview on 4/20/2021 at 10:30 AM as the Administrator was viewing the video footage, the Administrator stated, .this is making me sick to my stomach . During an interview on 4/20/2021 at 11:30 AM, the Director of Nursing (DON) confirmed she was not aware of Resident #1's elopement until after 8:15 AM on 4/13/2021, that RN #1 did not complete an event note, did not complete a head to toe assessment, and did not notify Administration that Resident #1 had eloped from the facility. The DON stated, .I did not know about the elopement until I arrived at work that morning. The Administrator informed me he had received a call from someone reporting they had brought a resident [Resident #1] back to the facility earlier that morning .I called [Named RN #1] about 10:00 AM to ask her about the incident .[Named RN #1] did not give a reason why there was no documentation of the elopement .she got sidetracked and just didn't report it to me . The DON confirmed that RN #1 should have notified her and the Administrator of the elopement. The DON confirmed that if RN #1 had reported the elopement, the Physician and Responsible Party would have been notified promptly. The DON confirmed that if the motorist had not called and reported the elopement, the facility would not have known Resident #1 eloped as there was no documentation in the clinical record regarding the elopement. Observation of the parking lot on 4/20/2021 at 3:45 PM, revealed a black asphalt area with lines for parking cars. There was a ditch to the left side of the parking lot that was 42 inches wide and 7 inches deep that is the length of the parking lot. The right side of the parking lot is adjacent to an unlevel grassy area. The parking lot has an outlet to the street with an 8 foot wide, 23 inches deep drainage ditch with a small amount of white gravel in the ditch. There was a 7 inch drop between the asphalt and the ground near the drainage ditch. During a telephone interview on 4/21/2021 at 1:22 PM, RN #1 stated, .I did not know the resident [Resident #1] was gone from the facility until I saw him get out of the car .got him in the building took him to his room .looked him over .did not do a thorough assessment . During an interview on 4/22/2021 at 10:45 AM, the DON confirmed the only reason facility administration knew about Resident #1's elopement was that on the morning of 4/13/ the Administrator had received a telephone call from the motorist that had located the resident. The DON stated the 24-hour report is utilized for discussion in the morning meeting, is based on the event notes and nurses' documentation of the residents' condition. There was not an event note or nurse's note completed for this incident of elopement so this information was not on the 24-hour report that was discussed in the morning meeting. The facility's corrective action plan included the following: On 4/13/2021-4/17/2021, the facility implemented the following: 1. On 4/13/2021, the DON completed an elopement risk assessment, a head to toe assessment, notified the Physician and the Responsible Party for Resident #1. The surveyors confirmed the information through review of the elopement risk assessment, the head to toe assessment, and by interview with the Physician and the DON. 2. The Administrator and Social Services Director interviewed Resident #1 on 4/13/2021 and he was found to have no psychosocial harm resulting from the event. Social assessments were completed for 72 hours following the event on 4/14/2021, 4/15/2021, and 4/16/2021 and Resident #1 continues to be found with no psychosocial harm noted. Psychiatric Services assessed Resident #1 on 4/16/2021. The Psychiatric Nurse Practitioner conducting the assessment agreed with the interventions implemented by the facility. The surveyors confirmed this through review of the medical record and interview. 3. The Administrator notified the Regional Director of Operations, the Regional Nurse Consultant, and the DON of the elopement by telephone on 4/13/2021. The surveyors confirmed this information through interviews with the Regional Director of Operations, the Regional Nurse Consultant, and the DON. 4. The Front Lobby door was assessed by the Director of Maintenance on 4/13/2021 and the door was adjusted from a timer lock to a fully locked door with a key code entry/exit only and the code was changed. A door lock/alarm audit tool was developed and implemented on 4/13/2021. Staff education regarding the new door code was implemented on 4/13/2021. 100 percent (%) of active employees have completed training and education as of 4/17/2021. The surveyors confirmed this information through interview with the Maintenance Director, review of the door audits, observation of the lobby door, the sign in sheets, the in-service education provided to employees, and the surveyors interviewed staff on all shifts. 5. All doors were checked for proper functioning of alarms by the Director of Maintenance and the Administrator on 4/13/2021, 4/14/2021, and 4/15/2021. Daily audits for front door checks for each shift continues since 4/13/2021. The surveyors confirmed this through review of the door check logs and interviews with the Administrator and Director of Maintenance. 6. Elopement risk assessments were reviewed on 100 % of residents by the Nurse Manager on 4/13/2021. All residents have been reassessed and plans of care were reviewed and revised as needed. Residents identified as high risk for elopement have interventions in place. The Interdisciplinary Team (IDT) team will review all new admissions for elopement risk and plans of care in the morning Quality Assurance (QA) meeting. The surveyors confirmed this through review of the elopement audit form and interviews with members of the IDT team. 7. The Regional Director of Operations and Regional Nurse Consultant educated facility Administration and Nurse Managers on ensuring patient safety through monitoring elopement risks/concerns. Administration and Nurse Managers were in-serviced on accidents and supervision policy, and elopement and wandering patient's policy on 4/14/2021. The surveyors confirmed this through review of the written education, sign in sheets, and interviews with the Administrator and Nurse Managers. 