Every finding on record at Heardmont Health and Rehabilitation

Based on observation, staff interviews, and review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to ensure a single use resident care item was not shared between residents in two of 21 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). Specifically, a foam wedge was taken from room [ROOM NUMBER] and used to reposition a resident bed in room [ROOM NUMBER]. This deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised October 2018, under the Policy statement revealed, Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Blood bore Pathogens Standard. Under the section titled Policy Interpretation and Implementation number one sub-section d, revealed reusable items are cleaned and disinfected or sterilized between residents, (1) Single resident use items are clean/disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans, urinals).Observation on 9/26/2025 at 8:15 am revealed, Certified Nursing Assistant (CNA) DD entered room [ROOM NUMBER] and took a foam wedge from the closet in the room and exited the room. Continued observation revealed, CNA DD then took the foam wedge to room [ROOM NUMBER] and used the foam wedge to reposition the resident in (bed 3) so that she could assist with the morning meal. During an interview on 9/26/2025 at 8:30 am with CNA DD revealed that she did go into room [ROOM NUMBER] and obtain a foam wedge from a closet and took the foam wedge into room [ROOM NUMBER]. She stated she wiped the wedge with a wipe and then placed the wedge on the right side of resident, to assist with maintaining the resident in an aligned supine position (on her back) at a 45-degree angle, so she could eat breakfast safely. She acknowledged that she should have placed a cover over the wedge before using it with the resident. She revealed that the resident in room [ROOM NUMBER] did not have a wedge of her own. CNA DD revealed that when residents do not have a wedge and they know another resident that has a wedge, they would use the other residents wedge for the resident who needed one. She revealed this was her normal practice. During an interview on 9/26/2025 at 2:49 pm with Registered Nurse (RN) AA, revealed that all residents should have a wedge for positioning if they need one. She stated staff should not use a wedge that was assigned to one resident for any other residents. She revealed it was not acceptable for staff to do this even if they clean the foam wedge and covered it. She stated this could cause cross contamination and possible infection control problems. She confirmed the facility uses foam wedges and she stated the proper procedure when a resident is identified to need a wedge is to notify the House Keeping Supervisor who would check the storage building and provide a new wedge for the resident who needed it. Interview on 9/26/2025 at 3:06 pm with the DON further explained that the facility used foam wedges for positioning residents. She revealed that the nursing staff determined which residents needed a foam wedge through observations. She revealed if the need for a foam wedge was determined then the nurse would call the physician for an order and then they would develop a care plan for this intervention. She revealed that if a foam wedge was stored in a residents closet it was specifically for that resident's use only. She stated it was not acceptable to use a foam wedge with multiple residents or share a foam wedge with multiple residents. She stated her expectation of staff was to use the foam wedge for the resident it was assigned to only. She stated the use of a foam wedge with more than one resident was not hygienic and could lead to cross contamination and facility acquired infections. Interview on 9/27/2025 10:36 am with the DON revealed the foam wedge utilized during breakfast in room [ROOM NUMBER] was a single resident use item and should not be shared with any other residents.

Based on observation, staff interview, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive person-centered care plan for five of 24 sampled residents (R) (R37, R20, R9, R22, R31) related to dementia for (R37 and R31), psychotropic medication use for (R37, R22, and R31), anxiety disorder for (R37), schizophrenia for (R9), and Activities of Daily Living (ADL) care for (R20). Findings include: A review of the policy titled Care Plans, Comprehensive-Person Centered, dated 2001 under the Policy Interpretation and Implementation revealed, 2. The comprehensive, person-centered care plan would be developed within seven days at the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions would be derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implantation of his or her plan of care including the right to: .(e.) participate in establishing the expected goals and outcomes of care 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. 1. A review of the Electronic Medical Record (EMR) revealed that R37 was admitted to the facility on [DATE] with diagnoses of unspecified dementia with agitation, major depressive disorder, and anxiety disorder. A review of the physician's (MD) orders revealed that R37 was prescribed buspirone HCl 15 milligrams (mg) by mouth (PO) two times a day on 10/23/2024, mirtazapine Tab 7.5 mg PO at bedtime (HS) on 7/1/2024, donepezil hydrochloride 10 mg PO HS on 7/1/2024, fluoxetine HCl Cap 40 mg PO one time a day on 7/1/2024, memantine HCl Tablet 5 mg PO twice a day on 8/29/2024, and fluoxetine HCl Cap 40 mg PO once per day on 7/1/2024. During an interview with the Minimum Data Set (MDS) Coordinator on 4/5/2025 at 2:29 pm, revealed, that she assumed the MDS Coordinator role in September 2024. She explained that she updated and developed resident care plans based on their diagnoses, from information gathered from the Wednesday weekly PAR meeting, via information provided directly by staff, during clinicals after morning meetings, and from the 24-hour report. She confirmed that R37 had not been cared planned for dementia with behaviors, anxiety disorder, and psychotropic medication use, adding that it was an oversight. During an interview with the Director of Nursing (DON) on 4/7/2025 at 8:10 a.m., she stated that she expected the MDS Coordinator to develop and update care plans for each resident in the facility. 37739 2. A review of the EMR revealed that R20 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, schizophrenia, legal blindness, anxiety, and major depressive disorder. During an observation on 4/5/2025 at 10:15 am, R20 was observed with obvious dental concerns. Her teeth were observed to be blackish, decayed, and broken to the root. R20 confirmed that she had pain, and it hurts when she eats. R20 was alert with confusion but was able to answer screening questions and was able to press the call light as directed. Certified Nursing Assistant (CNA) AA came to answer the call light, the resident stated that she had pain. The CNA stated that she would tell the nurse that she was experiencing pain. A review of the Quarterly MDS assessment dated [DATE] revealed R20 presented with a BIMS score of three, indicating severe cognitive impairment. A review of the Annual MDS assessment dated [DATE] noted obvious or likely cavity or broken natural teeth. A review of the care plan with the initiated date of 7/10/2024, and the next review date of 5/2/2025, revealed no dental care plan addressing the broken, missing, and decayed teeth. 