Every finding on record at Healthcare at College Park, LLC

Based on observations, interviews, and record reviews, the facility failed to assure that the ice machine was clean and properly functioning. The facility failed to maintain clean facility equipment and failed to document the cleaning of the ice machine. The census of the facility was 65. Findings include: On 8/6/2024 at 9:35 am a tour of the facilities kitchen was conducted with the Dietary Manager revealed the ice machine had a black residue. The residue appeared to be a result of build up from not being cleaned. It was confirmed that the residents in the facility was served ice from that machine. Record review of the log titled Ice Machine Cleaning Days, shows the last cleaning date was 8/6/2024 and had no issues. However, observation of ice machine on 8/6/2024, during the initial tour, revealed the ice machine had a black build up located on the inside where the ice is made. In addition there was no scoop for the ice located near the machine. In an interview on 8/8/2024 at 12:42 pm with the Administrator she revealed there was no policy relating to the facilities Ice Machine. She stated she was unaware of an ice machine in a facility needing a policy. She stated the facility keeps a log of each time the ice maker is cleaned. Her rationale for the ice maker having build up was that the responsible person needs in-service education relating to the proper maintenance of ice machines. In an interview with Dietary Kitchen Manager she revealed she had no knowledge of the ice machine being dirty. She stated if she was made aware it was not clean, she would not have served any of her resident's ice. She revealed that the kitchen staff is not in charge of cleaning the ice maker, the Housekeepers and Maintenance staff are responsible.

Based on interviews, record review and facility policy titled Antibiotic Stewardship, the facility failed to properly maintain an Antibiotic Stewardship Program. The deficient practice placed the resident at risk for not receiving the appropriate antibiotics to treat their infection and could place the resident at risk for developing antibiotic resistant infections. The facility census was 65. Findings: Review of the facility policy titled Antibiotic Stewardship with the revision date of December 2016, revealed that the policy statement is Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the facility's antibiotic stewardship program was revealed to monitor the use of antibiotics in their residents. Step 4 of the policy Interpretation revealed that if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. drug name, b. Dose, c. frequency of administration, d. duration of treatment, e. route of administration: and f. indications for use. Step 8 of the policy interpretation revealed that when a nurse calls the physician/prescriber to communicate a suspected infection, he or she will have the following information available: a. signs and symptoms; b. when symptoms were first observed; c. residents hydration status; d. current medication list; e. allergy information; f. infection type; g. any orders for warfarin and results of last INR; h. last creatinine clearance or serum creatinine, if available; and i. time of the last antibiotic dose. On 8/12/2024 at 3:28 pm, the Infection Preventionist (IP) provided infection control surveillance for February 2024 through July 2024. At that time she stated that she has been the IP since March of 2024. She stated that she obtained her certificate from the CDC on 2/24/2020. Review of the surveillance of infections revealed the following: 7/2024, there were no infections but there were four (4) antibiotic starts for the whole month. 6/2024, there was one (1) ear infection, and 3 antibiotic starts for the whole month. 5/2024, there were 4 other skin infections and one urinary tract infection for the month. There was a total of nine antibiotic starts. 4/2024, there were two urinary tract infections, I upper respiratory infection and 1 other infection with a total of 5 antibiotic starts. Per her documentation, only one met the criteria for infection. 3/3034, 4 urinary tract infections, one lower respiratory infection, one upper respiratory infection, and 4 other infections were seen on the map. There were 9 infections on the line listing, and there was no information about signs and symptoms. 1/2024- no infections, three antibiotic starts and no documentation of signs and symptoms. 12/2023- 1 upper respiratory infection with an antibiotic start. This was not counted on the summary report and no symptoms were charted. 11/2023, 1 upper respiratory infection, but no record of whether it was an antibiotic start. 10/2023, 1 upper respiratory and 1 other. No other documentation noted. 9/2023- 3 wounds and another that is called ascites. One wound was a surgical wound and the other 2 were decubitus. One was stated culture was MRSA, and no cultures were completed on the others. 8/2023- one lower respiratory and had a COVID outbreak and was not counted as any infections. Infection surveillance was requested for July /August 2023. Per the infection preventionist, and the information provided for August surveillance, there was COVID outbreak for the residents. The information that was provided by the DON just documentation that it was only Staff that had infections. An interview was conducted with the infection preventionist (IP) on 8/8/2024 at 4:25 pm. She stated that she has not been in the position for too long and understands that her documentation needs to give the picture of the situation. She stated that she is working with the providers and is in the process of trying to get the providers to start documenting, and to only order when they meet criteria. An interview with the Director of Nursing on 8/9/2024 at 5:50 pm revealed that all antibiotic use is monitored and that all infections are trended, and that the IP gets all the testing to properly monitor the antibiotic starts, and to educate staff to antibiotic stewardship documentation.

Based on observation, interview, and record review the facility failed to provide services that met professional standards of quality by the failure to administer 5:00 pm medications on 8/9/24, for seven of nine Residents (R) 27, R32, R20, R21, R45, R26 and R13. This failure could have caused adverse reactions in all seven of the residents who missed their medications. Findings Include: On 8/6/24 at 8:35 pm Certified Medication Aide (CMA) FF began her medication administration for the first-floor residents. As she passed her scheduled medications, she would tear off pouches from the roll in each resident labeled box, in her medication cart. The perforated individual pouches with resident names, medication names, and time, and date to be administered were then put in a separate drawer in her cart. She had a paper list of the residents she was passing medications to and would consult that as she passed the medications. Review of physician's orders revealed that seven residents' medications had not been given on 8/9/24 between 4:30 pm and 5:30 pm and was verified by the resident's individual medication administration record (MAR). The following residents missed their 5:00 pm medications: R27 - med order dated 7/1/24, for Hydrocortisone tablet 10 milligram (mg), give one and a half tablet, scheduled at 5:00 pm. med order dated 7/1/24, for Potassium Chloride 10 MEQ, scheduled at 5:00 pm. med order dated 7/1/24, for Ferrous Sulfate 325 mg, scheduled at 5:00 pm. med order dated 7/1/24, for Omeprazole 20 mg, scheduled at 4:30 pm. For R32, An order dated 7/1/24, for Docusate sodium 100 mg scheduled at 5:00 pm. An order dated 7/1/24, for Venlafaxine 25 mg scheduled at 5:00 pm. R20 - med order dated 7/1/24, for Levetiracetam 750 mg, give two tablets, scheduled at 05:00 pm. med order dated 7/1/24, for Memantine 5 mg scheduled at 05:00 pm. med order dated 7/1/24, for Metoprolol tartrate 50 mg scheduled at 05:00 pm. R21 - med order dated 7/1/24, for Calcium Carbonate 650 mg scheduled at 5:00 pm. med order dated 7/1/24, for Niacin 500 mg scheduled at 05:00 pm. R45 - medorder dated 7/16/24, for Renvela 800 mg scheduled at 5:00 pm med order dated 7/16/24, for Polyvinyl Alcohol Ophthalmic solution 1.4% scheduled at5:00 pm. R26 - med order dated 6/29/24, for Xarelto 20 mg scheduled at 5:00 pm. med order dated 7/1/24, for Boost scheduled at 4:30 pm. med order dated 7/25/24, for Gabapentin 400 mg scheduled at 5:00 pm. R13 - med order dated 7/1/24, for Dextromethorphan-Guaifenesin 10-100 mg/5 milliliter (ml), give 5ml, scheduled at 5:00 pm med order dated 7/1/24, for Oyster Shell Calcium 500 mg scheduled at 5:00 pm. On 8/6/24 at 9:05 pm, CMA FF stated that the password they had given her for the electronic health record (EHR) would not work, so she used her written paper medication list to pass the residents' medications. CMA FF confirmed the medication pouches that were placed in the separate drawer of her cart were extra medications for each of the residents that she had administered medications to. CMA FF stated that the pouches were for the 5:00 pm medication pass for today (8/6/24). CMA FF confirmed that the medication pouches would be placed in the pharmacy return receptacle in the locked medication room. CMA FF stated that she could not say why the medications were not passed as she only took the cart at 7:00 pm. On 8/10/24 at 10:07 am, the director of nursing services (DNS) confirmed that the seven residents' medications were in the receptacle and that the CMA should have reported it to the nurse who should have reported it to her. The DON confirmed that she was aware that the password for CMA FF had not worked, and she had contacted the information technology (IT) to have it reset and could not remember what date that was completed on. She stated that they had paper medication administration records (MAR) at each nurse station for that floor. She confirmed and verified that the 5:00 pm, and 9:00 pm medications were not signed for on 8/6/24. Review of the facility Administering Medications policy revised April 2019, documented medications were to be administered in a safe and timely manner, and as prescribed. That staffing schedules were arranged to ensure that medications were administered without unnecessary delay. Medications were to be administered within one hour of their prescribed time. If a medication was withheld, refused, or given at a time other than the prescribed time the individual administering the medication shall make note.

Based on observation, interview, and record review the facility failed to ensure seven of nine sampled Residents (R) 27, R32, R20, R21, R45, R26 and R13 were free from a significant medication error related to not administering medications according to the physician orders. Specifically, when medications, such as metoprolol tartrate, potassium, venlafaxine, Xarelto, and gabapentin, scheduled for 5:00 pm on 8/6/24 were not administered as ordered. Findings Include: On 8/6/24 at 8:35 pm, Certified Medication Aide (CMA) FF passed medications for her assigned first-floor residents. As she passed her scheduled medications, it was noted that the following resident's did not receive their 5:00 pm medications as ordered., and CMA FF did not notify licensd staff. R27 - med order dated 7/1/24, for Potassium Chloride 10 MEQ with the adverse effect of hypokalemia, scheduled at 5:00 pm. R32 - med order dated 7/1/24, for Venlafaxine 25 mg with the adverse effect of increased depression, scheduled at 5:00 pm. R20 - med order dated 7/1/24, for Levetiracetam 750 mg with the adverse effect of seizure activity, give two tablets, scheduled at 5:00 pm. - med order dated 7/1/24, for Memantine 5 mg with the adverse effect of dementia, scheduled at 5:00 pm. - med order dated 7/1/24, for Metoprolol tartrate 50 mg with the adverse effects of high blood pressure, scheduled at 5:00 pm. R21 - med order dated 7/1/24, for Niacin 500 mg with an adverse effect of high cholesterol, scheduled at 5:00 pm. R45 - med order dated 7/16/24, for Renvela 800 mg with an adverse effect of increased phosphorus in the blood possibly causing acute kidney injury, scheduled at 5:00 pm R26 - med order dated 6/29/24, for Xarelto 20 mg with an adverse effect of internal bleeding, scheduled at 5:00 pm. - med order dated 0/25/24, for Gabapentin 400 mg with an adverse effect of increased pain, scheduled at 5:00 pm. On 8/6/24 at 9:05 pm CMA FF confirmed the medication pouches that were placed in the separate drawer of her cart were medications not given at the scheduled time for each of the residents that she had administered medications scheduled for her shift to. CMA FF stated that the pouches were for the 5:00 pm medication pass. CMA FF stated that she could not say why the medications were not passed as she only took the cart at 7:00 pm. On 8/10/24 at 10:07 am, the director of nursing (DON) confirmed that the seven residents' medications were in the receptacle and that the CMA should have reported it to the nurse who should have reported it to her. She stated that they had paper medication administration records (MAR) at each nurse station for that floor. She confirmed that the 5:00 pm medications were not signed for or given on 8/6/24. On 8/12/24 at 3:43 pm, licensed practical nurse (LPN) unit manager DD confirmed that she had not gotten any reports of medications not being administered as ordered. LPN DD stated that the nurse would notify the provider and, depending on the medication, the resident may require monitoring for adverse reactions. On 8/12/24 at 4:18 pm, provider extender HH stated that she would expect facility staff to call if a resident was exhibiting adverse effects of a missed medication, however she stated that several residents at this facility tend to refuse their medications, so she would not expect a call every time. Physician extender HH confirmed that she had gotten no reports of missed medications. She confirmed that levetiracetam could result in seizure activity, metoprolol tartrate could result in high blood pressure crisis, potassium could result in hypokalemia, and gabapentin could result in the resident having unnecessary pain. Review of the facility Administer Medication policy revised April 2019, documented that if a medication was believed to be excessive or inappropriate for a resident, or the medication was identified as having potential adverse effects or was suspected of being associated with adverse effects for the resident, the staff preparing or administering the medication would contact the prescriber, the residents primary physician, or the facilities medical director to discuss the concern.