8. An elopement drill was completed by the Maintenance Director on 4/16/2021. All involved staff responded appropriately, and no additional follow up education was needed. The surveyors confirmed this through review of the elopement drill sign in sheet and interview with staff who participated in the elopement drill. 9. On duty personnel were educated by the Administrator and Nurse Managers on the front door protocol related to alarms and locking and the elopements and wandering policy on 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors reviewed the sign-in sheets, education, and interviewed staff on all shifts. 10. All off duty personnel will be educated on the front door protocol related to alarms and locking and the elopements and wandering policy upon returning to work beginning 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors reviewed the sign-in sheets, education, and interviewed staff on all shifts. 11. All newly hired personnel will be educated during orientation on the front door protocol related to alarms and locking and the elopements and wandering policy beginning on 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors reviewed new hire personnel files, the sign-in sheets, education, and interviewed staff on all shifts. 12. Audits of the front door locks, new hire orientation, new admission elopement risk assessments and plans of care were initiated on 4/13/2021 and are continuing daily. Daily audits will continue for 30 days, then weekly for 4 weeks, and monthly for one month and any adverse findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee. The surveyors reviewed the audits and interviewed members of the QAPI team.

Based on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent neglect and neglected to report an incident of elopement to Administration for 1 of 4 sampled residents (Resident #1) reviewed for wandering/elopement behaviors and neglect, which resulted in Immediate Jeopardy for Resident #1. Resident #1, a cognitively impaired vulnerable resident left his room and eloped through 2 unsecured exit doors to a heavily traveled street with a 40 miles per hour speed limit, crossed that street, crossed the rail road track and was found approximately 0.3 miles from the entrance door of the facility by a non-staff member motorist. The facility staff were unaware Resident #1 was missing from the facility for approximately 39 minutes, when a non-staff member returned Resident #1 to the facility and alerted staff of the resident's return. 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, Regional Director of Operations, and Regional Nurse Consultant were notified of the Immediate Jeopardy for F-600 on 4/21/2021 at 5:43 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 4/13/2021 through 4/16/2021. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors on 4/19/2021 through 4/23/2021. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, revised 5/2019, revealed, .The facility has a zero-tolerance policy for abuse .resident will not be subjected to mistreatment, neglect .The facility will attempt to identify and will investigate any reported violation .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .The facility has a prevention/intervention program which includes .Door Alarms for designated exit doors .Door locks requiring security code [key pad] access after-hours .Overhead paging system and designated codes .Routine environmental rounds .Encourage all personnel, residents, family members, visitors, volunteers, contractors, students and/or consultants to report any signs or suspected incidents of abuse to facility management immediately .The policy of this facility is that reports of abuse, neglect, exploitation .are promptly and thoroughly investigated .The investigation will begin immediately .Ensuring safety and well-being of the vulnerable individual are of utmost priority .Safety, security and support of the Resident .will be provided .it may be necessary to remove the resident from the location of the occurrence to ensure their safety and comfort are maintained. If indicated, a staff member may be assigned individually to the resident to ensure their safety and comfort are maintained . Review of the facility's policy titled, Elopements and Wandering Patients, dated 11/2017, revealed, .The facility ensures that residents who exhibits wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement .Elopement occurs when a resident leaves the premises or a safe area without authorization .the facility is equipped with door locks/alarms to help avoid elopements .The facility shall establish and utilize a systematic approach to monitoring and managing residents for elopement and unsafe wandering .Adequate supervision will be provided to help prevent accidents and elopements . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment for decision making and was unable to recall the correct year and month. Resident #1 required 1-person assistance for walking and 2-person physical assistance with transfers. Resident #1 was not steady during transition and walking and used a cane for mobility. Review of the Quarterly Fall Scale dated 2/17/2021, revealed Resident #1 had an unsteady balance, wore glasses, had urge incontinence, and health conditions which contributed to a risk for falling. Review of the facility's video camera footage of the Lobby dated 4/13/2021, revealed the following: a. At 4:44 AM and 0 seconds, Resident #1 was standing in the foyer of the lobby with a walking cane, wearing blue-green lounge pants, a plaid long sleeve shirt, baseball hat, face mask and tennis shoes. b. At 4:45 AM and 44 seconds, a staff member walked by Resident #1 standing in the foyer. c. At 4:46 AM and 55 seconds, Resident #1 exited the facility through 2 unsecured doors located on the East side of the building, which is the main entrance of the building. Review of the facility's video camera footage of the Drive Through (East Side main entrance) dated 