44168 3. Record review of the EMR for R9 revealed diagnoses that included paranoid schizophrenia, major depressive disorder, recurrent severe without psychotic features, and opioid dependence. Review of physician orders dated 6/28/2024 for R9 revealed orders to monitor for s/s (signs and symptoms) of aggression, outburst, delusions r/t (related to) oxcarbazepine every shift related to paranoid schizophrenia. A review of the care plan revealed there were no care plan areas, goals, or interventions related to paranoid schizophrenia. A review of the care plan revealed there were no care plan areas, goals, or interventions related to schizophrenia. Interview on 4/7/2025 at 9:30 am with the MDS Coordinator revealed that she was responsible for developing and entering care plans. She reviewed the care plan for R9 and confirmed that there was not a care plan related to schizophrenia. She stated the facility was changing systems and that she was in the process of moving care plans from the old system to the new system. The MDS Coordinator confirmed there was not a care plan in the old system related to schizophrenia. 49138 4. Review of the EMR revealed R22 was admitted to the facility on [DATE] with diagnoses including but not limited to sepsis due to escherichia coli, metabolic encephalopathy, pulmonary embolism without acute cor pulmonale, chronic respiratory failure and other specified anxiety disorders. Review of R22's Quarterly MDS assessment dated [DATE] for Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated R22 had little to no cognitive impairment, Section E - Behavior-behavior not exhibited, Section GG - Functional Abilities revealed, impairment on both sides to lower extremities, Section H - Bladder and Bowel revealed, frequently incontinent of bladder and always incontinent of bowel, Section N -Medications revealed, insulin injections, antianxiety, antidepressant, anticoagulant, diuretic, opioid, antiplatelet, hypoglycemic and anticonvulsant medication use; Section O - Special Treatments, Procedures, and Programs revealed oxygen therapy was received. Review of R22's care plan dated 2/5/2025 indicated there was no focus area, goal or interventions implemented for anxiety or psychotropic medication use for R22. Review of the Physician's Orders for R22 included but was not limited to: Observe closely for significant side effects of Anticonvulsant medication including drowsiness, ataxia, nystagmus, dizziness, blurred vision, nausea, rash, gum enlargement, jaundice-every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings dated 7/24/2024; Monitor for s/s of depression such as crying/etc.-every shift related to Major depressive disorder, recurrent, moderate dated 6/28/2024; and Buspirone HCl Oral Tablet 7.5 MG (Buspirone HCl)-Give 1 tablet by mouth every 12 hours related to other specified anxiety disorders dated 6/27/2024. During an interview with the MDS Coordinator on 4/5/2025 at 2:29 pm, she confirmed that R22 had not been care planned anxiety disorder, and psychotropic medication use, adding that it was an oversight. During an interview with the DON on 4/7/2025 at 8:10 a.m., she stated that she expected the MDS Coordinator to develop and update care plans for each resident in the facility. During a follow-up interview with the MDS Coordinator on 4/7/2025 at 8:15 a.m., she stated she had changed R22's care plan on 4/5/2025 after learning during an interview with this surveyor that the plan did not include care areas that should have been part of R22's comprehensive person-centered care plan. She added that the care plan was still not complete, but she was working on it. 5. Review of the EMR revealed R31 was admitted to the facility on [DATE] with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R31's Quarterly MDS assessment dated [DATE] revealed Section C - Cognitive Patterns revealed, a BIMS of 15, Section D - Mood revealed, a loss of interest or feeling down- never on 1 day, Section E - Behavior revealed, behaviors not exhibited and Section N - Medications revealed insulin injections, antipsychotic, antidepressant, diuretic, anticoagulant, hypoglycemic and anticonvulsant medication use. Review of R31's care plan dated 2/5/2025 indicated there was no focus area, goal or interventions implement for dementia or psychotropic medication Review of the Physician's Orders for R31 included but was not limited to: donepezil Hydrochloride Tab 10 mg Give 1 tablet orally at bedtime related to dementia, severity, without psych/mood dated 7/1/2024; levetiracetam Tab 750 mg Give 1 tablet orally two times a day related to dementia, severity, without psych/mood/anxiety dated 7/1/2024;Observe closely for significant side effects of Antidepressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. If monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings dated 8/1/2024. During an interview with the MDS Coordinator on 4/5/2025 at 2:29 pm, she confirmed that R31 had not been cared planned for dementia with behaviors, anxiety disorder, and psychotropic medication use, adding that it was an oversight. During an interview with the DON on 4/7/2025 at 8:10 a.m., she stated that she expected the MDS Coordinator to develop and update care plans for each resident in the facility. During a follow-up interview with the MDS Coordinator on 4/7/2025 at 8:15 a.m., she stated she had changed R31's care plan on 4/5/2025 after learning during an interview with this surveyor that the plan did not include care areas that should have been part of R31's comprehensive person-centered care plan. She added that the care plan was still not complete, but she was working on it.

Based on observations, staff interviews, and record reviews, the facility failed to develop an accurate Minimum Data Set (MDS) assessment for one of three Residents (R) (R14) related to dental status. Findings include: A review of the Electronic Medical Record (EMR) revealed that R14 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, major depressive disorder and dementia. During observations on 4/5/2025 at 11:03 am, 12:55 pm, and 2:00 pm, R14 was observed to have broken and decayed natural teeth. His mouth had a foul odor and a thick white caked residue when he spoke. He was alert with confusion. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. A review of the Admission MDS dated [DATE] for Section L (Oral/Dental status) revealed that the resident presented with no dental concerns. During an interview on 4/6/2025 at 11:40 am, the Administrator admitted the MDS assessment was inaccurate. During an interview on 4/6/2025 at 3:32 pm, the MDS Coordinator stated that dental concerns were not documented on the MDS assessment and the facility's administration had discussed putting a Process Improvement Plan in place. During an interview on 4/7/2025 at 12:20 pm, the Administrator confirmed that there was no current PIP in place related to MDS Assessments. The facility MDS Assessment policy was requested from the Regional Nurse Consultant (RNC) CC but was not provided at the time of exit.