Based on observation, interviews, review of relevant facility documentation, and review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, the facility failed to protect one of seven sampled residents (R5) from sexual abuse by another resident, R425. This deficiency had the potential to place R5 and other residents at risk for repeated sexual abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating revised September 2022, revealed the following: Reporting Allegations to the Administrator and Authorities, #6: Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Review of the electronic medical record (EMR) for R5 revealed she was a [AGE] year-old female admitted to the facility with diagnoses to include multiple sclerosis, obstructive sleep apnea, end-stage renal disease with hemodialysis, left hand contracture, idiopathic peripheral autonomic neuropathy, mood disorder, and major depressive disorder Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/25/24, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; a Mood score of zero, indicating no depression; and exhibited verbal behavioral symptoms directed towards others. In addition, she required maximum to dependent assistance for toileting hygiene, bathing, and dressing; setup for wheelchair mobility. She received antidepressant, diuretic, opioid, and hypoglycemic medications. Review of the Care Plan documented focus areas to include antidepressant medication and limited mobility related to stroke/hemiplegia, initiated 7/24/24. Review of the EMR for R425 revealed he was a [AGE] year old male admitted to the facility with diagnoses to include cerebral infarction with right-sided hemiplegia, and major depressive disorder. Review of the Quarterly MDS assessment, dated 11/29/23, documented a BIMS score of 14, indicating no cognitive impairment, a Mood score of 0, indicating no depression, and exhibited no behaviors. He required setup to supervision for all activities of daily living (ADLs). Review of the Care Plan for R425 revealed focus areas to include risk for alcohol intoxication, risk for injury related to smoking, non-compliance with medical care, verbally aggressive behavior, potential for adverse effects related to psychotropic medications, and physical altercations. Review of the Facility Reported Incidents (FRIs) dated 8/1/2023 through 8/6/2024 revealed FRI # 202313358 dated 12/11/23 which documented an abuse allegation involving R425 touching R5 inappropriately. The allegation was substantiated the same day, R425 was transferred to a local hospital for psychiatric evaluation and did not return. In an observation/interview with R5 in her room on 8/8/24 at 10:45 am, she was alert, oriented, and pleasant; dressed and groomed. She stated she was doing well and the facility staff took good care of her. She stated R425 groped her a few months ago when he walked up to her in her wheelchair and started rubbing on her legs. She stated she reported the incident immediately to staff and R425 was discharged from the facility not long after. She stated the facility staff acted immediately and she was pleased with how everything was handled. She stated R425 had a history of hitting and groping other residents, usually when he was drunk. When asked how she knew he was drunk, she stated he just looked like it. She stated he even hit her on the left side of her head a few weeks prior to the day he touched her inappropriately. She stated she now feels safe in the facility. In an interview with the Director of Nursing (DON) on 8/12/24 at 5:26 pm, she confirmed there was a substantiated sexual abuse allegation involving R5 and R425. She stated the two residents had once dated and periodically had conflict with each other but R5 was discharged from the facility after the last incident and now resides in an assisted living facility. In an interview with the Administrator on 8/12/24 at 6:00 pm, she stated she was not employed at the facility at the time of the incident and could not speak to the manner in which multiple allegations involving R425 were managed. She stated she would always advocate for the health and safety of the residents in her care.

Based on record review, staff interviews and review of the facility policy titled, Resident Assessment- Coordination with PASARR Program the facility failed to follow PASARR level II program recommendations for one of 28 residents (R)420 with a PASARR level II. Findings include: A review of the facility policy titled, Resident Assessment- Coordination with PASARR Program revealed 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the assessment, care planning, and transitions of care. A review of the medical records for R420 revealed a PASARR level II which documented recommendations for R420. The facility was able to complete a behavioral health assessment through CHE Behavioral Health. The PASARR level II further recommended, due to circumstances of this admit and diagnosis and onset of major stressors, specialized mental health services are recommended during SNF stay; specifically psychiatric care for assessment and medication monitoring, behavioral health monitoring and individual counseling for coping and adjustment as needed and desired. Recommend behavioral assessment to rule out history of depressive disorder. Relapse prevention is recommended. Crisis intervention is recommended as needed, the development of individualized interventions to maintain emotional and other health stability. Support and presence from her friends during stay is recommended. Other social and mental stimulation is recommended. Cognitive assessment to assist with care planning is recommended, and other care goals is recommended staff support for doing what's most important to her is recommended. An interview on 8/8/2024 at 10:57 am with the Director of Nursing (DON) revealed she has been working at the facility for two years. She revealed she was working at the facility when R420 was a resident and was familiar with R420's needs. When asked about the PASARR level II recommendations for R420 and how the facility addressed them, the DON was able to pull out the PASARR book. She informed R420 was seen by CHE Behavioral health and the assessment goes to mental health. The facility follows behind the residents every morning to ensure they are receiving the proper treatment. The DON revealed the assessment documented R420 has suicidal ideations but does not remember R420 stating anything related to that. The DON read through the recommendations which documented a referral for psychological assessment and behavior monitoring, stating we did both. She revealed the facility does not restrict visitation and had to end visitation for R420's significant other when he wanted to spend the night. She further revealed the recommendations were care planned but the behavior monitoring could have possibly been just for the diagnosis, care planned for behavior health. The DON revealed staff did not receive any special training but do receive behavioral health training quarterly. Continued interview with the DON revealed R420 did not receive any psych therapies although behavior monitoring was completed every shift which are 8 hours. She further revealed R420 did have behavioral episodes but only when it came to her boyfriend. When she pulled the MAR, the DON revealed she did not see any behavior monitoring documented on the MAR. In addition, she checked one other place in the electronic medical record and was not able to see any documentation for behavioral health monitoring. She revealed she is unsure of how she was not able to catch that. She revealed none of R420's diagnosis warranted the monitoring which is why she feels the nurse missed it but she should not have missed it. The DON revealed if these recommendations are not followed it will cause an increase in behaviors and more issues of defense with the residents. An interview on 8/8/2024 at 3:56 pm with the Administrator revealed she was not at the facility when R420 was a resident and has only been here for four months. She stated with PASARR's the social services coordinator does a review/audit to make sure they are in place.

Based on record review, staff interview, and a review of the facility's policy Comprehensive Care Plans the facility failed to develop a care plan that was consistent with the resident's specific conditions, risks, needs, and current standards of practice for one residents (R) R45. The sample size was 39. Findings include: Review of the policy titled Comprehensive Care Plans revealed that: Is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R45 received dialysis while a resident. Review of electronic medical record (EMR) revealed R45 diagnoses included but not limited to end stage renal disease and dependence on renal dialysis. Review of the physicians' orders revealed R45 was to receive dialysis on (Tuesday, Thursday, Saturday). Interview on 8/9/24 at 3:30 pm with R45 revealed he is scheduled to receive off-site dialysis treatment three times per week. Interview on 8/12/24 at 10:20 am with Licensed Practical Nurse (LPN) Unit Manager DD revealed that nurses have access to an electronic care plan to add information after MDS assessment. Interview with the Minimum Data Set (MDS) coordinator on 8/12/24 at 10:25 am revealed that he was not aware of his responsibility of developing a care plan related to resident's specific conditions. During an interview with Director of Nursing (DON) on 8/12/24 at 10:30 am, she stated that developing a care plan is an MDS coordinator responsibility

Based on observation, record review, resident and staff interviews, the facility failed to provide two hour check and change for one Resident (R14) dependent on staff for activities of daily living (ADLs) The sample size was 39. Findings include: Review of the medical record for R14 revealed an admitted [DATE] with diagnoses of but not limited to, esophageal reflux disease without esophagitis, neuromuscular dysfunction of bladder, paraplegia, and other lack of coordination. Review of the Minimum Data Set (MDS) assessment revealed R14 had a Brief Interview for Mental status (BIMS) score of 15, indicating R14 had no cognitive impairment. During an observation and interview on 8/12/2024 at 4:08 pm, R14 revealed she was not able to feel anything below her waist and was not sure when she was wet or soiled. Resident 14 revealed a Certified Nursing Assistant (CNA) changed her brief at 12:00 pm before lunch. During an interview on 8/12/2024 at 4:12 pm, CNA OO revealed she checked and changed R14 before lunch and did not check R14 until notified by this surveyor at 4:12 pm on 8/12/2024. The CNA OO revealed she offered R14 hydration at 3:00 pm but did not check R14's brief during that time. CNA OO reported she checked R14 at 4:18 pm, and R14 needed to be changed. Further during the interview CNA OO indicated she did not realize it had been more than two hours since R14 had been checked and changed. During an interview on 8/12/2024 at 4:22 pm, the Director of Nursing (DON) revealed residents who depend on staff for incontinent care should be checked and changed every two hours, and if they have increased incontinent periods; those residents are checked more frequently. The DON revealed she was not aware R14 had not been checked and changed since before lunch at or around 12:00 pm. The DON revealed her expectation is that the residents are checked and changed every two hours.

Based on observation, interview, and record review the facility failed to secure a central supply storage room that contained medications and medical supplies. Findings Include: On 8/7/24 at 3:03 pm a central supply room on the first floor was observed open with no staff member in the room. On 8/7/24 at 3:05 pm, licensed practical nurse (LPN) PP confirmed and verified the door to the central supply room on the first floor was open and not locked. LPN PP confirmed there were no other staff members in the central supply room on the first floor. LPN PP stated the door to the central supply room didn't have to be kept shut or locked, it was where they stored supplies and where staff obtained supplies needed. LPN PP confirmed that there were over the counter medications in the room and stated they had never been told to keep this room closed and locked. On 8/7/24 at 3:10 pm the Dircetor of Nursing (DON) revealed the door to this office belonged to the central supply clerk and the scheduler. The DON revealed supplies and over the counter medications were kept in the office and that office should have been shut and locked. Review of the facility's' Medication Labeling and Storage policy revised February 2023, documented the facility stored all medications and biologicals in locked compartments under proper temperature, and light controls. Only authorized personnel had access to the keys.

Based on observation, record review, and resident and staff interviews, the facility failed to properly protect resident (R) R37 from the risk of infection related to resident having an external catheter and per policy, was on enhanced barrier precautions. The staff were to use personal protective equipment (PPE) when rendering care for R37. The facility census was 65. Findings included: Review of the electronic medical record for R37 revealed that he was admitted on [DATE]. He was admitted with diagnoses that included but were not limited to unspecified injury of the cervical spinal cord, quadriplegia, central pain syndrome, and type 2 diabetes mellitus with diabetic autonomic neuropathy, depression and anxiety. R37 was interviewed on 8/9/2024 at 10:48 am., and stated that when staff is providing care for him, they are not gowned up and has never been. An observation was conducted on 8/9/2024 at 11:25 am. This observation revealed that two certified nurse's aides (CNA) entered the room of R37 to provide care. The resident's door was noted to have an Enhanced Barrier Precautions signage, which means that staff is to don (put on) personal protective equipment (PPE) when rendering care with R37, related to his catheter. The two CNAs entered without donning PPE. They then closed the door behind them. During an interview with CNA BB, at 12:12 pm on 8/9/2024, she verified that R37 was the resident that was on EBP. She stated that she was not told that they needed to use PPE. CNA RR was interviewed at 12:13 pm on 8/9/2024. She stated that there is usually a stop sign on the door when it is a room that they need to gown up for. When asked if that sign, that was on the door of R37, meant that she should gown up, she stated no, but then stated that yes, she is supposed to gown up when rendering care for that resident. An interview with Director of Nursing was completed on 8/9/2024 at 5:50 pm. She stated that she expects staff to properly wear PPE in the rooms that it is required in. She stated that EBP is used to protect the residents. AS