4/13/2021, revealed the following: a. At 4:46 AM and 56 seconds, Resident #1 exited the facility's main entrance doors. b. At 4:47 AM and 7 seconds, Resident #1 appeared to stumble. Review of the facility's video camera footage of the South East Front Parking Lot dated 4/13/2021, revealed the following: a. At 4:47 AM and 15 seconds, Resident #1 walked with a cane across the parking lot to the street. b. At 4:48 AM and 17 seconds, Resident #1 walked into the street and walked South down the street facing oncoming traffic. c. At 4:49 AM and 59 seconds, Resident #1 stopped walking and stood in the street. d. At 4:49 AM and 2 seconds, Resident #1 began walking across the street. e. At 4:49 AM and 14 seconds, Resident #1 crossed the 3-lane street, a heavily traveled street walking south and facing oncoming traffic. f. At 4:49 AM and 25 seconds, a vehicle was traveling South on the street and braked as it met Resident #1. g. At 4:51 AM and 57 seconds, Resident #1 walked South on the street until he was not visible on the video footage. There were 10 vehicles and 2 semi-trucks noted on the video that traveled North and South on the street and Resident #1 was no longer visible on the video camera footage. Review of the facility's video camera footage of the Drive Through (East Side main entrance) dated 4/13/2021, revealed the following: a. At 5:23 AM and 18 seconds, a vehicle arrived at the main entrance of the facility. A male exited the driver side of the vehicle and opened the facility's East main entrance exterior door. A female exited the passenger side of the vehicle and assisted Resident #1 out of the back seat of the vehicle. The driver motioned for someone to come to the door as the passenger assisted Resident #1 to the door and into the building. The video camera footage does not show a staff member or who the driver and passenger were talking to from inside the facility. b. At 5:24 AM and 54 seconds, Resident #1 ambulated back in the facility's East main entrance. Observation of the facility's East Main Exterior Door on 4/19/2021 at 4:45 AM, revealed the door was not locked when surveyors arrived at the facility. The entrance keypad door was locked, and a code had to be entered to open the door for entry into the facility. During an interview on 4/19/2021 at 7:03 AM, Registered Nurse (RN)#1 was asked, if she knew how Resident #1 had eloped from the building. RN #1 stated, .No, I did not know he was gone until I saw a man holding the front entrance door open and a lady assisting someone from the back seat of a vehicle .I recognized it was him [Resident #1] as he approached the door . RN #1 was asked what the facility did when Resident #1 was returned to the facility. RN#1 stated, .I took him back to his room and told his Certified Nursing Assistant (CNA #5) the situation and for her to remain on her hall .I called the Maintenance Director and told him that [Named Resident #1] had gotten out of the front door and explained the front doors were not locked .I informed the day shift that he [Resident #1] had gotten out and to keep close eyes on [Named Resident #1] . RN #1 was asked if she did an assessment on Resident #1 upon return to the facility. RN #1 stated, .I didn't write a note [clinical] about what happened .looked him over to make sure he was okay but did not complete a thorough assessment .I did not do any charting about the incident [elopement] . RN #1 confirmed the Director of Nursing (DON), Resident #1's Physician and family were not notified promptly. RN #1 confirmed a head to toe assessment was not completed or documented upon Resident #1's return to the facility. Observation of the facility's East Main Entrance Doors on 4/19/2021 at 12:15 PM, with the Maintenance Director, revealed the light was red on the code box and a code had to be entered to open the interior entrance door. During an interview on 4/19/2021 at 12:00 PM, the Administrator stated, . I found out at 8:15 AM [on 4/13/2021] from a family member of a past resident that she had brought a resident [Resident #1] back to the facility .by that time the Maintenance Director notified me there was a problem with the code box on the front entrance door . During an interview on 4/19/2021 at 12:15 PM, the Maintenance Director stated, .[Named RN #1] called me at 5:32 AM [on 4/13/2021], saying [Named Resident #1] was outside the exterior door and the light was green [indicating the door is unarmed and opens without alarm or code] on the door's code box [key pad box that unlocks the door when the code is put in] .I got here a little before 6:00 AM [on 4/13/2021] to check the doors and attempted to reset the timer on the code box and could not set it correctly .the door should have been locked [showing red] because it was on a timer and the doors would automatically open [without a code] at 5:00 AM .when the code box has a red light, a code must be entered, if the code box has a green light you do not have to put a code in for it to open and it does not alarm. The Maintenance Director was asked when the timer on the main entrance door code box was last checked. The Maintenance Director stated, .I haven't checked it since I've been here . During an interview on 4/21/2021 at 12:54 PM, RN #1 was asked if routine door checks were conducted on the 6:00 PM - 6:00 AM shift. RN #1 stated, .No, not before this incident .the Maintenance Director would lock the exterior door with his key before he leaves everyday .it was not locked the morning [4/13/2021] he [Resident #1] got out, because when he was brought back the man opened the exterior door to let him in . During a telephone interview on 4/21/2021 at 2:18 PM, Licensed Practical Nurse (LPN) #3 was asked if she was aware Resident #1 had eloped from the facility. LPN #3 stated, .I was told per verbal report from [Named RN #1], that [Named Resident #1] had gotten out the front doors and that the front doors were not locking, and she had called maintenance about it . LPN #3 was asked if getting out the front doors and eloping from the facility were incidents that should be processed the same way. LPN #3 