Based on observations, interviews, record review, and a review of the facility policy titled Care Plans - Baseline, the facility failed to develop a baseline care plan for one of five sampled Residents (R) (R345) reviewed for catheter care and Activities of Daily Living (ADL) care. Findings include: A review of the policy titled Care Plans-Baseline dated 2001 under the Policy Statement revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. Under Policy Interpretation and Implementation revealed, 1. The baseline care plan includes instructions needed to provide effective person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including . physician orders. 2. The baseline care plan is used until staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). 3. The resident and/or resident representative are provided a written summary of the baseline care plan. A review of the Electronic Medical Record (EMR) revealed that R345 was admitted to the facility on [DATE] with diagnoses of, but not limited to, type 2 diabetes mellitus, morbid (severe) obesity, chronic kidney disease, acute diastolic (congestive) heart failure, hypertensive heart disease, lymphedema, and necrotizing fasciitis. During an observation and interview on 4/5/2025 at 10:41 am, R345 was observed in his room sitting on the side of his bed with two hospital gowns on. He was unshaven with a full uneven beard and his hair was thick, patchy, uncombed, and uneven. He was observed to have two urinary catheters in privacy bags attached to the railing of the bed. He said that he had the catheters for a month or so. His legs were extremely swollen and dry. The sheets on his bed were visibly dirty and stained. He stated that he had just recently returned from the hospital. He stated that he would like a shave, but he had not asked anyone. He also confirmed that he had personal clothes but had not gotten dressed yet. He stated he had only received bed baths since he had been at the facility due to his conditions, but he would like a shower, shave, and haircut. During an interview on 4/5/2025 at 3:50 pm, Licensed Practical Nurse (LPN) EE confirmed that R345 had a supra pubic catheter, and catheter care was observed with no concerns. During an observation on 4/6/2025 at 2:15 pm, R345 was observed still dressed in two hospital gowns, not shaven, hair not combed and confirmed that he had not received a shower. His bed was still soiled with the dirt and stains from the day before. A review of the Order Summary Report for April 2025 revealed the following physician orders: Cleanse the area around the suprapubic catheter with soap and water. Pat dry. Apply dry dressing daily and PRN excessive drainage. every night shift AND as needed excessive drainage; Urinary Catheter Care every shift; Urinary Catheter: Drainage Bag - Change one time a day starting on the 25th and ending on the 25th of every month; Urinary Catheter: 16 F 10cc bulb every shift AND as needed for Occlusion or Leakage as Needed. A review of the ADL Documentation revealed that R345 was scheduled to receive a shower on Mondays, Wednesdays, and Fridays on the 11:00 pm to 7:00 am shift. The shower sheets dated 3/26/2025, 3/28/2025, 3/31/2025, 4/2/2025, and 4/4/2025 revealed that the resident had been getting a bed bath since admission however, the shower sheets were not signed. A review of the baseline care plan for R345 dated 3/25/2025 revealed that it had not been completed. There were no check marks for daily preference related to bathing, self-care abilities, or functional abilities, and no checks for indwelling or suprapubic catheter. During an interview on 4/6/2025 at 2:20 pm, the Unit Manager (UM) revealed that R345 had been receiving bed baths, but nothing related to his condition limits him to just a bed bath. She confirmed that the staff should be offering showers, shaving, and hair care during shower days and bed baths. On 4/6/2025 at 2:40 pm, contact information was requested from the UM for the 11:00 pm to 7:00 am staff that were assigned to R345 over the last seven days but was never provided. During an interview on 4/6/2025 at 2:50 pm, Regional Nurse Consultant (RNC) CC confirmed that R345 stated that he would like a shower and that the staff were going to be showering and shaving him today. During an interview on 4/6/2025 at 1:16 pm, the Minimum Data Set (MDS) Coordinator revealed that she had started completing the comprehensive admission assessment, but the baseline was not completed. She stated that this was her first survey in this position as the MDS Coordinator. She was a floor nurse before and was just getting acclimated to the position. She stated that she opened up the baseline care plan to complete it but just started inputting data into the comprehensive assessment instead of completing the baseline first and that the comprehensive care plan was still in progress.

Based on observations, interviews, record review, and a review of the facility policy titled Discharge Summary and Plan, the facility failed to develop and implement an effective discharge planning process for one of two Residents (R) R6 reviewed for discharges. Specifically, the facility failed to ensure documentation that R6 had been asked about their interest in receiving information regarding returning to the community, updating the resident's comprehensive care plan and discharge plan, and if discharge to the community was determined not to be feasible, ensuring to document who made the determination and why. Findings include: A review of the facility policy titled Discharge Summary and Plan dated 2001 under the Policy Statement revealed, When a resident's discharge is anticipated, a discharge summary and post-discharge plan are developed to assist the resident with discharge. Under Policy Interpretation and Implementation revealed, 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family. 7. Residents are asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the president's post- discharge preferences. 8. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. A review of the Electronic Medical Record (EMR) revealed that R6 was admitted to the facility on [DATE] and readmitted on [DATE]. The emergency contact and responsible party was documented as Family (F)B. The next contact person on the list is FA. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Pattern) revealed that R6 has a Brief Interview of Mental Status (BIMS) of 10, indicating moderate cognitive impairment. During an observation on [DATE] at 9:19 am, R6 was observed in her room sitting in her wheelchair with two visitors. During an interview with R6 and her visitors at that time, R6 introduced the visitors as FA and her husband. She expressed that she didn't have any concerns except that she wanted to go home. FA stated that they wanted to take their family member home, but they did not have a say in the resident care and the staff at the facility did not include them in care plan meetings. FA stated that FB was the emergency contact but was not able to visit. She stated that she and her husband visit a couple of times a week with R6. The resident confirmed that she did not recall having any discharge planning to determine if discharge with FA was a feasible option and that she would like FA to be included in her care plan meetings. FA stated that she and her husband were both home full-time and could care for R6. During a phone interview on [DATE] at 9:51 am, FB stated that she was the responsible party for R6, but she had health issues and could not visit as much as she would like. She stated she would not be opposed to FA being invited because she visits more. She stated that she had not spoken to the facility regarding a discharge plan because she could not take care of R6. During an interview on [DATE] at 9:57 am, the MDS Coordinator stated that she was not in charge of discharge planning. She revealed she organized the care plan meetings, but she did not routinely ask about discharge planning. She stated R6 was alert and able to answer questions. The resident did voice that she wanted to go home and be with her husband, but the husband was deceased . She stated that she was trained to only ask the responsible party about attending the care plan meetings. She confirmed that she had not discussed with the responsible party or the resident if she wanted someone else to attend the care plan meetings. She further confirmed that she does not write any notes related to discussing discharge planning with the residents or responsible party. She confirmed that she does not know who the person would be to speak about doing the actual discharge planning and that she had not been told up to this point that she was the person responsible for discharge planning. During an interview on [DATE] at 10:18 am, the Nursing Home Administrator (NHA) confirmed that FB was the point of contact for R6 and that she was the one invited to the care plan meetings. She confirmed that discharge planning should be documented in the medical record.