Based on observations, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety in the kitchen. Specifically, the facility failed to: - Store food items off the floor in the dry storage area and - Maintain a clean dry storage area. This deficient practice had the potential to affect 66 residents who received nutrition from the kitchen (total census: 68). Findings included: 1. A review of a facility policy titled, Food Safety Requirements, updated 11/02/2022, revealed, It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety. The policy also indicated, Dry food storage-keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. Observations of the dry storage area on 01/03/2023 at 9:05 AM revealed a 25-pound bag of sugar and a 35-pound box of canola oil on the floor of the dry storage room. During an interview with the Certified Dietary Manager (CDM) on 01/03/2023 at 9:09 AM, she stated everything should be stored on the shelves in dry storage. She stated the bag of sugar and box of cooking oil should have made it onto a shelf. She stated the food delivery arrived late on 01/02/2023 and she had left for the day. During an interview with Cook #1 on 01/05/2023 at 2:28 PM, he stated nothing should be stored on the floor of the dry storage area. He stated he was not at work on Monday (01/02/2023) to help put away the order, but if he saw something on the floor of dry storage, he would pick it up and place it on the shelf. He stated he normally would put away the orders and do the cleaning on Mondays and Thursdays, but the kitchen was short a cook, so he had been taking on extra cook duties. During an interview with the Director of Clinical Services (DCS) and Administrator on 01/05/2023 at 3:18 PM, the DCS and Administrator both stated nothing should be stored on the floor of the dry storage area. 2. A review of a facility policy titled, Dietary Services, updated in 2012, revealed the purpose of the policy was, To prevent contamination of food products and therefore prevent food borne illness. The policy also indicated, All floor surfaces must be wet mopped daily and as needed using a bucket with wringer and germicide. Observations of the dry storage area on 01/03/2023 at 9:05 AM revealed the floor underneath the storage rack was littered with sugar and sugar substitute packets, wrappers, food crumbs, condiment packets, and a coating of a dirt-like substance. During an interview with the CDM on 01/03/2023 at 9:09 AM, she stated cleaning of the dry storage area and kitchen occurred every night. During an interview with Cook #1 on 01/05/2023 at 2:28 PM, he stated all the kitchen staff helped keep the kitchen clean. He stated he was assigned to clean the dry storage area on Mondays and Thursdays and when he cleaned the dry storage area, he would sweep and mop, using bleach. He stated the floors should be swept and mopped daily underneath the storage racks to remove all the debris. He stated the kitchen was short a cook, so he had been taking on extra cook duties. During an interview with the Director of Clinical Services (DCS) and Administrator on 01/05/2023 at 3:18 PM, the DCS and Administrator both stated the kitchen should have a cleaning schedule that included pulling the storage racks out of the storage room and cleaning the floor underneath. The Administrator stated the kitchen staff tried to mop up the dirt substance, but the floor had to be stripped to remove the substance.

Based on observation, interviews, and facility policy review, the facility failed to maintain confidentiality of medical records that had been damaged in 1 of 1 record storage rooms. Observations revealed water-damaged medical records were stacked outside a storage building with protected health information (PHI) exposed. Findings included: A review of a facility policy titled, Confidentiality of Personal and Medical Records, dated as implemented 12/28/2022, revealed, The facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. A review of a facility policy titled, Flood Damaged Medical Records, dated as implemented 12/28/2022, revealed, The facility's policy is to establish procedures for preparing and responding to flooding resulting in damaged medical records. The policy also indicated, Secure damaged medical records to protect PHI during your assessment of the damage. During an interview with the Certified Dietary Manager (CDM) on 01/03/2023 at 9:21 AM, she stated the facility pipes burst in the basement, causing a flood during a period of cold weather the previous week (12/25/2022-12/31/2022). She stated the facility had to empty out the basement and had been piling stuff out in the alley. She stated the furniture and resident records that had been in the basement needed to be disposed of and they had been stacking the damaged resident records alongside the storage unit used to hold nursing supplies. Observations on 01/03/2023 at 9:24 AM revealed multiple stacks of water-damaged resident records in the alley next to the facility. The records were piled along the length of an approximately 17-foot-long storage container. Some of the stacks were approximately five feet high. Approximately half of the resident records were covered haphazardly by a tarp and others were exposed, with residents' PHI visible. During an interview with the Director of Clinical Services (DCS) on 01/03/2023 at 4:25 PM, she stated all the records in the alley should have been stored and disposed of following the facility's policy. She stated she was made aware of the exposed resident records and spoke with the corporate office about how to secure them. She stated the damaged resident records should be secured until they could be disposed of. During an interview with the Administrator on 01/03/2023 at 4:27 PM, he stated the damaged records were moved out into the alley on Friday (12/30/2022). He stated the damaged records should have been kept secured under lock and key until a determination from corporate was received to destroy or salvage the records. During an interview with the Maintenance Director on 01/04/2023 at 9:11 AM, he stated he had overseen moving the records out of the basement. He stated no outside individuals had been brought in to assist with the record removal. He stated the basement of the facility flooded 12/24/2022 and 12/25/2022 when the pipes burst from the cold weather. He revealed no one was able to get into the basement until 12/27/2022, at which point the water began to be pumped out. He stated the basement had flooded with seven feet of water. He indicated he had moved furniture and resident records into the alley on 12/28/2022 and 12/29/2022. According to the Maintenance Director, the Administrator, on the phone with corporate, had directed him to put the water-damaged resident records in the alley so someone from corporate could come over and go through them. He stated no one from corporate had gone through the records yet, so the records had remained in the alley. During an interview with the Administrator on 01/04/2023 at 9:47 AM, he stated a corporate member had instructed him to place the records in the alley. He stated the Director of Nursing was supposed to go through the records to see if anything could be salvaged. He indicated there was only one record room in the basement where the discharged resident records were stored. During an interview with the Corporate Maintenance Risk Manager on 01/05/2022 at 1:00 PM, he stated he had instructed the facility to remove the water-damaged records into the alley. He stated there was five feet of water in the records room and paper was everywhere. He stated that after the water was pumped out, there were two feet of damaged records covering the floor that had to be removed before removing the furniture. He stated that on 12/28/2022, the records were removed to the alley, covered with a tarp, and monitored by a staff member. He stated he had instructed the facility to secure the damaged records back in the facility on 12/28/2022. The Corporate Maintenance Risk Manager stated he was made aware by the facility on 01/03/2023 that the records were still exposed in the alley. He stated he came to the facility to assess the situation and instructed the facility to secure the damaged records in the basement that day. He stated corporate and management had determined the records were not salvageable from the water damage and should be destroyed securely.

Based on record review, staff interviews, and review of the facility policy titled, Electronic Transmission of the Minimum Data Set (MDS), the facility failed to ensure MDS assessments were transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment and Submission and Processing (ASAP) system for 5 of 19 residents (R) (R#1, R#4, R#22, R#25, and R#43) reviewed for MDS transmittal. Findings included: Review of a facility policy titled, Electronic Transmission of the MDS, dated [DATE], revealed, All MDS assessments (e.g. [for example], admission. annual, significant, quarterly review, etc. [et cetera]) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1, revealed, Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. Additionally, the manual indicated, All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 1. A review of the quarterly Minimum Data Set (MDS) for R#1 with an assessment reference date (ARD) (last date of the look back period for the assessment) of 11/10/2022 revealed that as of 1/03/2023, the assessment had not been signed by the Registered Nurse (RN) MDS Coordinator and had not been transmitted. 2. A review of the quarterly MDS for R#4 with an ARD of 11/02/2022 revealed that as of 1/03/2023, the assessment, which was signed by the RN MDS Coordinator on 12/30/2022, had not been transmitted. 3. A review of the quarterly MDS for R#22 with an ARD of 12/14/2022 revealed that as of 1/03/2023, the RN MDS Coordinator had not signed the assessment, and the assessment had not been transmitted. 4. A review of the quarterly MDS for R#25 with an ARD of 11/17/2022 revealed that as of 1/03/2023, the RN MDS Coordinator had not signed the assessment and the assessment had not been transmitted. 5. A review of the quarterly MDS for R#43 with an ARD of 11/03/2022 revealed that as of 1/03/2023, the assessment had not been signed by the RN MDS Coordinator and the assessment had not been transmitted. During an interview on 1/04/2023 at 10:15 a.m., Licensed Practical Nurse (LPN) #7 (facility MDS Nurse) indicated the corporate RN MDS Coordinator was responsible for signing and completing the MDS. LPN #7 further indicated the corporate RN had been on family medical leave since November 2022 and that was why the MDS assessments had not been transmitted. LPN #7 indicated she was aware the MDS assessments were not transmitted timely. During an interview on 1/05/2022 at 4:54 p.m., the Director of Clinical Services revealed the Corporate RN MDS Coordinator was out on family medical leave and was responsible for signing off on the MDS for facilities that did not have an MDS Coordinator. The Director of Clinical Services further indicated it was her expectation that the MDS assessments were submitted timely in accordance with the federal regulations. During an interview on 1/05/2022 at 5:15 p.m., the Administrator revealed he was unaware the MDS assessments were not transmitted timely. The Administrator further indicated it was his expectation that the MDS assessments be transmitted timely in accordance with the federal regulations.

Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure interventions were developed, care planned, and implemented to address behavioral symptoms for 1 (Resident #11) of 4 sampled residents reviewed for psychotropic medications. Resident #11 exhibited behavioral changes related to telephone use and the facility failed to develop behavioral health interventions to address the behaviors. Findings included: Review of a facility policy titled, Care Plan Revisions Upon Status Change, revision date 11/01/2022, revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Upon identification of a change in status, the nurse will notify the MDS [Minimum Data Set] coordinator, the physician, and the resident representative, if applicable. The MDS coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. A review of a Face Sheet revealed Resident #11 had diagnoses that included paranoid schizophrenia, delusional disorders, bipolar disorder, and psychotic disorder with delusions. The quarterly Minimum Data Set, dated dated [DATE], revealed Resident #11 exhibited no behavioral symptoms during the seven-day look back period. A review of Resident #11's Care Plan, dated 12/02/2019, revealed the resident had a problem area of inappropriate conversation and may mistake facts or accuse others of things. The goal was for the resident to have no increased incidence of undesirable behavior through the next review. A planned intervention was to observe for and eliminate contributing factors whenever possible. There were no revisions to this problem area on the care plan since the onset date of 12/02/2019. A review of Resident #11's Progress Notes, dated from July 2022 through December 2022, revealed an incident occurred on 08/17/2022 in which the resident was accused of making harassing phone calls and the resident's family member came and took the resident's phone. There were no other documented incidents indicating the resident was using the cell phone to make harassing phone calls. On 01/04/2023 at 9:54 AM, during an interview with the Social Services staff member, she stated she had been working for the facility since June 2022, and Resident #11's behaviors started in July. She indicated Family Member #3 had given a cell phone to the resident and the resident had used the cell phone to call the news, the police, and different facilities, harassing them. The Social Services staff stated the resident had called the family member and threatened to have them arrested, so the family member came and took the phone back. On 01/04/2023 at 2:43 PM, during an interview with Family Member #3, the family member stated they took Resident #11's phone after the resident had called other family members and cursed at them. Family Member #3 stated the resident would also call the police and call people to come get the resident, and then it was hard to get the resident back into the facility. The family member stated the police said someone would have to start paying for the non-emergent phone calls. The family member indicated that was the reason the phone was picked up. On 01/05/2023 at 4:26 PM, during a follow-up interview with the Social Services staff, she stated if the resident was having behaviors such as abusing the cell phone, this should be included on the care plan. She stated she had never witnessed the behaviors, but she listened to some of the inappropriate messages which had been left on Family Member #3's cell phone. On 01/05/2023 at 4:38 PM, during an interview with Registered Nurse (RN) #4, she stated while Resident #11's roommate was in the hospital, Resident #11 kept calling the roommate's cell phone, and the family of the roommate wanted Resident #11 to quit calling. She stated the family asked the resident to stop calling. On 01/05/2023 at 4:46 PM, during an interview with Certified Nursing Assistant (CNA) #5, she stated she had not witnessed the behaviors, but other staff told her Resident #11 had called the police one time, called the state, and called Resident #11's roommate's phone and told that resident's family that the resident was going to die. On 01/05/2023 at 4:56 PM, during an interview with Licensed Practical Nurse (LPN) #6, she stated sometimes Resident #11 would call people, cursing them and being loud. She stated she would hear it because she had an office right across the hall. She stated Resident #11 would tell people their fathers were not really their father. Resident #11 would call their family members and say bad things to them. She stated she never documented the things she heard Resident #11 say. On 01/05/2023 at 5:46 PM, during an interview with the Director of Clinical Services (DCS), she stated there should have been a care conference regarding the phone and the behaviors exhibited by Resident #11. She stated the care plan should be updated with the behaviors regarding the phone and confirmed the care plan did not reflect the behaviors. On 01/05/2023 at 5:50 PM, during an interview with the Administrator, he stated he would expect the care plan to reflect any behavior the resident was exhibiting, and indicated the care plan should be updated if the resident had new behaviors.