stated, .Yes, they should be treated the same .I had to put the pieces together that it was [Named Resident #1] after a family member called and asked to speak to the Administrator about picking a man up in a flannel shirt this morning .that's when I realized that it was [Named Resident #1] .I saw him [Resident #1] around 8:30 [AM] and asked him and he did not remember leaving the building. LPN #3 was asked if she reported the incident once she realized it was Resident #1 that had eloped from the building. LPN #3 stated, .No, I did not . LPN #3 confirmed she did not report the incident when she was made aware Resident #1 had eloped from the facility, she did not complete a head to toe assessment, and did not closely or frequently monitor Resident #1. The facility's corrective action plan included the following: On 4/13/2021-4/17/2021, the facility implemented the following: 1. Resident #1 was assessed head to toe in the facility with no injuries. The Physician of Resident #1 was notified of the event on 4/13/2021 and was agreeable with the immediate interventions with no recommended changes. Resident #1's elopement risk assessment was completed by the DON on 4/13/2021. The plan of care was revised with new interventions implemented for elopement risk on 4/13/2021. The surveyors verified this through medical record review of the head to toe assessment, the elopement risk assessment dated [DATE], the plan of care, and interviews with the DON. 2. The Administrator and Social Services Director interviewed Resident #1 on 4/13/2021 and the resident was found to have no psychosocial harm resulting from the event. Social assessments were completed for 72 hours following the event on 4/14/2021, 4/15/2021, and 4/16/2021 and Resident #1 continues to be found with no psychosocial harm noted. Psychiatric Services assessed Resident #1 on 4/16/2021. The Psychiatric Nurse Practitioner conducting the assessment agreed with the interventions implemented by the facility. The surveyors verified through medical record review of the Psychiatric notes, behavior monitoring and interviewed the DON. 3. The front Lobby door was assessed by the Director of Maintenance on 4/13/2021 and the door was adjusted from a timer lock to a full lock with key code entry/exit only and the code was changed. The door lock/alarm audit tools were developed and implemented on 4/13/2021. Staff education regarding the new door code was implemented on 4/13/2021. 100 percent (%) of the active employees have completed training and education as of 4/17/2021. The surveyors verified this by observation of the front entrance door with key code entry/exit and interview with the Maintenance Director. Doors were found to be secure and alarms were audible if attempts of exit with code entry. Staff education and audit tool was verified by review of in-service sign-in sheets, education, and audit of the front door main entrance, and staff were interviewed on all shifts. 4. Elopement risk assessments were reviewed on 100% of residents by the Nurse Managers on 4/13/2021. All residents were reassessed and plans of care were reviewed and revised as needed. Residents identified as high risk for elopement have interventions in place. The Interdisciplinary team (IDT) will review all new admissions for elopement risk assessment and plans of care in morning Quality Assurance (QA) meetings. The surveyor verified this through medical record review and interviews with the IDT members. 5. The Regional Director of Operations and Regional Nurse Consultant educated facility Administration and Nurse Managers on ensuring patient safety through monitoring elopement risks/concerns. Administration and Nurse Managers were in-serviced on accidents and supervision policy, elopements and wandering patient's policy, the abuse prohibition plan, and the post elopement procedure on 4/14/2021. The surveyors verified this through interview with Nurse Managers, and review of the in-service sign in sheets and education. 6. An elopement drill was completed by the Maintenance Director on 4/16/2021. All involved staff responded appropriately, and no additional education was needed. The surveyors verified through interview with staff on all shifts and review of the elopement drill. 7. On duty personnel were educated by the Administrator and Nurse Mangers on the elopement and wandering patient's policy, post elopement procedures, and abuse prohibition plan beginning on 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors verified this through interview with staff on all shifts, review of the working schedule, in-service sign in sheets and education. 8. All off duty personnel will be educated upon return to work on the elopement and wandering patient's policy, post elopement procedures, and abuse prohibition plan beginning on 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors verified this through interview with staff on all shifts, review of in-service sign in sheets, and education. 9. All newly hired personnel will be educated during orientation on the elopement and wandering patient's policy, post elopement procedures, and abuse prohibition beginning on 4/13/2021. 100% of active employees have completed training and education as of 4/17/2021. The surveyors verified this through interview with staff on all shifts, review of the in-services sign in sheets, and education. 10. The Medical Director was notified by the nurse of the elopement on 4/13/2021. The IDT and the Medical Director agreed with the protocols and interventions that were put in place. The surveyors verified this through interview with the Medical Director and staff and review of the IDT meeting notes. 11. Audits of the front door locks, new hire orientation, and new admissions elopement risk assessments along with plans of care were initiated on 4/13/2021 and are continuing daily. Daily audits will continue for 30 days, then weekly for 4 weeks, and monthly for one month and any adverse findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee. The surveyors verified this through interview with QAPI members and review of audit logs.