Based on observations, interviews, record review, and review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to provide Activities of Daily Living (ADL) care for three of 24 sampled Residents (R) (R14, R20, and R345) related to personal hygiene and showers. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated March 2018 under the Policy Statement revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. 1. A review of the Electronic Medical Record (EMR) revealed that R14 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, major depressive disorder and dementia. During observations on 4/5/2025 at 11:03 am, 12:55 pm, and 2:00 pm, R14 was observed to have broken and decayed natural teeth. His mouth had a foul odor and a thick white caked residue when he spoke. He was alert with confusion. During an interview on 4/5/2025 at 3:33 pm, Certified Nursing Assistant (CNA) AA stated that she did not brush R14's teeth and did not assist him with set up or encourage him to brush his teeth today. She stated that she had no reason why she did not complete this task. 2. A review of the EMR revealed that R20 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, schizophrenia, legal blindness, anxiety, and major depressive disorder During an observation on 4/5/2025 at 10:15 am, R20 was observed with obvious dental concerns. Her teeth were observed to be blackish, decayed, and broken to the root. R20 confirmed that she had pain, and it hurts when she eats. R20 was alert with confusion but was able to answer screening questions and was able to press the call light as directed. CNA AA came to answer the call light, the resident stated that she had pain. The CNA stated that she would tell the nurse that she was experiencing pain. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed that R20 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. A review of the Annual MDS assessment dated [DATE] for Section L (Oral/Dental status) revealed, obvious or likely cavity or broken natural teeth. During an interview on 4/5/2025 at 3:33 pm, CNA AA stated that she did not brush R20's teeth and did not assist her with set up or encourage her to brush her teeth today. She stated that she had no reason why she did not complete this task. 3. A review of the EMR revealed that R345 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, morbid (severe) obesity, chronic kidney disease, acute diastolic (congestive) heart failure, hypertensive heart disease, lymphedema, and necrotizing fasciitis. During an observation and interview on 4/5/2025 at 10:41 am, R345 was observed in his room sitting on the side of his bed with two hospital gowns on. He was unshaven with a full uneven beard and his hair was thick/patchy, uncombed, and uneven. His legs were extremely swollen and dry. The sheets on his bed were visibly dirty and stained. He stated that he had just recently returned from the hospital. He stated that he would like a shave, but he had not asked anyone. He also confirmed that he had personal clothes but had not gotten dressed yet. He stated he has only received bed baths since he has been at the facility due to his conditions, but he would like a shower, shave, and haircut. During an observation on 4/6/2025 at 2:15 pm, R345 was observed still dressed in two hospital gowns, not shaven, hair not combed and confirmed that he had not received a shower. His bed was still soiled with the dirt and stains from the day before. A review of the ADL Documentation revealed that R345 was scheduled to receive a shower on Mondays, Wednesdays, and Fridays on the 11:00 pm to 7:00 am shift. The shower sheets dated 3/26/2025, 3/28/2025, 3/31/2025, 4/2/2025, and 4/4/2025 revealed that the resident had been getting a bed bath since admission however, the shower sheets were not signed. A review of the baseline care plan for R345 dated 3/25/2025 revealed that it had not been completed. There were no check marks for daily preference related to bathing, self-care abilities, or functional abilities. During an interview on 4/6/2025 at 2:20 pm, the Unit Manager (UM) revealed that R345 had been receiving bed baths, but nothing related to his condition limits him to just a bed bath. She confirmed that the staff should be offering showers, shaving, and hair care during shower days and bed baths. On 4/6/2025 at 2:40 pm, contact information was requested from the UM for the 11:00 pm to 7:00 am staff that were assigned to R345 over the last seven days but was never provided. During an interview on 4/6/2025 at 2:50 pm, Regional Nurse Consultant (RNC) CC confirmed that R345 stated that he would like a shower and that the staff were going to be showering and shaving him today. During an interview on 4/6/2025 at 1:16 pm, the MDS Coordinator revealed that she had started doing the comprehensive admission assessment, but the baseline was not completed. She stated that this was her first survey in this position as the MDS Coordinator. She was a floor nurse before and is just getting acclimated to the position. She stated that she opened up the baseline care plan to complete it but just started inputting data into the comprehensive assessment instead of completing the baseline first and the comprehensive care plan is still in progress. The contact information was requested for the third shift staff assigned to bathe the resident over the last week from the Regional Nurse Consultant (RNC) CC but was not provided at the time of exit.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure one of two residents (R) (R22) reviewed for oxygen was administered oxygen as ordered by the physician. Findings include: Review of the policy titled Oxygen Administration dated October 2010 under the Purpose section revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section titled Preparation revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident . Under the section titled Documentation revealed, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 3. The rate of oxygen flow, route, and rationale. Observation on 4/5/2025 at 9:30 am revealed R22 was receiving oxygen (O2) by way of (via) nasal cannula (NC) with the oxygen flow rate set at 3 liters per minute (LPM) Observation on 4/6/2025 at 10:09 am revealed R22 receiving O2 via NC with the oxygen flow rate set at 3 LPM. Observation on 4/6/2025 at 1:35 pm revealed R22 receiving O2 via NC with the oxygen flow rate set at 3 LPM. Review of the Electronic Medical Record (EMR) revealed R22 was admitted to the with diagnoses including but not limited to sepsis due to escherichia coli, metabolic encephalopathy, pulmonary embolism without acute cor pulmonale and chronic respiratory failure. Review of R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated R22 has little to no cognitive impairment, Section E - Behavior revealed, behavior not exhibited, Section GG - Functional Abilities revealed, lower extremity(impairment on both sides), and Section O - Special Treatments, Procedures, and Programs revealed, oxygen therapy was received. Review of R22's care plan dated 2/5/2025 indicated focus area of R22 revealed he receives oxygen therapy r/t (related to) chronic for respiratory failure. Goals included but not limited to R22 will have no s/sx (sign and symptoms) of poor oxygen absorption through the review date. Interventions include giving medications as ordered by physicians. Monitor/document side effects and effectiveness, If R22 is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return R22 to the usual oxygen delivery method after the meal. Monitor for s/sx of respiratory distress and report to Medial Director (MD). Review of the Physician's Orders for R22 included but was not limited to: O2 at 2 LPM. via nasal cannula for O2 sat below 90%-every shift related to Obstructive sleep apnea dated 6/28/2024 Interview on 4/6/2025 at 1:37 pm with Licensed Practical Nurse (LPN) LPN DD confirmed orders for O2 and that R22's oxygen flow rate was set at 3LPM. During the interview, LPN DD adjusted the oxygen flow rate to 2LPM as ordered. Interview on 4/7/2025 at 8:57 am with R22 revealed that he did not change the flow of his oxygen. Interview on 4/7/2025 at 10:00 am with Director of Nursing (DON) and Regional Nurse Consultant (RNC) CC, both revealed that all physician orders should be followed. RNC CC stated the residents' oxygen flow rate should be checked daily as it should be set according to the physician orders. An interview on 4/7/2025 at 11:29 am with the Administrator revealed she expects nursing staff to follow physician orders as they should be rounding every shift.