Based on record review, staff interviews, and review of the facility policy titled Abuse Prevention Program, the facility failed to ensure an allegation of sexual abuse and a resident elopement was reported to the State Survey Agency within the required time frame for three of nine sampled residents (R) (R#3 and R#9 and R#5) related to R#3 eloping from the facility; R#3 being found naked sitting on R#9's bed; and R#3 being found in R#5's room exposing himself. Findings include: Review of the revised policy titled Abuse Prevention Program dated December 2016 indicated Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of the clinical record for R#3 revealed he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#3's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as three, which indicated severe cognitive impairment. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 8/4/22 revealed that R#3 exhibits inappropriate behaviors such as cursing, insulting, and using profanity. Wanders into other residents' rooms. Intervention to be implemented Monitor resident's behavior. Report any change in cognitive status to physician. Review of the Family Nurse Practitioner (FNP) Behavioral Progress Notes on 7/11/22 and 7/25/22 indicated resident (R#3) frequently masturbate in hallway and frequently going into female residents' room for the last two weeks causing fearfulness and discomfort with other residents. Current facility is not appropriate for resident (R#3). Resident (R#3) requires a more controlled environment due to persistent aggressiveness, inappropriate sexually behavior and elopement risk. Review of the clinical record for R#9 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#9's annual MDS dated [DATE] revealed a BIMS was assessed as seven, which indicated severe cognitive impairment. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the CAAS. Review of the care plan initiated 8/12/22 revealed that R#9 suffers from [CONDITION(S)] related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention to be implemented approach warmly and positively. Review of the clinical record for R#5 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#5's quarterly MDS dated [DATE] revealed a BIMS interview was not conducted resident rarely/never understood, which indicated severe cognitive impairment. Section D revealed mood none. Section E revealed physical, verbal, and wandering behavior exhibited. Review of the care plan initiated 6/3/22 revealed that R#5 cognitive and communication deficits. Intervention to be implemented encourage resident to participate in activities as tolerated. Review of Departmental Nurses Note for R#3 dated 7/8/22 indicated resident (R#3) noted to be standing in the hallway with his private part out jerking. Encouraged resident to go to his room to have privacy he refused; continue to do it; unable to redirect. Review of the Departmental Nurses Note for R#3 dated 7/9/22 indicated resident (R#3) alert pacing up and down unit following (R#5) from (her room); will look at her (R#5) then pull out his private part and start j ing {sic}. Review of the Departmental Nurses Note dated 7/9/22 indicated the staff witness R#3 following R#5 to her room. The Licensed Practical Nurse (LPN) documented R#3 exposed himself and was masturbating. Review of Departmental Nurses Note for R#3 dated 7/24/22 at 10:53 p.m. indicated at 4:00 p.m. resident (R#3) escape through the back door toward the parking lot. Review of Departmental Nurses Note for R#3 dated 9/4/22 indicated around 2:50 p.m. staff heard a scream in (R#9's room). Staff entered the room and observed (R#3) naked sitting on the side of (R#9) bed. An interview on 9/28/22 at 2:39 p.m. with LPN DD confirmed that the R#9 had been masturbating and exposing himself to the female residents. The LPN stated on 9/4/22 she heard screaming and went investigate where it was coming from. Upon entering R#9's room, R#3 was sitting on R#9 bed naked. She stated R#9 was screaming get him off my bed and out of my room. She stated her and another staff escorted R#3 from the room. She stated she interviewed R#9, the resident told her that he (R#3) did not touch her, but she wanted him to stay out of her room. The LPN stated she did not notify the Administrator or DON. She stated, Why would I need to notify Administrator or DON if the resident (R#9) said he (R#3) did not touch her (R#9). An interview on 9/28/22 at 2:45 p.m. with the Administrator stated he was not aware that R#3 was found naked sitting on R#9 bed. He also stated he was not aware that R#3 had been masturbating and exposing himself to the female residents on the 2nd floor. The Administrator stated the staff should have report R#3 behavior. He stated the incident will be reported to SSA today and start an investigation. A phone interview on 10/4/22 at 3:33 p.m. with the Administrator stated the facility did not report R#3 elopement to the SSA. The Administrator stated he would submit the report to the SSA today and start an investigation. The Administrator stated going forward that departmental notes will be review daily to identify and address concerns timely.

Based on staff interviews, record reviews, review of the facility policies and facility assessment the facility failed to provide staff in sufficient numbers to care for the behavioral health needs of its residents. This failure resulted in one of nine sample residents(R)(R#2) eloping from the facility undetected. The facility census was 64. Findings include: Review of the policy titled Staffing revision date October 2017 indicated Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Review of the policy titled Wandering and Elopements revision date March 2019 indicated: Policy Statement-The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation- I. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the Facility Assessment Tool last revised date of 2022 revealed that the facility has an average daily census of 78-88 and routinely cares for residents with psychiatric/mood disorders defined as disorders including [CONDITION(S)], impaired cognition, mental disorder, depression, [CONDITION(S)] disorder, [CONDITION(S)], post-traumatic stress disorder, and anxiety disorder. The assessment tool also documented that the facility uses a staffing plan based on the resident population and their needs for care and support, ensure that the facility have sufficient staff to meet the needs of the residents at any given time. Staffing is based on census; acuity needs of the residents. The acuity level is assessed periodically by the nursing leadership to ensure that appropriate staffing is present. The facility assessment tool also documented that the average percent (%) of residents identified with behavioral health needs was 8%. The License Nurse to resident ratio 1:22 and the Certified Nursing Assistants (CNAs) to resident ratio documented 1:15. Review of the residents in the facility that require behavioral services revealed fifty-six out of sixty-four residents are seen by the facility's contracted behavioral services company. Review of the second floor 3:00 p.m. - 11:00 p.m. Daily Staffing dated 9/9/22 indicated one Licensed Practical Nurse (LPN), one CNA 3:00 p.m.-7:00 p.m., one CNA 7:00 p.m.-11:00 p.m. the census on second floor was thirty-two. Review of the clinical record for R#2 revealed he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#2's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as three, which indicated severe cognitive impairment. Section D revealed mood none. Section E revealed no behavior exhibited. Review of the care plan initiated 8/2/22 revealed that R#2 potential for behaviors related to [CONDITION(S)] disorder. Intervention to be implemented visual checks every two hours and as needed. Assess the reason why resident wants to leave the facility. Review of the hospital records indicated an admitted and time of 9/9/22 at 5:26 p.m. History of Present Illness R#2 who was found on the street two blocks away from his nursing home. (R#2) denied any shortness of breath, chest pain, cough, dizziness, headaches, fevers, or chills at this time. The resident requested that the hospital find him a nursing home. The emergency department attending physician placed a call to (the nursing home). The residence confirmed that the patient has been living there and has been missing (unclear for what duration of time). The hospital assessment was adult abuse and neglect, altered mental status, and intellectual disability. Review of the Departmental Nurses Note dated 9/9/22 indicated at 8pm nurse went to resident (R#2) room to check on him and give him his night medication unable to found {sic} resident (R#2) this writer ask staff they said he was downstairs smoking. Nurse went to smoking area and one resident was outside. I asked him if he seen resident (R#2) he said no. This writer alert other nurses and CNA we did room search up and down did not find resident. Some staff went outside the building to look for resident then we received phone call from a (hospital physician) said that they have our resident (R#2) in the hospital . an ambulance brought him in the hospital and told them they pick him up on the road where he appeared confuse and lost. Resident (R#2) has a history of eloping from smoking area. The Nurse Practitioner (NP) on call, Administrator, Director of Nursing (DON), and Responsible Party (RP) were all notified. An interview on 9/15/22 at 11:30 a.m. with LPN DD stated on 9/9/22 R#2 had a good day and did not appear to be upset about anything. She stated when she left around 5:30 p.m. R#2 was sitting in the doorway of his room. An interview on 9/15/22 at 11:35 a.m. with CNA EE stated she worked 7:00 a.m. to 3:00 p.m. on 9/9/22. She stated R#2 was upset all week because he could not get any money out of his account. She stated he talked about not having money all shift on 9/9/22. An interview on 9/16/22 at 2:05 p.m. with LPN GG stated on 9/9/22 she was working a double on 9/9/22 due to not having enough staff. The LPN stated the census on 9/9/22 was 32 residents. She stated one CNA agreed to work over and assist her with dinner. The LPN stated She stated short staff is not unusual but has become the normal. The LPN confirmed that there was no assignment sheet completed for 9/9/22. She stated she does not complete the assignment sheet when there is only one CNA. The LPN stated trays usually arrive to the floor around 5:00 p.m. She stated R#2 ate dinner in the dining room. She stated at 7:45 p.m. she started passing medication and R#2 was not in the room. She stated she continued her medication pass and ask the CNA working to go down to the smoke porch area and ask R#2 to return to the second floor for his medication. The CNA could not locate R#2 in the smoke porch area. She stated she stopped her medication pass went downstairs to look and could not find R#2. Stated she alerted the first-floor nurse and CNA and started checking the resident rooms and the bathrooms. The nurse stated she started the search outside the facility. She stated another staff called and alerted her that the hospital called, and stated R#2 was safe and at the hospital. She returned to the facility and notified the DON, NP, and the RP. The LPN stated this was R#2 third time eloping from the facility. An interview on 9/20/22 at 12:09 p.m. with CNA HH stated the charge nurse begged her to stay and assist with the dinner trays. The CNA stated R#2 ate all his dinner sat in the DR and watch television. she stated R#2 left out of the dayroom he went to the bathroom across the hall and then down to his room. The CNA stated she left the floor between 6:30 p.m. - 7:00 p.m. She stated she exited the building from the smoke porch door there were no staff or resident sitting on the porch or the end of the ramp. A phone interview on 9/21/22 at 1:27 p.m. with CNA II stated she arrived at work late between 7:15 p.m. -7:30 p.m. The employee stated she went out to the smoke porch to bring the residents from 2nd floor inside. She stated the only resident outside was R#7. She stated there were no other residents outside. She stated she did not see R#2 at any time on 9/9/22. An interview on 9/22/22 at 3:07 p.m. with Staff JJ stated somedays you are begging staff to stay and work. The staff stated the facility works short many days. The second-floor acuity level is high all the residents have some type of behavior that requires constant redirection. There should be three to four staff and sometimes there are only one nurse and one CNA. The staff does not feel as though the facility value their employees. An interview on 9/23/22 at 10:40 a.m. with the Administrator stated the facility is actively looking for employees. He stated the facility has a continuous hiring ad. He stated the facility is also working on increasing the staff pay. A phone interview on 10/3/22 at 2:03 p.m., the DON stated she has several open positions. The DON stated the following open positions: two-unit managers, and one infection control preventionist, nine LPNs, and fifteen CNA's. The DON stated the second floor should have at least three CNAs on the 3-11 shift to adequately take care of the residents.

Based on observation, interviews, and review of the facility documents the facility failed to ensure that the one exit door out of six (first-floor ramp exit door) was working properly. This failure resulted in one Resident (R#2) eloping from the facility undetected via the first-floor ramp exit door (smoke porch door). Findings include: Review of the policy titled Maintenance Service revision date December 2009 revealed: Policy Statement-Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation- 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. Review of the manufacture's manual on page #9 the section titled Hardware Maintenance/Adjustment revealed all exposed hardware fasteners should be tight. Fasteners should be inspected at least once per year to ensure they remain tight. Some hardware adjustment and minor door/frame realignment may be necessary over time even if the doors are initially installed correctly. Review of the Maintenance Monthly Report dated July 2022 to September 2022 no documentation of the door maglocks or hardware adjustment were checked/performed monthly and function correctly. Review of the Face Sheet for R#2 revealed he was readmitted to the facility on [DATE] with multiple diagnoses of, but not limited to [CONDITION(S)] disorder, [CONDITION(S)] disorder, and anxiety. Review of Departmental Nursing Note dated 9/9/22 indicated: at 8:00 p.m. the nurse went to resident (R#2) room to check on him and give him his night medication. The nurse was unable to locate the resident (R#2). The staff was alerted a search was started to locate the resident (R#2). During the search the facility received a call from a local hospital stating that the resident (R#2) had been picked up on the side of the road appeared confused and lost. The note stated the resident (R#2) has a history of eloping from the smoke porch exit door. Review of the work order dated 9/16/22 revealed the double door going out to the smoking area seems to be having trouble closing. The lock is unlocking intermittently will need to be investigated further. An observation on 9/15/22 at 11:16 a.m. with the Administrator of the first-floor ramp exit door located at the smoke porch area the door was not properly closing. The door would not shut automatically as designed. The door would close but not attach to the maglock. The lower area of the door has a visible gap.