Based on policy review, video camera footage review, medical record review, and interview, the facility failed to ensure Resident #1's Physician, Responsible Party, and facility Administration were promptly notified of an incident of elopement for 1 of 4 sampled residents (Resident #1) reviewed for notification, which resulted in Immediate Jeopardy for Resident #1. Resident #1, a cognitively impaired vulnerable resident eloped from the facility and was found by a non-staff member (motorist) walking in the road approximately 0.3 mile from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, and Regional Nurse Consultant were notified of the Immediate Jeopardy for F-580 on 4/22/2021 at 7:11 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-580. The Immediate Jeopardy was effective 4/13/2021 through 4/16/2021. The facility's corrective action plan, which removed the immediacy of the jeopardy, was received and corrective actions were validated onsite by the surveyors 4/19/2021 through 4/23/2021. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, dated 11/2017, revealed, .a nurse will perform a physical assessment, document, and report findings to physician . Review of the facility's policy titled, Notification of Change, revised 11/2017, revealed, .to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative .when there is a change requiring notification .Circumstances requiring notification include .Accidents .Significant change in the resident's physical, mental or psychosocial condition .a need to alter treatment . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment for decision making and the resident was unable to recall the correct year and month. Review of the video camera footage dated 4/13/2021, revealed Resident #1 exited the facility through the front lobby doors at 4:46 AM and he was brought back to the facility at 5:23 AM, by a non-staff member (motorist) that had found Resident #1 walking on the street approximately 0.3 mile from the facility. Review of the Nurse's Event Note dated 4/13/2021, revealed the Administrator received a telephone call at 8:15 AM and the person calling reported they had assisted a resident back to the facility after finding him near a convenience store, walking along the street that is in front of the facility. The caller informed the Administrator that she and her husband stopped and talked with the resident at approximately 5:00 AM inquiring where he was going. The caller said the resident stated that he was on his way to work. The caller then inquired where the resident lived, and the resident informed them that he lived at (Named Nursing Facility). The caller stated she and her husband assisted the resident into their vehicle and returned him to the facility. The caller stated the resident was assisted into the facility and placed in the care of a nurse. The Administrator was unaware the resident had eloped from the facility at that time. According to the Event Note dated 4/13/2021 the Physician was notified at 11:00 AM and orders were received for blood to be drawn for laboratory tests and a wander guard (a mechanical ankle or wrist band tracking system that automatically locks the doors and alarms when the device is close to the door) was placed on the resident. The Responsible Party was notified at 11:17 AM. This notification to the Physician at 11:00 AM was the first notification the Physician received of Resident #1's elopement. The Physician was notified of Resident #1's elopement from the facility 5 hours and 37 minutes after Resident #1 was returned to the facility. The Responsible Party was notified of the resident's elopement 5 hours and 54 minutes after Resident #1 was returned to the facility. Due to the delay in notifying the DON and the Physician, an assessment of Resident #1 was not completed upon the resident's return to the facility. During interviews beginning on 4/19/2021 at 6:27 AM, Certified Nursing Assistant (CNA) # 5, Registered Nurse (RN) #1, the Maintenance Director, and Licensed Practical Nurse (LPN) #3 confirmed they were aware a resident (Resident #1) had exited the facility through a door on 4/13/2021 and did not report the elopement to the Administrator, the Director of Nursing, the Physician, or the Responsible Party. RN #1, the Maintenance Director, and LPN #3 did not report the incident of elopement to Administration. During an interview on 4/19/2021 at 7:03 AM, RN #1 stated, .lady [the motorist] reported they [motorist and her husband] had found him [Resident #1] down by the store .I didn't write a note [clinical] about what happened .looked him over to make sure he was okay but did not complete a thorough assessment .I did not do any charting about the incident [elopement] .didn't inform the DON [of the elopement] until around 10:00 AM that morning when she called me to ask me about it . During a telephone interview on 4/19/2021 at 3:30 PM, the non-staff member (motorist) who found Resident #1, stated, .we [motorist and her husband] were on our way to work early Tuesday [4/13/2021] morning probably around 4:49 [AM] .we crossed the railroad tracks and saw an elderly man [Resident #1] walking real slow with a cane in the road .we pulled up beside him, started talking to him .he finally told us where he lived at [Named Nursing Facility] .I had to get out of the car because there was a diesel truck traveling north on [Named