Based on observations, interviews, record reviews, and a review of the facility policy titled Dental Services, the facility failed to provide routine dental services for two of three Residents (R) (R14 and R20) reviewed for dental concerns. Findings include: A review of the facility policy titled Dental Services dated 2001 under the Policy Statement revealed, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Under the Policy Interpretation and Implementation section revealed, 1. Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly; . referral to the resident's personal dentist; referral to a community dentist; or referral to other health care organizations that provide dental services 11. All dental services provided are recorded in the resident's medical record . 1. A review of the Electronic Medical Record (EMR) revealed that R14 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, major depressive disorder and dementia. Further review revealed that the resident's funding source was Medicare A on 3/26/2025; Medicaid - Georgia on 3/20/2025; Medicare A on 2/28/2025; Medicare A on 2/27/2025; Medicaid - Georgia on 2/24/2025; Medicaid - Georgia on 1/1/2025; Medicaid - Georgia on 10/7/2024; Medicaid - Georgia on 10/1/2024; and Medicaid - Georgia on 9/12/2024. During observations on 4/5/2025 at 11:03 am, 12:55 pm, and 2:00 pm, R14 was observed to have broken and decayed natural teeth. His mouth had a foul odor and a thick white caked residue when he spoke. He was alert with confusion. A review of the EMR and the physical medical record revealed no information related to any dental services or consultations for R14. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed that R14 had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. A review of the Admission MDS dated [DATE] for Section L (Oral/Dental status) revealed the resident presented with no dental concerns. A review of the care plan with the initiated date of 9/12/2024 and the next review date of 6/25/2025 revealed no dental care plan for R14 addressing the missing, broken, and decayed teeth. 2. A review of the EMR revealed that R20 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, schizophrenia, legal blindness, anxiety, and major depressive disorder. It was documented that the resident's funding source was Georgia Medicaid. During an observation on 4/5/2025 at 10:15 am, R20 was observed with obvious dental concerns. Her teeth were observed to be blackish, decayed, and broken to the root. R20 confirmed that she had pain, and it hurts when she eats. R20 was alert with confusion but was able to answer screening questions and was able to press the call light as directed. Certified Nursing Assistant (CNA) AA came to answer the call light, the resident stated that she had pain. The CNA stated that she would tell the nurse that she was experiencing pain. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed that R20 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. A review of the Annual MDS assessment dated [DATE] for Section L (Oral/Dental status) revealed, obvious or likely cavity or broken natural teeth. A review of the care plan with the initiated date of 7/10/2024, and the next review date of 5/2/2025, revealed no dental care plan addressing the broken, missing, and decayed teeth. A review of the EMR and physical medical record revealed no information related to any dental services or consultations for R20. During an interview with the Nursing Home Administrator (NHA) on 4/5/2025 at 3:06 pm, she confirmed that they were currently operating without a Social Worker and that the Human Resources (HR) Director handles scheduling for all dental consults. During an interview with the HR Director on 4/5/2025 at 3:07 pm, she revealed that she returned to the facility in October 2023 and that she had not done any dental consults for residents. She confirmed that at this time, the facility did not have a contract with any dental provider. However, they have an appointment on Monday, 4/7/2025, with a new company. She stated that the last dentist who came to the facility was years ago. In the interim, they take residents to a Medicaid dental provider in a nearby city for emergency services. She again confirmed that she did not schedule any dental consultations and that dental consults were set up with the nursing department and transportation was set up by the Business Office Manager (BOM). She stated that she did not know if there was a list of residents who had last seen the dentist. During an interview on 4/5/2025 at 3:18 pm, the BOM confirmed that she does set up transportation for all dental consults. She provided a list of all residents who had services in the last 12 months. There were only a few residents on the list and R14 and R20 were not on the list. During an interview on 4/5/2025 at 3:20 pm, the NHA confirmed that they do not have a contracted dental provider and have not had one for over a year. In the interim, if a resident has concerns, they go to an outside dental provider who takes Medicaid. The nurse or the Unit Manager (UM) will set that up. If the resident has pain, cavities, broken, or decayed teeth, they should be referred out to receive dental services. During an interview on 4/5/2025 at 3:33 pm, CNA AA stated that she did not brush the residents' (R14 and R20) teeth and did not assist them with set up or encourage them to brush their teeth today. She stated that she had no reason why she did not complete this task. During an interview on 4/5/2025 at 3:40 pm, Regional Nurse Consultant (RNC) BB stated that the facility will have the new dental company coming in on Monday (4/7/2025). She observed R14 and R20 and confirmed that they had missing, broken, and decayed natural teeth. She confirmed that R14 and R20 should have had a referral to an outside dentist for dental services due to their dental status.