Based on staff interviews, record reviews, and the facility policy titled Change of Condition Policy the facility failed to notify the physician of a significant change in condition for one resident (R) (R#4) of 34 sampled residents related to his physical, mental and psychosocial status and the need for medical treatment. On 1/26/22, R#4 exhibited with slurred speech, disorientation, and behaviors of threatening staff. The facility staff did not inform the physician of these symptoms/behaviors and the need for further evaluation from a healthcare professional. On 3/17/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator QQQ (interim), Administrator RRR (current - hired 2/22/22), and Licensed Practical Nurse (LPN) NN were informed of the Immediate Jeopardy (IJ) on 3/17/22 at 4:02 p.m. The noncompliance related to the IJ was identified to have existed on 1/26/22. The IJ is outlined as follows: Resident #4 was admitted to facility on 11/24/21. On 1/26/22 at 11:00 a.m., facility staff found R#4 in his room. The resident presented with slurred speech, was unable to maintain balance and was presumed to be intoxicated. R#4 was told that he could not drink alcohol in the facility. Facility staff stated that the resident became agitated and threatened staff with a knife and threatened to shoot staff. Resident #4 refused to leave the building and police were called. Staff had R#4 sign an Against Medical Advice (AMA) form, assisted resident into a wheelchair and escorted him outside the building. Police arrived and advised that the matter was civil, and that the facility could not just put the resident out on the street. The facility staff placed R#4's belongings outside on the ground in a plastic bag next to him. On 1/26/22 at 3:30 p.m. police returned to the facility and R#4 was still sitting in his wheelchair outside of the building. The weather was approximately 30 degrees Fahrenheit (F) and windy. Resident #4 was not provided hydration, medication, food, or any mean of toileting. Resident #4 asked to go back into the building, but staff refused to allow him to return so he had to soil himself. The police body cams revealed that the Social Service Director (SSD), Director of Nursing (DON) DD and Administrator CC refused to allow the resident to return to the facility. The police requested the facility call the Physician or ambulance to come get the resident for medical treatment. Neither Administrator CC, DON DD, or SSD offered to notify the Physician or Nurse Practitioner (NP). Emergency Medical Services (EMS) was called by the officers and transported R#4 to the hospital. Review of Acute Care Notes for the hospital stay of 1/26/22 to 2/18/22 revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.10(g)(14)(i) -(iv)(15) -- Notify of Changes (injury/decline/room, etc.) (F580, Scope/Severity: J); 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.15(c)(7) -- Preparation for Safe/Orderly Transfer/Discharge (F624, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.70 -- Administration (F835, Scope/Severity: J). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J). At the time of exit on 3/29/22, the IJ remained ongoing. Findings include: Review of the policy titled Change of Condition Policy revised 3/29/19 indicated: Guidelines: Any staff member who notices a resident status change shall immediately notify the appropriate licensed personnel. Acute or Sudden onset or a marked changed in condition such as: elevated temperature, alter mental status, dizziness, chest pain, shortness of breath, low or high blood sugars, pain after fall etc. After assessing the resident, the licensed personnel shall contact the physician regarding status change. When the physician is unavailable, the alternate will be contacted. In the absence of either, the Medical Director (MD) will be called. Family members and/or guardians will be notified in all instances of change in condition, including but not limited to, changes in lab work, diet, and medication changes. Then inform resident of their condition change, if appropriate. Notification of the appropriate individuals is to be documented in the medical record. Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#4's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 11, which indicated moderate cognitive impairment. Section D revealed moods of feeling down, depressed, hopeless. Section E revealed no behavior exhibited. Section G revealed the resident requires one-person physical assistance with Activities of Daily Living (ADL). Section H revealed the resident was frequently incontinent of bowel and bladder, Cognitive Loss, and ADL Functional/Rehabilitation Potential. Urinary Incontinence triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of phone contact information document (undated) located at each nursing station revealed the contact information for the resident healthcare providers (physicians and nurse practitioners). This document also included Change in Condition - Call Nurse NP. Call Provider immediately for abnormal vital signs, resident skipping meal due to malaise, altered mental status, acute cough, SOB (shortness of breath) etc. Review of the Nursing Departmental Notes dated 1/26/22 revealed: Staff found alcohol and a knife in (R#4) room and after which resident had stated he will not follow the facility's rules and wants to leave. (R#4) was a danger to the other residents and that the nursing home would not have anything to do with him. Review of the Social Service Departmental Notes for R#4 dated 1/26/22 revealed: Staff found a half full mini liquor bottle in resident room. When social worker and nurse went to inquire about the liquor, resident noted lying in the bed, slurred speech, unable to maintain balance, more liquor bottles, ashes, and lighter found in room. Resident stated he wanted to leave because he is not going to follow the facility rules. He stated he is grown and can do what he wanted to do. Resident signed the AMA form and refused to comply with facility rules. Resident was asked several times to leave facility, became upset, noted cussing, threatened to shoot staff, no gun noted but knife was found in room. Police were notified. Resident was escorted off facility property. Review of the emergency call obtained from the local police department revealed on 1/26/22 a call was made from the facility at 11:03 a.m. Administrator CC identified herself during the call and informed the emergency operator that she needed a police officer. She stated, I have a resident (referring to R#4) that is intoxicated, and he signed AMA to leave the facility. We are trying to get him out of the facility. He is refusing to leave after he signed the documentation. He threatened a staff member stating he will pull a pistol out on us, and he had a knife . in his room that we were able to retrieve. During an interview on 2/15/22 at 4:24 p.m. with the MD, he stated that he was not notified that R#4 had a change in condition and had signed an AMA on 1/26/22. During an interview on 2/16/22 at 9:37 a.m. with Licensed Practical Nurse (LPN) OO, she stated that on 1/26/22 the MDS coordinator came to her and said R#4 was drunk. She stated upon arrival to R#4's room, several administrative staff were already in the room talking to the resident. She stated R#4 was told by the Administrator that he was going to have to leave the facility for drinking alcohol. She stated R#4 was sitting on the side of the bed and was not responding to what the anyone was saying. The LPN stated R#4 appeared to be confused. The LPN confirmed that she was the nurse in charge of R#4's care, and she did not take any vital signs, call the physician, or document the resident's behavior in electronic medical record. During an interview on 2/17/22 at 10:12 a.m. with the MDS Coordinator, he stated that he remembers the incident on 1/26/22 because it was a bunch of loud noise and commotion. He stated that he and the SSD went into R#4's room, and that the resident appeared drunk; R#4 was unable to maintain balance and his speech was slurred. The MDS Coordinator stated he had never witnessed R#4 exhibiting this or any kind of behavior like this in the past. He also stated R#4 had no documented behavior of the kind he witnessed. The MDS Coordinator confirmed he did not report to nurse in care of R#4 that the resident was unable to maintain his balance or that he exhibited slurred speech. During an interview on 2/17/22 at 12:00 p.m. with the DON DD (the previous DON), she confirmed that the MD was not notified on 1/26/22 and that R#4 was observed in his room with slurred speech, unable to maintain balance, and showed behaviors of threatening staff. The DON further stated she never calls the MD because it is the job of the NP to update the MD on the clinical condition of the residents in the facility. During an interview on 2/21/22 at 12:52 p.m. with the LPN MM, she stated that on 1/26/22 Administrator CC (the previous administrator) and DON DD informed her that R#4 had to leave the facility because he was intoxicated. She stated she left work that day around 3:30 p.m. and R#4 was sitting outside in a wheelchair. She asked R#4 who was picking him up and the resident said nobody. She confirmed that she did not notify the physician that the resident was intoxicated and had no safe discharge arrangements. She stated the nurse in care of R#4 was instructed to notify the physician. During an interview on 2/22/22 at 2:46 p.m. with the NP HH, she stated that on 1/26/22 she did not receive a call that R#4 was intoxicated with slurred speech, unable to maintain balance, and had threatened staff. She stated that had she been notified, an order would have been given to send R#4 to the emergency room to be medical assessed. During an interview on 3/8/22 at 3:37 p.m. with the SSD, she stated that she spoke with R#4 on 1/14/22 about consuming alcohol. The resident was told he needs to take care of himself and was advised not to drink alcohol. The SSD stated she did not speak in detail about the alcohol use because it was not a big deal. She stated at the time she was talking to R#4, he was not drinking or intoxicated. She confirmed that R#4 was not asked if he wanted any assistance with his use of alcohol. She stated she did not notify the MD or the FNP to assist with getting the resident assistance for alcohol abuse. A phone interview on 3/15/22 at 2:09 p.m. with the Vice President (VP) confirmed the MD had not been notified of the incident involving R#4. He then stated the MD would be notified immediately. During an interview on 3/24/22 at 8:51 a.m. with LPN UU, she stated each nursing station has a binder with the MD and the NP's contact information. The LPN stated the MD's personal cell number is also included in case the after hour or weekend healthcare provider does not return the call. The LPN stated she has used the MD's personal number before. Cross Reference to F-Tag 600