Street] .I had to flag the diesel truck down, I was afraid the truck was going to hit him [Resident #1] .we got him in the car and took him to [Named Facility] . During an interview on 4/20/2021 at 11:30 AM, the DON confirmed that if RN #1 had reported the elopement to Administration, a head to toe assessment would have been performed earlier, the Physician would have been notified earlier, the orders would have been implemented earlier, and the Responsible Party would have been notified promptly. During an interview on 4/22/ 1 at 10:45 AM, the DON confirmed the only way that facility administration knew about Resident #1's elopement was because of the phone call received from the non-staff member that morning. The 24-hour report is run to discuss in morning meeting and that is based on the documentation of event notes and nurses' documentation of residents' condition. There was not an event note or nurse note completed at that time so this would not have been on the 24-hour report which is discussed in the morning meeting. Refer to F-600 and F-680. The facility's corrective action plan included the following: On 4/13/2021-4/17/2021, the facility implemented the following: 1. Resident #1 was assessed in the facility on 4/13/2021 with no injuries noted. The Physician of the resident was notified of the event on 4/13/2021, was agreeable with the immediate interventions, and had no recommended changes. Resident #1's elopement risk assessment was completed by the DON on 4/13/2021. The plan of care was revised with new interventions implemented for elopement risk on 4/13/2021. The surveyors verified and reviewed Resident #1's elopement assessments and Care Plan. 2. Elopement risk assessments and medical records were reviewed for any further potential incidents of elopement by the Nurse Managers and Regional Nurse Consultant on 100 percent (%) of residents 4/13/2021 through 4/16/2021. There were no incidents that would have required notifications. All residents have been reassessed and the plans of care were reviewed and revised as needed. Residents identified as high risk for elopement have interventions in place. The Interdisciplinary Team (IDT) will review all new admissions for elopement risk assessments and plans of care in the morning Quality Assurance (QA) meeting. The surveyors verified this through review of the audit tools, assessments, and interviewed the DON and the Regional Nurse Consultant. 3. The Regional Director of Operations and Regional Nurse Consultant educated facility Administration and Nurse Managers on ensuring patient safety through monitoring elopement risks/concerns. Administration and the Nurse Managers were in-serviced on accidents and the supervision policy, elopements, the wandering patient's policy, the abuse prohibition plan, and the post elopement procedure which included notifications on 4/14/2021. The surveyors verified this through interviews with the Administrator, Nurse Management and staff, and review of education and in-service sign in sheets. 4. An elopement drill was completed by the Maintenance Director on 4/16/21. All involved staff responded appropriately, and no additional follow up education was needed. The surveyors verified this through review of the sign in sheets for the elopement drill and interviewed the Maintenance Director and staff on all shifts. 5. On duty personnel were educated by the Administrator and Nurse Managers on the elopements and wandering patient policy, post elopement procedures which included notifications, and abuse prohibition plan beginning on 4/13/2021. 100 % of active employees have completed the training and education as of 4/17/2021. The surveyors verified this through review of the education, in-service sign in sheets, and interview with staff on all shifts. 6. All off duty personnel will be educated upon return to work on the elopements and wandering patient policy, post elopement procedure which includes notifications and abuse prohibition plan beginning on 4/13/2021. 100% of active employees have completed the training and education as of 4/17/2021. The surveyors verified this through interviews with staff on all shifts and review of the in-service sign in sheets. 7. All newly hired personnel will be educated during orientation on the elopements and wandering patient's policy, post elopement procedures which includes notifications, and abuse prohibition plan beginning on 4/13/2021. The surveyors verified this through review of the personnel files of new hires, in-services, and education sign in sheets. 8. The Medical Director was notified by the nurse of the elopement on 4/13/2021. The IDT and the Medical Director agreed with the protocols and interventions that were put in place. The surveyors verified this through interview with the Medical Director and staff and review of the IDT meeting notes. 9. Audits of the front door locks, new hire orientation, new admission elopement risk assessments, plans of care, medical record review for any potential incidents of elopement that would include notification were initiated on 4/13/2021 and continue daily. Daily audits will continue for 30 days, then weekly for 4 weeks, and monthly for one month and any adverse findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee. The surveyors verified this by review of the audits and the QAPI meeting sign in sheets and interviewed QAPI members.

Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, medical record review, observation, and interview, the facility failed to ensure a pressure injury was accurately assessed, identified, and a physician's order for treatment was promptly obtained before the pressure injury deteriorated to an Unstageable pressure injury for 1 of 3 sampled residents (Resident #44) reviewed with in-house acquired pressure injuries. This failure of the facility resulted in actual Harm for Resident #44. The findings include: Review of the NPUAP quick reference guide, 2nd addition, published 2014, showed, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Stage II (2): Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III (3): Full Thickness Skin Loss .Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling .Stage IV (4): Full Thickness Tissue Loss .with exposed bone, tendon or muscle. Slough or eschar (non-viable dark tissue) may be present on some parts of the wound bed, Often include undermining and tunneling .Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing . Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management, dated 11/2019, showed, .The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. It is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcers present, and to promote wound healing of various types of wounds in accordance with current standards of practice and Physicians orders .'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence .'Avoidable' means the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice: monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . Review of the medical record, showed Resident #44 was admitted to the facility on [DATE] at 1:50 PM with [DIAGNOSES REDACTED]. Review of a Nursing Admission/Readmission form dated 1/11/2020, showed Resident #44 had normal skin color, and no pressure injuries, venous ulcers, arterial ulcers, or diabetic ulcers were present. The form also showed that there were no rashes or non-ulcer [MEDICAL CONDITION] present. Review of the Braden Scale for Predicting Pressure Injury Risk dated 1/11/2020, showed a Braden Score of 12, which indicated Resident #44 was at high risk for Pressure Injury. Review of a Daily Focus Charting form dated 1/12/2020 at 3:38 PM, showed, .SKIN CONDITION DOCUMENTATION .Skin condition(s) present .Pressure ulcer .Stage 2 sacral area (at the bottom of the spine and lies between the fifth segment of the spine and the coccyx (tailbone))-multiple areas .approx (approximately) 4 cm (centimeters) diameter w/ (with) [DIAGNOSES REDACTED] (redness of the skin) or open PI (Pressure Injury) . Review of the medical record, showed that there was no documentation that the physician was notified and there was no Physician's Order for treatment obtained for the Stage 2 pressure injury to the sacral area on 1/12/2020. Review of the Wound and Pressure Injury Information form dated 1/13/2020, showed, .Location .Coccyx .Type of Wound .Pressure .Pressure Injury: (Stage) 3 .Length 4.5 cm x (by) Width 5.0 cm x Depth UTD (Unable to Determine) .Tissue Type .Slough .If slough/necrotic (dead/non-viable) tissue present, what % (percent) of wound bed is covered .25%-50% .MD (Medical Doctor) Notified Date .01/13/2020 . Review of the Physician Orders dated 1/13/2020, showed, .Santyl 250 (an agent for removal of dead tissue from wounds) unit/gram topical ointment (Apply) .Cleanse area to coccyx with WC (Wound Cleanser) or NS (Normal Saline). pat dry. Apply Santyl 250 unit/gram topical ointment, Calcium alginate and cover with dry dressing QD (every day) until resolved . Review of the Wound and Pressure Injury Information form dated 1/14/2020, showed, .Location .Coccyx .Type of Wound Pressure .Pressure Injury: Unstageable .Length 4.0 cm x Width 4.0 cm x Depth UTD cm .Tissue Type .Slough .If slough/necrotic tissue present, what % of wound bed is covered .25%-50% .Exudate .Serous . During an interview conducted on 3/5/2020 at 6:29 PM, the Treatment Nurse (the nurse who assessed the wound on 1/13/2020) stated that the pressure injury appeared the same on 1/13/2020 and 1/14/2020 when the Wound Care Physician assessed the pressure injury. The Treatment Nurse stated that the Wound Care Physician explained to her why the wound should be staged as an unstageable pressure injury with slough present in the wound bed. The Treatment Nurse confirmed her assessment of the pressure injury at a Stage 3 was inaccurate on 1/13/2020. During an interview conducted on 3/5/2020 at 7:16 PM, the Regional Nurse Manager was asked if she felt that Resident #44's pressure injury had been assessed accurately. The Regional Nurse Manager stated, No, I do not. Review of a Wound Care Physician form titled, INITIAL WOUND EVALUATION & (and) MANAGEMENT SUMMARY, dated 1/14/2020, showed that Resident #44 had an unstageable pressure injury on her coccyx due to necrotic tissue that required surgical debridement. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated Resident #44 was severely cognitively impaired. Resident #44 required extensive assistance for bed mobility, toileting, and personal hygiene, and was totally dependent on staff for transfers. Resident #44 had 1 Unstageable pressure ulcer. Review of the Care Plan dated 1/23/2020, showed that Resident #44 had a pressure injury to her coccyx with interventions of, .Assess and record the size .of skin discoloration, [MEDICAL CONDITION] .Perform complete skin assessment and record .Perform nutritional screening. Adjust diet/supplement as indicated to reduce the risk of skin breakdown .Provide care according to MD and wound consultant orders/recommendations .Use pillows, pads, or wedges to reduce pressure on heals (heels) and pressure points. Turn/reposition .Use pressure-reducing mattress .Observe for changes in pressure ulcer, report