Based on observations, record review, staff interviews, and review of facility's policy titled Infection Prevention Control Program the Transmission of Communicable Disease, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, and investigation to prevent the onset and spread of infections. Specifically, the facility failed to provide complete and accurate surveillance data; failed to follow infection control practices in the laundry room and failed to properly label and store resident personal care items. The census was 42 residents. Findings include: 1. Review of the policy titled Infection Prevention Control Program the Transmission of Communicable Disease dated 5/10/2023 revealed Policy Explanation and Compliance Guidelines: Number 1. The Infection Preventionist is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Number 3. Surveillance a: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon facility assessment. b: The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. Review of the facility's surveillance data for the past 12 months documents titled Line Listing of Resident Infections revealed incomplete data February 2024 through August 2023. The Line Listing did not have data collected for Cultures and there was no indication of whether the infection was HAI (Healthcare Associated Infection) or CAI (Community Acquired Infection). There was no monthly surveillance data, no line listing, no mapping, and no summary report collected during the month of April 2023 and September 2023 through December 2023. 2. Review of the policy titled Infection Prevention Control Program the Transmission of Communicable Disease dated 5/10/2023 revealed Policy Explanation and Compliance Guidelines: Number 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infections. C. Clean linen shall be delivered to resident care units on covered linen carts. Observation on 3/16/2024 at 8:40 am, of laundry services revealed entrance to dirty side of laundry room was located outside the facility. Clean side entrance was located inside the facility. Laundry room had one commercial washing machine and two commercial dryers, in working condition. Located across from the two dryers was a small folding table with white linens waiting to be folded, and employee personal items, including purse and an opened bottle of drinking water. Also sitting on the folding table was a 3.78 Liter bottle of Clorox bleach. Observation on 3/16/2024 at 8:45 am dryer lint trap in both commercial dryers had thick layer of lint across filters. Interview on 3/16/2024 at 8:45 am, Laundry Aide EE stated she had been employed at the facility for one year. She stated that she knew she was not supposed to place her personal items on the folding table, but she stated there was nowhere else to put her purse. She stated the Clorox jug was stored under the table, but she just had not put it up yet, after putting some Clorox in the washer earlier. She stated that she cleans the dryer lint traps every two hours. When asked to review the lint trap logs, she stated she did not document when she check the lint traps. She stated she had checked them that morning when she arrived at work. Observation on 3/17/2024 at 2:11 pm, Laundry Aide EE was observed delivering resident personal laundry in a buggy that was uncovered. Interview on 3/17/2024 at 2:13 pm, Laundry Aide EE exited from resident room, and stated she forgot to cover the clothing when she entered the residents room. 3. Observation on 3/16/2024 at 10:20 am and 4:18 pm, revealed in room seven, one unbagged and un-labelled urinal on grab bar, in a shared bathroom. Observation on 3/17/2024 at 8:05 am, in room seven, unbagged and un-labelled urinal remained on grab bar in a shared bathroom. Interview on 3/17/2024 at 2:28 p.m. with Director of Nursing (DON), stated she was working as the Assistant Director of Nursing (ADON) prior to a three-month family medical leave. She stated when she returned to work in August 2023, she assumed the role of DON, and the role of Infection Preventionist. She stated she didn't have enough time to keep up with the responsibilities of the full-time DON and the Infection Preventionist duties. During further interview, she stated they were actively looking to hire an ADON, and that person will assume the responsibilities of the Infection Preventionist.

Based on record review, interviews and review of policies titled Vaccination of Residents and Pneumococcal Vaccine, the facility failed to provide education, offer, or administer pneumonia vaccinations for three of five sampled residents (R) (R9, R25, R39) reviewed for vaccinations. Findings include: Review of the policy titled Vaccination of Residents revised October 2019, documented the policy statement that all residents will be offered vaccines that aid in preventing infectious diseases unless contraindicated or the resident has already been vaccinated. Policy Interpretation and Implementation: Number 1. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. Number 2. Provisions of such education will be documented in the resident's medical record. Number 3. All new residents shall be assessed for current vaccination status upon admission. Number 4. The resident or the resident's legal representative may refuse vaccines for any reason. Number 5. If vaccines are refused, the refusal shall be documented in the resident's medical record. Review of the policy titled Pneumococcal Vaccine revised March 2022, documented the policy statement is all residents are offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: Number 1. Prio to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Number 2. Assessments of pneumococcal vaccination status are conducted within five working days of the residents admission if not conducted prior to admission. Number 3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Number 5. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the residents medical record indicating the date of the refusal of the pneumococcal vaccination. 1. Review of the clinical record for R9 revealed she was admitted to the facility on [DATE], was [AGE] years old with diagnoses of morbid obesity, encephalopathy, diabetes, obstructive sleep apnea (OSA), chronic kidney disease, depression, and hypertensive heart disease. There was no indication that the pneumonia vaccine was offered or administered to the resident. 2. Review of the clinical record for R25 revealed she was admitted to the facility on [DATE], was [AGE] years old with diagnoses of schizophrenia, anxiety, hypertensive heart disease, diabetes, depression, and cardiac arrhythmia. There was no indication that the pneumonia vaccine was offered or administered to the resident. 3. Review of the clinical record for R39 revealed he was admitted to the facility on [DATE], was [AGE] years old with diagnoses of dementia, depression, restlessness, agitation, and vitamin B-12 deficiency. There was no indication that the pneumonia vaccine was offered or administered to the resident. Interview on 3/17/2024 at 2:32 pm with Director of Nursing/Infection Preventionist, stated she was responsible for the Infection Control Program (ICP) until an Assistant Director of Nursing (ADON) is hired. She stated she didn't have as much time to focus on the ICP because the duties of the Director of Nursing take up most of her time. She stated that she was not aware that the residents had to be offered the pneumonia vaccine if they had not already had it. She stated that she was not aware that the facility was even offering the pneumonia vaccine to the residents. She confirmed there was no documented evidence that R9, R25, or R39 had been offered the pneumonia vaccine at the facility.