Based on staff interviews, record reviews, facility documents, and the facility policies, the facility failed to ensure that one resident (R) (R#4) of 34 sampled residents was protected from neglect by three staff members. On 3/17/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator QQQ (interim), Administrator RRR (current - hired 2/22/22), and Licensed Practical Nurse (LPN) NN were informed of the Immediate Jeopardy (IJ) on 3/17/22 at 4:02 p.m. The noncompliance related to the IJ was identified to have existed on 1/26/22. The IJ is outlined as follows: Resident #4 was admitted to facility on 11/24/21. On 1/26/22 at 11:00 a.m., facility staff found R#4 in his room. The resident presented with slurred speech, was unable to maintain balance and was presumed to be intoxicated. R#4 was told that he could not drink alcohol in the facility. Facility staff stated that the resident became agitated and threatened staff with a knife and threatened to shoot staff. Resident #4 refused to leave the building and police were called. Staff had R#4 sign an Against Medical Advice (AMA) form, assisted resident into a wheelchair and escorted him outside the building. Police arrived and advised that the matter was civil, and that the facility could not just put the resident out on the street. The facility staff placed R#4's belongings outside on the ground in a plastic bag next to him. On 1/26/22 at 3:30 p.m. police returned to the facility and R#4 was still sitting in his wheelchair outside of the building. The weather was approximately 30 degrees Fahrenheit (F) and windy. Resident #4 was not provided hydration, medication, food, or any mean of toileting. Resident #4 asked to go back into the building, but staff refused to allow him to return so he had to soil himself. The police body cams revealed that the Social Service Director (SSD), Director of Nursing (DON) DD and Administrator CC refused to allow the resident to return to the facility. The police requested the facility call the Physician or ambulance to come get the resident for medical treatment. Neither Administrator CC, DON DD, or SSD offered to notify the Physician or Nurse Practitioner (NP). Emergency Medical Services (EMS) was called by the officers and transported R#4 to the hospital. Review of Acute Care Notes for the hospital stay of 1/26/22 to 2/18/22 revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.10(g)(14)(i) -(iv)(15) -- Notify of Changes (injury/decline/room, etc.) (F580, Scope/Severity: J); 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.15(c)(7) -- Preparation for Safe/Orderly Transfer/Discharge (F624, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.70 -- Administration (F835, Scope/Severity: J). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J). At the time of exit on 3/29/22, the IJ remained ongoing. Findings include: Review of the undated policy titled Abuse, Neglect and Exploitation revealed: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Policy Explanation and Compliance Guidelines: 8. ''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. Review of the policy titled Against Medical Advice Policy & Procedure dated 3/27/16 indicated: Policy: Appropriate discharge planning and communication of a resident's discharge is necessary. However, if a resident decides to leave the facility without physician' s orders is an unsafe discharge. The resident will be leaving AMA. Procedure- 1. Responsible Party and Physician must be notified of AMA immediately. 2. AMA form should be completed and signed by resident prior to leaving the facility. Facility must notify State Ombudsman. 6. Facility must notify Adult Protection APS (if necessary). 7. Once resident has left the facility AMA, he/she will not be allowed to return to the facility. Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#4's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 11, which indicated moderate cognitive impairment. Section D revealed moods of feeling down, depressed, hopeless. Section E revealed no behavior exhibited. Section G revealed the resident requires one-person physical assistance with Activities of Daily Living (ADL). Section H revealed the resident was frequently incontinent of bowel and bladder, Cognitive Loss, and ADL Functional/Rehabilitation Potential. Urinary Incontinence triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the Social Service Departmental Notes for R#4 dated 1/26/22 revealed: Staff found a half full mini liquor bottle in resident room. When social worker and nurse went to inquire about the liquor, resident noted lying in the bed, slurred speech, unable to maintain balance, more liquor bottles, ashes, and lighter found in room. Resident stated he wanted to leave because he is not going to follow the facility rules. He stated he is grown and can do what he wanted to do. Resident signed AMA, refused to comply with facility rules. Resident was asked several times to leave facility, became upset, noted cussing, threatened to shoot staff, no gun noted but knife was found in room. Police notified. Resident was escorted off facility property. Review of the emergency call obtained from the local police department revealed on 1/26/22 a call was made from the facility at 11:03 a.m. Administrator CC identified herself during the call and informed the emergency operator that she needed a police officer. She stated, I have a resident (referring to R#4) that is intoxicated, and he signed AMA to leave the facility. We are trying to get him out of the facility. He is refusing to leave after he signed the documentation. He threatened a staff member stating he will pull a pistol out on us, and he had a knife . in his room that we were able to retrieve. Review of the local police departments Event Report dated 1/26/22 revealed: The call was placed at 11:03 a.m. the police arrived at the facility at 11:08 a.m. Nature of call: drunk. While on scene I spoke with the Administrator CC. She stated that (R#4) was under the influence of alcohol . She advised that (R#4) signed an (AMA) form while impaired and wanted him removed from the property. I spoke with (Lieutenant's name) who advised this matter was civil and the agency couldn't just (put) this male out on the street. The cite still put (R#4) belongings out. Review of the police body camera video dated 1/26/22 at 3:33 p.m. shows R#4 sitting outside in a wheelchair on the ramp as the wind was heard blowing. The resident was wrapped in a thin blue blanket. The resident had a dark color shoe on the left foot and the right foot was wrapped in gauze. The resident had some belongings in a clear large bag that were sitting away from the resident on the curb. The male police officer asked the resident had he eaten. R#4 answered he had not eaten. The resident stated he had some food in his bag and then pointed to a clear, plastic, large trash bag on the curb. Resident#4 stated to the female police officer that the staff was speaking down to him. The resident told the female police officer he asked for a urinal, but the facility refused to give him one, so he was forced to lean over and urinate while seated in his wheelchair. DON DD and SSD walked over to the where the police were standing with the resident. At 4:30 p.m. the blanket was now over R#4's head. Further review of the body camera video revealed the SSD on the phone. The person (on the phone with the SSD) identified themselves over the speaker phone as the Ombudsman. The Ombudsman informed the facility that the discharge was a challenge because R#4 had nowhere to go. The Ombudsman asked could he go back into the facility. The DON stated, No. He cannot go in his room. The DON told the police she handles the residents' clinical part, and the SSD is the advocate for these people. Administrator CC called the SSD's phone (while in the presence of the officer), and the call is placed on speaker. Administrator CC stated to the police officers, You do not have any jurisdiction over the nursing home. She continued to state that everything was explained to R#4 and that he signed the AMA form. She stated, (R#4) is not coming back in the facility. The female officer asks who else can give the permission for the ambulance to come to get the resident for medical treatment. None of the facility staff answered the question of who had permission to send R#4 to the hospital for treatment. Review of hospital emergency room notes dated 1/26/22 revealed the following: Upon arrival to the emergency room , (R#4) was having nausea and vomiting. The resident was dehydrated with a low blood pressure. A computerized tomography (CT) scan was completed and revealed left side deep vein [CONDITION(S)] (DVT) of the neck (symptom - neck pain, slurred speech, confusion lack of responsiveness). The resident was diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/15/22 at 11:03 a.m. with the Ombudsman, she stated that on 1/26/22 the SSD put her on the speaker phone with the DON and two officers. The female police officer told her that R#4 was sitting in the cold and was covered in urine. The female officer stated R#4 had no weapon and was not making threats. The Ombudsman stated she asked the SSD and DON could the resident go back into the facility, and she was told no because R#4 signed AMA papers. During an interview on 2/15/22 at 4:24 p.m. with the Medical Director (MD), he stated he was not notified that R#4 had a change in condition and had signed an AMA form on 1/26/22. He further stated he was not made aware that the resident sat outside for more than five hours. The MD stated that if the facility would have notified him of the events taken place on 1/26/22, he would have given an order to send the resident to the hospital to be assessed. During an interview on 2/16/22 at 9:37 a.m. with Licensed Practical Nurse (LPN) OO, they stated that on 1/26/22, while in R#4's room, Administrator CC communicated to the resident that he was going to have to leave the facility for drinking alcohol. The LPN stated R#4 did not respond and appeared confused as the Administrator was explaining the AMA. The resident was handed the paper and instructed to sign the AMA form. After the resident signed the AMA form, the SSD told the Housekeeping Supervisor to take the resident outside. The resident was assisted to the wheelchair and was rolled outside by the Housekeeping Supervisor (HKS). During an interview on 2/16/22 at 12:11 p.m. with the HKS, he stated that on the day of the event, before lunch time, he was summoned to R#4's room by the SSD to search the resident's room for a gun. The HKS stated R#4 was calmly sitting on the side of the bed. The HKS stated he search the resident's room and did not find any weapons. He stated after searching the room the SSD instructed him to wheel the resident outside to the facility's resident smoke porch. The HKS stated when he left work around 5:00 p.m., R#4 was still sitting outside. A phone interview on 2/16/22 at 1:37 p.m. with the family of R#4, they stated the family received a call from the facility on 1/26/22. The family stated the caller informed the family that R#4 was being put out of the facility because he was intoxicated and was not following the rules and regulations. She stated the caller never said (R#4) was signing himself out AMA. During an interview on 2/16/22 at 4:30 p.m. with the Admission Coordinator, she stated the admission packet was reviewed with the family of R#4. The Admission Coordinator stated R#4 was in the hospital when the admission packet was signed by the family. The Admission Coordinator stated it is not her responsibility to inform the resident that the consumption of alcoholic beverage is prohibited inside the facility. She also confirmed that it is not part of the facility's admission packet that the use of alcoholic beverages is not permitted in the facility. Review of the facility's currently used Admission Packet revealed no documentation against the consumption of alcoholic beverages in the facility. During an interview on 2/17/22 at 11:10 a.m. with SSD, she stated that on 1/26/22, while in R#4 room, she noticed two mini alcohol bottles fall out of the resident's pocket. The SSD also stated, R#4 exhibit the following behaviors: not able to sit up, drowsy, slurred speech, and appeared drunk. The SSD stated she did not report this behavior to R#4's charge nurse. The SSD stated the resident was not following the rules and regulations pertaining to alcohol use and the AMA form was explained to the resident. The SSD stated it is not her responsibility to inform the resident that the consumption of alcoholic beverage is prohibited inside the facility. The SSD stated the admission packet has the information of no use of alcohol in the facility and is reviewed with the residents by the Admission Coordinator. During an interview on 2/17/22 at 11:50 a.m. with Administrator CC, she stated R#4 said he wanted to leave. She stated the AMA form was explained to the resident. She stated after the resident signed the AMA form, he was asked to wait outside for his ride. She stated the resident refuse to leave and became upset and threaten her and the SSD. She stated she left the room and called the police to have the resident escorted off the property. She stated she left around 2:00 p.m. and the resident was sitting outside. The Administrator stated the admission packet has the information of no use of alcohol in the facility and is reviewed with the residents by the Admission Coordinator. The Administrator then reviewed and confirmed there is no documentation in the admission packet that states alcoholic beverages were not allowed in the facility. During an interview on 2/21/22 at 10:45 a.m. with Police Officer NNN, she stated two officers arrived at the facility at 11:08 a.m. after an emergency call stating it was a drunk person with a weapon. She stated upon arrival the staff met them outside and reported that a resident signed an AMA form and would not leave. She stated that (R#4) was sitting outside with no jacket, socks, or shoes. She stated both of his feet were wrapped in white gauze. She spoke with the resident who was calm and informed her that the facility would not allow him back inside. She stated the resident had no weapon. She stated she placed a call to the supervisor on duty and updated him on what was going on at the facility. She was told by her supervisor to leave because the facility could not leave a resident outside in 30-degree (F) weather. She stated she and the other officer left and informed the facility that they were leaving, and the resident could not be left in the cold. She stated around 3:30 p.m. she was riding her assigned route which is the same area of the facility and notice R#4 sitting outside. She stated she got out of the car, approached the resident and he was shivering, cold to touch, smelled of urine, and his right foot was swollen and oozing a brown substance through the gauze. She stated he had a shoe on his left foot and a coat on. The officer stated R#4 did not know how long he had been outside, the year, or the current president's name. She stated at some point the DON and SSD came outside. She stated after speaking with the staff at the facility and the Administrator via phone, the DON and SSD refused to take the resident back inside the facility. She stated she asked the DON and SSD could the facility have the resident transferred to the hospital for medical treatment and they refused. She stated the staff continued to repeat that R#4 is no longer a resident at the facility. Police Officer NNN stated that the fire and rescue team was called by the police. The rescue team did ask the facility for a face sheet with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility refused to provide the rescue team with any information. She stated R#4 was transferred to the hospital by the fire and rescue team. During an interview on 2/21/22 at 12:52 p.m. with LPN MM, she stated on 1/26/22 the Administrator CC and DON DD informed her that R#4 had to leave the facility because he was intoxicated. She stated she left work around 3:30 p.m. that day and R#4 was sitting outside in a wheelchair. She asked R#4 who was picking him up and the resident said nobody. She confirmed that she did not notify the physician that the resident was intoxicated and that no safe discharge arrangements had been put in place. She stated the nurse in care of R#4 was instructed to notify the physician. During an interview on 2/22/22 at 2:46 p.m. with Nurse Practitioner HH, she stated on 1/26/22 she did not receive a call from the facility that R#4 was intoxicated, with slurred speech, unable to maintain balance, and in possession of a weapon. She stated she does not give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/1/22 at 9:15 a.m. with R#4, he stated on the day that the nursing home put him out of the facility the SSD entered his room asking questions and was intimidating him. He stated multiple staff kept entering his room asking questions that he cannot remember. The SSD directed one of the staff members to put him in the wheelchair and push him out to the smoke porch. The resident stated he had on no coat or shoes when he was pushed out to the smoke porch. The resident stated that as he was being pushed outside, his foot was scraping against the concrete and caused his wound on his foot to reopen. The resident stated he does not remember signing that he wanted to leave AMA. The signed AMA paper was showed to R#4, and he denied that the signed paper was his signature. The resident stated he asked the staff if he could go back to his room and was told no. The resident stated he sat outside for hours in the cold, embarrassed because he had urinated on himself. The resident stated he was treated worse than a dog. During an interview on 3/1/22 at 3:55 p.m., LPN QQ stated on 1/26/22 when she arrived at work, she noticed the R#4 sitting outside but did not realize anything was wrong. Shortly after arriving to work, the SSD stated that alcohol was found in R#4 room, and he was not allowed in the facility. An interview on 3/2/22 at 11:45 a.m. with Registered Nurse (RN) JJ, he stated upon arriving to work on 1/26/22 at 3:00 p.m. he seen the R#4 sitting outside. He stated the SSD greeted him as he entered the facility and informed him R#4 is no longer our resident. He stated he ask the SSD who was coming to pick R#4 up because he was sitting outside in the cold. The RN stated the SSD informed him the R#4 is no longer a resident and he is not to be allowed in the facility. During an interview on 3/9/22 at 3:30 p.m. with the Administrator QQQ, she stated that on 1/26/22 she received a call from the previous Administrator (CC). She stated during the call she was briefed on what was going on with R#4. The Interim Administrator stated to the previous Administrator it is very cold outside and the resident cannot continue to stay outside. She stated she encouraged the previous Administrator to bring the resident back inside and have the SSD to find an alternate placement for R#4 the next day. She stated the previous Administrator told her she did not want the resident back in the facility. The Interim Administrator stated the next call she received was on 2/7/22 from the facility staff informing her that the previous Administrator, DON, and SSD had been arrested.