to MD if there is an increase in size or stage and follow up as indicated .Treatment as ordered, monitor and report if ineffective . Observation in the resident's room during wound care on 3/3/2020 at 2:42 PM, showed Resident #44 was lying in bed on her right side with a pressure injury to the coccyx with slough and necrotic tissue present. During an interview conducted on 3/5/2020 at 2:27 PM, Resident #44's Physician stated, .I would say that the first one (wound classified as a Stage 2 on 1/12/2020) was not assessed correctly . During an interview conducted on 3/5/2020 at 10:50 AM, the Director of Nursing (DON) and the Regional Nurse Manager were asked if there were any orders for wound care to be provided on 1/12/2020 to Resident #44's sacral/coccyx area. The Regional Nurse Manager confirmed orders were not obtained for the Stage 2 pressure injury discovered on 1/12/2020, and stated, I could not find any orders . During a telephone interview conducted on 3/5/2020 at 11:20 AM, Registered Nurse (RN) #1 was asked about the Stage 2 pressure injury that he discovered on Resident #44's sacral area on 1/12/2020. RN #1 stated, I don't remember any specifics . RN #1 was asked if he actually saw the pressure ulcer. RN #1 stated, I'm sorry I can't say I saw the wound . RN #1 was asked about his documentation on the Daily Focus Charting form dated 1/12/2020. RN #1 stated, If there was a measurement on the form, I actually saw it . RN #1 was asked if he obtained treatment orders when he discovered the pressure injury. RN #1 confirmed he did notify the physician or obtain a treatment order for the pressure injury. The facility's failure to ensure a pressure injury was accurately assessed, identified, and treatment orders were obtained promptly before the pressure injury deteriorated resulted in actual Harm for Resident #44.

Based on the National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, facility policy review, medical record review, observation, and interview, the facility failed to ensure a pressure injury was promptly reported to the physician and failed to obtain a physician's orders [REDACTED].#44) sampled residents reviewed with in-house acquired pressure injuries. The failure of the facility to promptly report a pressure injury to the physician and obtain treatment orders before the pressure injury deteriorated resulted in actual Harm for Resident #44. The findings include: Review of the NPUAP quick reference guide, 2nd addition, published 2014, showed, .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .Stage II (2): Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III (3): Full Thickness Skin Loss .Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling .Stage IV (4): Full Thickness Tissue Loss .with exposed bone, tendon or muscle. Slough or eschar (non-viable dark tissue) may be present on some parts of the wound bed, Often include undermining and tunneling .Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined . Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management, revised 11/2019, showed, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. It is the policy of this facility to implement evidenced-based interventions for all residents who are assessed at risk or who have a pressure ulcers present, and to promote wound healing of various types of wounds in accordance with current standards of practice and Physicians orders . Review of the medical record, showed Resident #44 was admitted to the facility on [DATE] at 1:50 PM with [DIAGNOSES REDACTED]. Review of a Nursing Admission/Readmission form dated 1/11/2020, showed Resident #44 had no pressure injuries or ulcers, and no rashes or non-ulcer [MEDICAL CONDITION] were present. Review of a Daily Focus Charting form dated 1/12/2020, showed that Resident #44 had a Stage 2 pressure injury approximately 4 centimeters (cm) in diameter to the sacral area (at the bottom of the spine and lies between the fifth segment of the spine and the coccyx (tailbone)). Review of the medical record, showed that there was no documentation the physician was notified for treatment orders for the Stage 2 pressure injury to the sacral area on 1/12/2020. Review of the Wound and Pressure Injury Information form dated 1/13/2020, showed that Resident #44 had a Stage 3 pressure injury to the coccyx measuring 4.5 cm in length, 5 cm in width, the depth was unable to be determined due to the wound bed was covered with 25-50% slough, and the physician was notified of this pressure injury on 1/13/2020 at 5:24 PM. Review of the Physician order [REDACTED].Santyl 250 unit/gram topical ointment (Apply) .Cleanse area to coccyx with WC (Wound Cleanser) or NS (Normal Saline). pat dry. Apply Santyl 250 unit/gram topical ointment, Calcium alginate and cover with dry dressing QD (every day) until resolved . Review of the Wound and Pressure Injury Information form dated 1/14/2020, showed, Resident #44 had an Unstageable pressure injury to the coccyx area measuring 4 cm in length, 4 cm in width, and the depth was unable to be determined due to the wound bed was covered with 25 to 50% slough. Observation in the resident's room during wound care on 3/3/2020 at 2:42 PM, showed Resident #44 was lying in bed on her right side with a pressure injury to the coccyx with slough and necrotic (dead) tissue present. During a telephone interview conducted on 3/5/2020 at 11:20 AM, Registered Nurse (RN) #1 was asked if he notified the physician and obtained treatment orders when he discovered the pressure injury to the sacral/coccyx area. RN #1 confirmed he did not notify the physician to obtain a treatment order for the pressure injury. The facility's failure to promptly notify the physician and obtain treatment orders before the pressure injury deteriorated resulted in actual Harm for Resident #44.