Based on staff interviews, record review, and review of the facility's policies titled Medication Monitoring PRN Orders for Psychotropic and Antipsychotic Drugs, and Medication Monitoring Anti-Anxiety Drugs, the facility failed to ensure that psychotropic medications, specifically antianxiety medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of six residents (R) (R33 and R7) sampled for the use of unnecessary medications and failed to ensure routine medication evaluation for one of six residents (R7) sampled for the use of unnecessary medications. These deficient practices had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. Findings include: A review of the facility policy titled Medication Monitoring PRN Orders for Psychotropic and Antipsychotic Drugs, effective date October 2022, revealed a policy of In certain situations, psychotropic medications may be prescribed on a PRN basis, . The Procedure section line number 3 stated: See the Psychotropic Drug Orders table for time limitations and exceptions. The PRN psychotropic drug orders table revealed PRN orders for psychotropic medications that included antianxiety medications had a time limitation of 14 days. The table stated the order may be extended beyond 14 days if the prescriber believes it is appropriate to extend the order. The Require Action section stated the prescriber should document the rationale for the extended period in the medical record and indicate a specific duration. A review of the facility policy titled Medication Monitoring Anti-Anxiety Drugs, dated October 2022, revealed the Procedure section line number 8 stated: The consultant pharmacist will review residents receiving anti-anxiety drugs monthly and report irregularities to the attending physician. 1. A review of R33's Quarterly Minimum Data Set (MDS) dated [DATE] for Section N (Medications) revealed R33 was taking an anti-anxiety medication. A review of the care plan revealed a Problem area dated 9/21/2022, with a PRN medication added date of 7/16/2023, of I am at risk for side effects from anti-anxiety use. A review of the physician orders revealed an order dated 1/1/2024 for lorazepam (a medication used to treat anxiety) 0.5 milligrams (mg) one tablet by mouth every six hours as needed for agitation. A review of the Face Sheet revealed that R33's diagnoses included unspecified dementia with agitation. A review of the medication administration record (MARS) dated January 2024, February 2024, and March 2024, revealed that R33 was administered the lorazepam 0.5mg by mouth on 1/8/2024 at 8:19 pm, 2/12/2024 at 9:57 am, 2/26/2024 at 7:38 am, and 3/15/2024 at 12:51 pm and 9:26 am. A review of the Consultant Pharmacist Communication to Physician document dated 12/14/2023 revealed Ativan (brand name for lorazepam) 0.5 mg 1 tablet by mouth every four hours as needed for agitation was listed as reviewed by the consulting pharmacist, and there were no recommended changes. The document was signed by the physician and the physician had marked I agree. There was not a Consultant Pharmacist Communication to Physician document dated after 1/1/2024. In an interview on 3/16/2024 at 10:20 am, Licensed Practical (LPN) AA stated R33 was ordered lorazepam as a PRN medication for agitation. She stated some medications had an automatic end date, but she was unsure who was responsible for monitoring to ensure the medications did have an end date. In an interview on 3/16/2024 at 10:40 am, LPN BB stated she thought medications were reviewed periodically but was unsure who was responsible for the reviews. In an interview on 3/16/2024 at 1:30 pm, the Director of Nursing (DON) stated physician medication orders were monitored by the physician and pharmacist. She stated that about one month ago, she had asked the physician for an end date, but not a rationale, for PRN antipsychotic medication orders, and had not received a reply. She further stated the pharmacist provided an oversite of the physician's medication orders, but there was no oversite provided by nursing. In an interview on 3/16/2024 at 3:20 pm, the Administrator stated the DON and MDS Coordinator were responsible for reviewing physician orders and ensuring PRN antipsychotic orders had a 14-day end date or a physician documented rationale for continuing the medication as well as a definitive end date. 33548 2. A review of the Face Sheet revealed R7 admitted on [DATE] with diagnoses that included but not limited to anxiety disorder. A review of R7's Quarterly Minimum Data Set (MDS) dated [DATE] for Section N (Medications) revealed R7 was taking an anti-anxiety medication. A review of the physician orders revealed an order dated 11/15/2023 for lorazepam 0.5mg every four hours as needed (prn) for anxiety or agitation. The prn lorazepam order did not have a stop date. Further review of the physician orders revealed an order dated 11/18/2023 to admit to Hospice Compassionate Hospice. A review of the nursing progress notes dated 3/11/2024 revealed R7 was given prn Ativan (lorazepam) for agitation. A review of the consultant pharmacist report titled Anti-anxiety Drug Report dated 3/1/2024 revealed R7 was not listed as receiving anti-anxiety medication. During an interview on 3/16/2024 at 1:30 pm, the DON confirmed that R7 was ordered lorazepam prn. The DON stated that the lorazepam was ordered by the hospice provider as a standing order. The DON confirmed that the facility was responsible for monitoring any resident in the facility with a prn order for an anti-anxiety medication. The DON revealed that she spoke with the facility's physician regarding prn anti-anxiety medications needing a stop date and she had not heard back from them for orders. The DON revealed that there was currently no monitoring of prn anti-anxiety medication and stated that she expected the consultant pharmacist to monitor and notify the facility of any prn orders needing a stop date.

Based on staff interview, record review, and review of the facility's policy titled Infection Prevention Control Program the Transmission of Communicable Diseases, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for one of 22 sampled Residents (R) (R6). Findings include: Review of the policy titled Infection Prevention Control Program the Transmission of Communicable Disease dated 5/10/2023 revealed Policy Explanation and Compliance Guidelines: Number 1. The Infection Preventionist is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Number 6. Antibiotic Stewardship: a. an antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included depression, diabetes, restless leg, and injury of right index finger. Review of the McGeer Criteria worksheet titled LTC Skin, Soft Tissue, and Mucosal Infection Worksheet, dated 1/15/2024 for R6 documented type of infection was indicated as cellulitis, soft tissue, or wound. Under signs/symptoms heading, indicated a check mark by entry new or increased presence of at least four of the following: heat at the affected site; redness at the affected site; swelling at the tenderness or pain at affected site; serous drainage at the affected site; and one constitutional criterion (fever, leukocytosis, change in mental status, acute functional decline). However, there was no criteria marked for this infection. Review of the January 2024 Medication Administration Record (MAR) revealed clindamycin HCL 150 milligram (mg) one capsule by mouth three times (t.i.d.) per day for right middle finger wound was ordered on 1/15/2024 for one month. Review of the February 2024 MAR revealed clindamycin HCL 150 mg one capsule by mouth four times (q.i.d.) per day times four weeks was ordered on 2/15/2024. Review of the March 2024 MAR revealed clindamycin HCL 150 mg one capsule by mouth q.i.d., with date to discontinue on 3/21/2024. Interview on 3/17/2024 at 2:32 pm with Director of Nursing/Infection Preventionist, stated she was responsible for the Infection Control Program (ICP) until an Assistant Director of Nursing (ADON) is hired. She stated she didn't have as much time to focus on the ICP because the duties of the Director of Nursing take up most of her time. She stated that she tried to complete the Infection Control reports, including the Antibiotic Stewardship, at the end of each month, but stated she hasn't really been trained on what she was supposed to do, since the previous Infection Preventionist left when she was out on leave. During further interview, she verified that the McGreer Criteria worksheet was incomplete for R6, and stated she was not sure why the resident was prescribed two months of antibiotics.