Based on record review, staff interviews, and the review of the facilities policies, the facility failed to ensure a safe and orderly discharge from the facility for one resident (R) (R#4) of 17 residents reviewed for Safe/Orderly Transfer/Discharge. On 3/17/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator QQQ (interim), Administrator RRR (current - hired 2/22/22), and Licensed Practical Nurse (LPN) NN were informed of the Immediate Jeopardy (IJ) on 3/17/22 at 4:02 p.m. The noncompliance related to the IJ was identified to have existed on 1/26/22. The IJ is outlined as follows: Resident #4 was admitted to facility on 11/24/21. On 1/26/22 at 11:00 a.m., facility staff found R#4 in his room. The resident presented with slurred speech, was unable to maintain balance and was presumed to be intoxicated. R#4 was told that he could not drink alcohol in the facility. Facility staff stated that the resident became agitated and threatened staff with a knife and threatened to shoot staff. Resident #4 refused to leave the building and police were called. Staff had R#4 sign an Against Medical Advice (AMA) form, assisted resident into a wheelchair and escorted him outside the building. Police arrived and advised that the matter was civil, and that the facility could not just put the resident out on the street. The facility staff placed R#4's belongings outside on the ground in a plastic bag next to him. On 1/26/22 at 3:30 p.m. police returned to the facility and R#4 was still sitting in his wheelchair outside of the building. The weather was approximately 30 degrees Fahrenheit (F) and windy. Resident #4 was not provided hydration, medication, food, or any mean of toileting. Resident #4 asked to go back into the building, but staff refused to allow him to return so he had to soil himself. The police body cams revealed that the Social Service Director (SSD), Director of Nursing (DON) DD and Administrator CC refused to allow the resident to return to the facility. The police requested the facility call the Physician or ambulance to come get the resident for medical treatment. Neither Administrator CC, DON DD, or SSD offered to notify the Physician or Nurse Practitioner (NP). Emergency Medical Services (EMS) was called by the officers and transported R#4 to the hospital. Review of Acute Care Notes for the hospital stay of 1/26/22 to 2/18/22 revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.10(g)(14)(i) -(iv)(15) -- Notify of Changes (injury/decline/room, etc.) (F580, Scope/Severity: J); 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.15(c)(7) -- Preparation for Safe/Orderly Transfer/Discharge (F624, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.70 -- Administration (F835, Scope/Severity: J). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J). At the time of exit on 3/29/22, the IJ remained ongoing. Findings include: Review of the policy titled Discharging the Resident Revised December 2016 indicated: The purpose of this procedure is to provide guidelines for the discharge process. Preparation: Discharges can be frightening to the resident. Approach the discharge in a positive manner. Review of the policy titled Discharging a Resident without a Physician's Approval dated 10/2012 indicated: Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident' s Attending Physician will be promptly notified. Authorization must be signed by the resident; provided, however if the resident is a minor or physically or mentally incompetent to execute this authorization, the authorization must be signed by a legal representative. Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] for R#4, revealed a Brief Interview for Mental Status (BIMS) was assessed as 11, which indicated moderate cognitive impairment. Section D revealed a mood assessment: feeling down, depressed, hopeless. Section E revealed an assessment of no behavior exhibited. Section Q revealed no active discharge plan in place for the resident to return to the community. Cognitive Loss triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 11/24/21 revealed that R#4 had no documented discharge care plan. Review of the Nursing Departmental Notes dated 1/26/22 revealed the following: Staff found alcohol and a knife in (R#4) room and after which resident had stated he will not follow the facility's rules and wants to leave. (R#4) was a danger to the other residents and that the nursing home would not have anything to do with him. Review of the Social Service Departmental Notes for R#4 dated 1/26/22 revealed: Staff found a half full mini liquor bottle in resident room. When social worker and nurse went to inquire about the liquor, resident noted lying in the bed, slurred speech, unable to maintain balance, more liquor bottles, ashes, and lighter found in room. Resident stated he wanted to leave because he is not going to follow the facility rules. He stated he is grown and can do what he wanted to do. Resident signed the AMA form and refused to comply with facility rules. Resident was asked several times to leave facility, became upset, noted cussing, threatened to shoot staff, no gun noted but knife was found in room. Police were notified. Resident was escorted off facility property. Review of the emergency call obtained from the local police department revealed on 1/26/22 a call was made from the facility at 11:03 a.m. Administrator CC identified herself during the call and informed the emergency operator that she needed a police officer. She stated, I have a resident (referring to R#4) that is intoxicated, and he signed AMA to leave the facility. We are trying to get him out of the facility. He is refusing to leave after he signed the documentation. He threatened a staff member stating he will pull a pistol out on us, and he had a knife . in his room that we were able to retrieve. During an interview on 2/16/22 at 12:11 p.m. with the Housekeeping Supervisor (HKS), he stated that on 1/26/22, the SSD instructed him to wheel R#4 outside to the facility's resident smoke porch. Review of the police body camera video dated 1/26/22 at 3:33 p.m. shows R#4 sitting outside in a wheelchair on the ramp as the wind was heard blowing. The resident was wrapped in a thin blue blanket. The resident had some belongings in a clear large bag that were sitting away from the resident on the curb. The male police officer asked the resident had he eaten. R#4 answered he had not eaten. The resident stated he had some food in his bag and then pointed to a clear, plastic, large trash bag on the curb. The resident told the female police officer he asked for a urinal, but the facility refused to give him one, so he was forced to lean over and urinate while seated in his wheelchair. At 4:30 p.m. the blanket was now over R#4's head. Further review of the body camera video revealed the SSD on the phone. The person (on the phone with the SSD) identified themselves over the speaker phone as the Ombudsman. The Ombudsman informed the facility that the discharge was a challenge because R#4 had nowhere to go. The Ombudsman asked could he go back into the facility. The DON stated, No. He cannot go in his room. The DON told the police she handles the residents' clinical part, and the SSD is the advocate for these people. Administrator CC called the SSD's phone (while in the presence of the officer), and the call is placed on speaker. Administrator CC stated to the police officers, You do not have any jurisdiction over the nursing home. She continued to state that everything was explained to R#4 and that he signed the AMA form. She stated, (R#4) is not coming back in the facility. The female officer asks who else can give the permission for the ambulance to come to get the resident for medical treatment. None of the facility staff answered the question of who had permission to send R#4 to the hospital for treatment. During an interview on 2/17/22 at 12:00 p.m. with the DON DD, she stated she was not aware that R#4 had never left the facility property until she was called outside to speak with the police. She confirmed that the Medical Director (MD) was not notified on 1/26/22 that R#4 signed an AMA form, had no place to go, and remained outside of the facility for over five hours. The DON also stated there is nothing she would have done differently regarding R#4's discharge. During an interview on 2/21/22 at 10:45 a.m. with Police Officer NNN, she stated around 3:30 p.m. she was riding her assigned route, which is the same area of the facility, and notice R#4 sitting outside. She stated she got out of the car, approached the resident and he was shivering, cold to touch, smelled of urine, and his right foot was swollen and oozing a brown substance through the gauze. She stated he had a shoe on his left foot and a coat on. The officer stated R#4 did not know how long he had been outside, the year, or the current president's name. She stated at some point DON DD and SSD came outside. She stated after speaking with the staff at the facility and the Administrator via phone, the DON and SSD refused to take the resident back inside the facility. She stated she asked the DON and SSD could the facility have the resident transferred to the hospital for medical treatment and they refused. She stated the staff continued to repeat that R#4 is no longer a resident at the facility. Police Officer NNN stated that the fire and rescue team was called by the police. The rescue team did ask the facility for a face sheet with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility refused to provide the rescue team with any information. She stated R#4 was transferred to the hospital by the fire and rescue team. During an interview on 3/1/22 at 9:15 a.m. with R#4, he stated that on 1/26/22 the SSD directed one of the staff members to put him in the wheelchair and push him out to the smoke porch. The resident stated when the police arrived the SSD and DON told the police he signed an AMA to leave the facility and the officer asked to see his copy. The resident stated he could not show the paper to the officer because he did not have a copy. He stated that he did not remember signing anything saying that he wanted to leave AMA. The signed AMA paper was shown to R#4, and he denied that the signed paper was his signature. During a phone interview on 3/1/22 at 9:35 a.m. with the family of R#4, they stated they did not receive any information from the facility on where R#4 went after he was put out of the facility, and they were unaware that he had signed an AMA. Review of hospital emergency room notes dated 1/26/22 revealed the following: Upon arrival to the emergency room , (R#4) was having nausea and vomiting. The resident was dehydrated with a low blood pressure. A computerized tomography (CT) scan was completed and revealed left side deep vein [CONDITION(S)] (DVT) of the neck (symptom - neck pain, slurred speech, confusion lack of responsiveness). The resident was diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference to F-Tag 600

Based on staff interviews, record reviews, and the facility policy titled Care Planning - Interdisciplinary Team, the facility failed to implement the cognitive loss care plan interventions of reducing extraneous environmental stimuli, approaching resident calmly, and interacting in a non-judgmental manner for one resident (R) (R#4) of 34 sampled resident. On 3/17/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator QQQ (interim), Administrator RRR (current - hired 2/22/22), and Licensed Practical Nurse (LPN) NN were informed of the Immediate Jeopardy (IJ) on 3/17/22 at 4:02 p.m. The noncompliance related to the IJ was identified to have existed on 1/26/22. The IJ is outlined as follows: Resident #4 was admitted to facility on 11/24/21. On 1/26/22 at 11:00 a.m., facility staff found R#4 in his room. The resident presented with slurred speech, was unable to maintain balance and was presumed to be intoxicated. R#4 was told that he could not drink alcohol in the facility. Facility staff stated that the resident became agitated and threatened staff with a knife and threatened to shoot staff. Resident #4 refused to leave the building and police were called. Staff had R#4 sign an Against Medical Advice (AMA) form, assisted resident into a wheelchair and escorted him outside the building. Police arrived and advised that the matter was civil, and that the facility could not just put the resident out on the street. The facility staff placed R#4's belongings outside on the ground in a plastic bag next to him. On 1/26/22 at 3:30 p.m. police returned to the facility and R#4 was still sitting in his wheelchair outside of the building. The weather was approximately 30 degrees Fahrenheit (F) and windy. Resident #4 was not provided hydration, medication, food, or any mean of toileting. Resident #4 asked to go back into the building, but staff refused to allow him to return so he had to soil himself. The police body cams revealed that the Social Service Director (SSD), Director of Nursing (DON) DD and Administrator CC refused to allow the resident to return to the facility. The police requested the facility call the Physician or ambulance to come get the resident for medical treatment. Neither Administrator CC, DON DD, or SSD offered to notify the Physician or Nurse Practitioner (NP). Emergency Medical Services (EMS) was called by the officers and transported R#4 to the hospital. Review of Acute Care Notes for the hospital stay of 1/26/22 to 2/18/22 revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.10(g)(14)(i) -(iv)(15) -- Notify of Changes (injury/decline/room, etc.) (F580, Scope/Severity: J); 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.15(c)(7) -- Preparation for Safe/Orderly Transfer/Discharge (F624, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.70 -- Administration (F835, Scope/Severity: J). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J). At the time of exit on 3/29/22, the IJ remained ongoing. Findings include: Review of the policy titled Care Planning-Interdisciplinary Team revision date December 2008 indicated: Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation: The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: The DON. Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R#4's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 11, which indicated moderate cognitive impairment. Section D revealed moods of feeling down, depressed, hopeless. Section E revealed no behaviors exhibited. Cognitive Loss triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 11/24/21 revealed that R#4 was at risk for cognitive loss related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention to be implemented included reduce extraneous environmental stimuli (loud noises, TV, unnecessary talk or motion, ect.) or accompany (R#4) to a quiet area. Approach (R#4) calmly. Interact with (R#4) in a non-judgmental manner. Review of the care plan initiated 11/24/21 revealed that R#4 was receiving [CONDITION(S)] medications for the management of [CONDITION(S)]. Intervention to be implemented included monitor and document episodes of delusional thinking, decline in mood or behaviors (R#4) may have and report to physician. Review of the Departmental Notes (Social Services) dated 1/26/22 revealed: Staff found a half full mini liquor bottle in (R#4's) room. When social worker and nurse went to inquire about the liquor, resident noted lying in the bed, slurred speech, unable to maintain balance, more liquor bottles, ashes, and lighter found in room. Resident was escorted off facility property. Review of the emergency call obtained from the local police department revealed on 1/26/22 a call was made from the facility at 11:03 a.m. Administrator CC identified herself during the call and informed the emergency operator that she needed a police officer. She stated, I have a resident (referring to R#4) that is intoxicated, and he signed AMA to leave the facility. We are trying to get him out of the facility. He is refusing to leave after he signed the documentation. He threatened a staff member stating he will pull a pistol out on us, and he had a knife . in his room that we were able to retrieve. During an interview on 2/16/22 at 12:11 p.m. with the Housekeeping Supervisor (HKS), he stated that on 1/26/22, the SSD instructed him to wheel R#4 outside to the facility's resident smoke porch. Review of the police body camera video dated 1/26/22 at 3:33 p.m. shows R#4 sitting outside in a wheelchair on the ramp as the wind was heard blowing. The resident was wrapped in a thin blue blanket. The resident had some belongings in a clear large bag that were sitting away from the resident on the curb. The male police officer asked the resident had he eaten. R#4 answered he had not eaten. The resident stated he had some food in his bag and then pointed to a clear, plastic, large trash bag on the curb. The resident told the female police officer he asked for a urinal, but the facility refused to give him one, so he was forced to lean over and urinate while seated in his wheelchair. During an interview on 2/21/22 at 10:45 a.m. with Police Officer NNN, she stated two officers arrived at the facility at 11:08 a.m. after an emergency call stating it was a drunk person with a weapon. She stated upon arrival the staff met them outside and reported that a resident signed an AMA form and would not leave. She stated that (R#4) was sitting outside with no jacket, socks, or shoes. She stated both of his feet were wrapped in white gauze. She spoke with the resident who was calm and informed her that the facility would not allow him back inside. She was told by her supervisor to leave because the facility could not leave a resident outside in 30-degree (F) weather. She stated she and the other officer left and informed the facility that they were leaving, and the resident could not be left in the cold. She stated around 3:30 p.m. she was riding her assigned route which is the same area of the facility and notice R#4 sitting outside. She stated she got out of the car, approached the resident and he was shivering, cold to touch, smelled of urine, and his right foot was swollen and oozing a brown substance through the gauze. She stated he had a shoe on his left foot and a coat on. The officer stated R#4 did not know how long he had been outside, the year, or the current president's name. She stated at some point the DON and SSD came outside. She stated after speaking with the staff at the facility and the Administrator via phone, the DON and SSD refused to take the resident back inside the facility. She stated she asked the DON and SSD could the facility have the resident transferred to the hospital for medical treatment and they refused. She stated the staff continued to repeat that R#4 is no longer a resident at the facility. Police Officer NNN stated that the fire and rescue team was called by the police. The rescue team did ask the facility for a face sheet with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility refused to provide the rescue team with any information. She stated R#4 was transferred to the hospital by the fire and rescue team. Review of hospital emergency room notes 1/26/22 revealed that upon arrival to the emergency room , R#4 was having nausea and vomiting. The resident was dehydrated with a low blood pressure. A computerized tomography (CT) scan was completed and revealed left side deep vein [CONDITION(S)] (DVT) of the neck (symptom- neck pain, slurred speech, confusion lack of responsiveness). The resident was diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/15/22 at 4:24 p.m. with the Medical Director (MD) he stated that he was not notified that R#4 had a change in condition and that he had signed an AMA form on 1/26/22. During an interview on 2/16/22 at 9:37 a.m. with Licensed Practical Nurse (LPN) OO, she stated that on 1/26/22, a nurse walked up to her and said that R#4 was drunk. She stated upon arrival to R#4's room, several administrative staff were already in the room talking to the resident. She stated R#4 was told by the Administrator CC that he was going to have to leave the facility for drinking alcohol. She stated R#4 was sitting on the side of the bed and was not responding to what anyone was saying. The LPN stated R#4 appeared to be confused. During an interview on 2/17/22 at 10:12 a.m. with the MDS Coordinator, he stated that he is responsible for initiating the care plans. He confirmed the cognitive loss care plan was initiated based on the residents BIMS and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the care plan should be followed as implemented and updated as needed. Cross Reference to F-tag 600

Based on record review, review of the Nursing Home Administrator and Director of Nursing Job Descriptions, and staff interviews, facility administration failed to effectively oversee the facility's discharge process. The facility census was 70 residents. On 3/17/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator QQQ (interim), Administrator RRR (current - hired 2/22/22), and Licensed Practical Nurse (LPN) NN were informed of the Immediate Jeopardy (IJ) on 3/17/22 at 4:02 p.m. The noncompliance related to the IJ was identified to have existed on 1/26/22. The IJ is outlined as follows: Resident #4 was admitted to facility on 11/24/21. On 1/26/22 at 11:00 a.m. facility staff found R#4 in his room. The resident presented with slurred speech, was unable to maintain balance and was presumed to be intoxicated. R#4 was told that he could not drink alcohol in the facility. Facility staff stated that the resident became agitated and threatened staff with a knife and threatened to shoot staff. Resident #4 refused to leave the building and police were called. Staff had R#4 sign an Against Medical Advice (AMA) form, assisted resident into a wheelchair and escorted him outside the building. Police arrived and advised that the matter was civil, and that the facility could not just put the resident out on the street. The facility staff placed R#4's belongings outside on the ground in a plastic bag next to him. On 1/26/22 at 3:30 p.m. police returned to the facility and R#4 was still sitting in his wheelchair outside of the building. The weather was approximately 30 degrees Fahrenheit (F) and windy. Resident #4 was not provided hydration, medication, food, or any mean of toileting. Resident #4 asked to go back into the building, but staff refused to allow him to return so he had to soil himself. The police body cams revealed that the Social Service Director (SSD), Director of Nursing (DON) and Administrator refused to allow the resident to return to the facility. The police requested the facility call the Physician or ambulance to come get the resident for medical treatment. Neither the Administrator, DON, or SSD offered to notify the Physician or Nurse Practitioner. Emergency Medical Services (EMS) was called by the officers and transported R#4 to the hospital. Review of Acute Care Notes for the hospital stay of 1/26/22 to 2/18/22 revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.10(g)(14)(i) -(iv)(15) -- Notify of Changes (injury/decline/room, etc.) (F580, Scope/Severity: J); 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.15(c)(7) -- Preparation For Safe/Orderly Transfer/Discharge (F624, Scope/Severity: J); 42 C.F.R. 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.70 -- Administration (F835, Scope/Severity: J). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1) -- Free from Abuse and Neglect (F600, Scope/Severity: J). At the time of exit on 3/29/22, the IJ remained ongoing. Findings include: The facility had a Job Description for the Administrator. A summary of the job is to lead and direct the overall operation of the facility in accordance with resident needs, government regulations and company policies so as to maintain care for the residents .Facility management functions included directs and coordinates medical, nursing, and administrative staffs and services. The facility had a Job Description for the Director of Nursing. The primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Essential job functions included to assure residents of a comfortable, clean, orderly and safe environment. A review of the management changes at the facility revealed the following: On 2/7/22, Administrator CC and DON DD were arrested. At that time, Administrator QQQ (from another facility) became interim Administrator until Administrator RRR was hired on 2/22/22. The interim DON accepted a full-time position on 3/22/22. Facility Administration, specifically the previous Administrator and DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure the physician was notified of a significant change in condition for R#4. Cross refer to F580. 2. Administration failed to ensure that R#4 was protected from neglect by three staff members. Cross refer to F600. 3. Administration failed to ensure a safe and orderly discharge from the facility for R#4. Cross refer to F624. 4. Administration failed to ensure the cognitive loss care plan interventions of reducing extraneous environmental stimuli, approaching resident calmly, and interacting in a non-judgmental manner were implemented for R#4. Cross refer to F656. Review of the Police Report revealed that warrants were issued and Administrator CC, DON DD, and the previous social worker were arrested on 2/7/22 for neglect to a disabled adult, elder person. During an interview on 3/9/22 at 3:30 p.m. with the Administrator QQQ, she stated that on 1/26/22 she received a call from the previous Administrator (CC). She stated during the call she was briefed on what was going on with R#4. She told Administrator CC it is very cold outside, and the resident cannot continue to stay outside. She encouraged Administrator CC to bring the resident back inside and have the SSD to find an alternate placement for R#4 the next day. She stated the previous Administrator told her she did not want the resident back in the facility. An interview on 3/15/22 at 2:09 p.m. with Vice President (VP) revealed that Administrator CC never contacted him about R#4 and only sent an email the day after the incident regarding the resident having alcohol and signing out AMA. The VP stated he took immediate action and did not allow Administrator CC, DON DD, and SSD to return to the building (facility). He stated he hired a new Administrator for the facility. The corporate administrative staff should be notified of all discharges from the facility including AMA and resident's not being allowed to return to the facility. The VP stated that safety first should always be our primary goal to our residents. He stated it is not the company's policy to treat anyone the way R#4 was treated on 1/26/22. The goal of the company is to ensure that the residents are safe while in the facility. When the resident is discharged the facility should make sure the resident has safe transportation and somewhere safe to be discharged to. He stated the company is deeply concerned and embarrassed about what happen on 1/26/22 and 2/7/22.

Based on staff interviews and record reviews, the facility failed to ensure one resident (R) (R#4) of 34 sampled residents received appropriate services related to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#4's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 11, which indicated moderately cognitive impairment. Section D revealed a mood feeling down, depressed, hopeless. Section E revealed that the resident exhibited no documented behaviors. Section K revealed that he has no swallowing problems. Review of the hospital discharge record dated 11/24/21 revealed a discharge order for R#4 to follow up with gastroenterologist (GI). Review of the Nurse Practitioner (NP) progress note dated 12/10/21 revealed: (R#4) complained of dysphagia on current diet. Patient with a history of throat cancer, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Consider soft diet. Aspiration precautions. Continue to follow with Speech therapy as indicated. Follow up with oncologist as scheduled. Review of a written physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient has lost weight. Oncologists follow-up appointment pending. Review of the Departmental Notes (Nurse Notes) dated 1/7/22 revealed R#4 transferred to an acute care hospital for evaluation and treatment related to difficulty swallowing and unable to keep liquid/food down. Review of R#4's hospital discharge records dated 1/8/22 revealed a discharge order to follow-up with otolaryngology. Review of the Departmental Notes (Nurse Notes) revealed R#4 transfer to the hospital on 1/9/22 because he is unable to eat or drink. Resident return to the facility on [DATE] with an appointment with the oncologist. Review of hospital emergency room (ER) notes dated 1/26/22 revealed that upon arrival to the ER, R#4 exhibited nausea and vomiting. He was determined to be dehydrated with a low blood pressure. R#4 was diagnosed with an [CONDITION(S)] stricture which required a gastrostomy tube to meet nutritional needs. During an interview on 3/1/22 at 9:15 a.m. with R#4, stated he was having an increase in throat and neck pain. The resident also stated he was not able to swallow his food and was losing weight. He stated he missed the oncologist (cancer specialist) appointment three times due to transportation was not set up. The resident stated he also missed his appointment with the otolaryngology (head and neck specialist). The resident stated he must follow up with the GI physician for regular [CONDITION(S)] dilation. He stated his follow-up with GI was never scheduled. During an interview on 3/3/22 at 12:30 p.m. with the Administrator QQQ, she confirmed the hospital discharge orders to follow up with the otolaryngology, gastroenterologist. She also confirmed the follow-up order written by the NP to see the oncologist. She stated the order for the Oncologist was discontinued on 12/11/21 by the previous DON. Administrator QQQ stated the orders for the follow-up appointments with the otolaryngology and gastroenterologist was an oversight and should have been followed through. During a phone interview on 3/8/22 at 9:00 a.m. with the Medical Director (MD), he stated he did not give the DON an order to discontinue the oncologist order on 12/11/21 for R#4. During an interview on 3/8/22 at 9:45 a.m. with Physician AA, he stated he was not aware that the order to follow up with the oncologist had been discontinued. He stated the oncologist order was given because R#4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician stated it was vital for that appointment to be followed through. During an interview on 3/8/22 at 11:25 am. with the Staffing Coordinator, she stated R#4 return from the hospital on 1/12/22 with an oncologist appointment for 1/13/22. She stated R#4 missed his appointment on 1/13/22 due to needing more time (3 days) to schedule transportation. She stated she did not consider sending R#4 to the appointment on 1/13/22 via non-emergency transportation. She also stated she did not make the Administrator or DON aware of R#4's missed appointment.