Based on staff interviews, record review, and review of the facility's document titled Nursing Facility Services Agreement, the facility failed to implement a communication process which included documentation between the facility and hospice provider to ensure one of 22 sampled Residents (R) (R7), care needs were met and addressed. Findings include: Review of the facility's document titled Nursing Facility Services Agreement with an effective date of May 11, 2021 under Section three (e) of page nine revealed, Provision of Information revealed Hospice shall promote open and frequent communication with Facility and shall provide facility with sufficient information to ensure that the provision of Facility Services under this Agreement is in accordance with the hospice patient's Plan of Care, assessments, treatment planning and care coordination. Review of the Face Sheet revealed R7 admitted on [DATE] with diagnoses that included but not limited to malignant neoplasm of colon, malignant neoplasm of large intestine, and malignant neoplasm of rectum. Review of R7's physician orders revealed an order to admit to Hospice, Compassionate Hospice, with an order date of 11/18/2023. Review of R7's medical record revealed there was no documentation from the hospice provider regarding dates of visits, which staff visited, what care services were provided during visit, or if any issues or concerns were identified during hospice visits. During an interview on 3/16/2024 at 10:10 am the Director of Nursing (DON) revealed that hospice did not provide the facility with any type of communication sheet once they completed their visit with R7. The DON confirmed that without hospice documentation, facility nursing staff were not aware of which care services were provided to R7. Continued interview with the DON revealed the current method of communication between the facility and hospice was verbal once hospice staff completed their visit. DON stated they would let the nurses once the visit was complete. The DON stated that the hospice aide did require a signature on the hospice's electronic device, but the facility did not receive a copy of that electronic document. Further interview with the DON revealed that if hospice staff identified a concern with R7during their visit, hospice staff would state this at the end of visit and the facility would contact the physician if necessary depending on issue. During an interview on 3/17/2024 at 11:40 am, Liscense Practical Nurse (LPN) BB revealed she thought there was a hospice communication book but after searching no book was located. LPN BB stated that when hospice staff were in the building to visit and provide services, they would notify the nurse working the unit. LPN BB revealed that once a hospice visit had been completed, they would re-approach the nurse and verbally discuss the visit, discuss what care was provided, and if any concerns were noted. LPN BB revealed that other nursing staff would only know when hospice had a visit with R7, if the nurse documented that information on the 24-hour report used by second shift staff. During an interview on 3/17/2024 at 11:45 am, Registered Nurse (RN) DD confirmed that there was no documentation provided by hospice staff to indicate when they visited and what care services were provided.

Based on observation, staff interviews, and review of the facility-provided recipes titled Chicken Breast Strips 3oz Conv PU and French Fries Conv PU, the facility failed to follow the recipes to ensure puree foods were prepared by methods to conserve nutritive value. This deficient practice had the potential to alter the nutrition values for four residents who receive an oral puree diet. The census was 42 residents. Findings include: Review of the undated recipe titled Chicken Breast Strips 3oz Conv PU under the section titled Ingredients & Instructions revealed the ingredients included Chicken Breast Strips three-ounce (oz) Conv, Stock Chicken/Soup Base Conv, And Food Thickener Bulk. Review of the undated recipe titled French Fries Conv PU under the section titled Ingredients & Instructions revealed the ingredients included, French Fries Conv, 2% milk hot, and Food Thickener Bulk. Observation on 3/16/2024 at 11:00 am of Dietary Cook CC prepare puree chicken tenders revealed he placed ten fried chicken tenders into the blender bowl and added one, four ounce can of cream of chicken soup and added a partial unmeasured amount from another four ounce can of cream of chicken soup and began to puree. Dietary Cook CC opened blender lid, stirred contents, and added an unmeasured amount of hot water as well as additional cream of chicken soup to the blender bowl. Once Dietary Cook CC achieved puree consistency, he placed the puree chicken in a steam table pan and placed it in the oven. Dietary Cook CC then took another blender bowl and placed an unmeasured amount of fried onion rings along with an unmeasured amount of hot milk and began to puree. Dietary Cook CC opened the lid to the blender to stir and added an unmeasured amount of hot water five times. Once the fried onion rings were at puree consistency Dietary Cook CC placed them in a steam table pan and placed it in the oven. During an interview on 3/16/2024 at 11:00 am Dietary Cook CC confirmed that the cream of chicken soup was not listed on the recipe for pureed chicken tenders as an ingredient. Dietary Cook CC stated that he used the cream of chicken soup to add flavor. Dietary Cook CC confirmed that the recipe for puree French fries did not list hot water as an ingredient. Dietary Cook CC revealed he did not heat additional milk for the pureed onion rings due to not wanting to dilute the flavor. Dietary Cook CC could not explain how the water would add flavor over adding additional milk. During an interview on 3/16/2024 at 11:00 am the Certified Dietary Manager (CDM) revealed they do not have a recipe for puree onion rings and use the puree French fry recipe in its place. The CDM confirmed that the recipe for the puree chicken tenders did not list cream of chicken soup or plain water as an ingredient. Continued interview with the CDM revealed that the cream of chicken soup is added to the puree chicken tenders to add flavor. The CDM revealed that the facility's Registered Dietitian (RD) had not been made aware and had no knowledge that the cream of chicken soup was being added to the puree chicken tenders which would increase calories, fat, carbohydrate, and sodium content. The CDM stated that the sodium content would likely be the same with the use of the cream of chicken soup since the recipe listed chicken broth as an ingredient. Further interview with the CDM, confirmed that the recipe for puree French fries did not list plain water as an ingredient. The CDM stated that they facility uses whole milk and since the recipe listed 2% milk as an ingredient, the water they added was diluting the whole milk to 2% milk. The CDM confirmed that she had not notified the facility RD to the modification made to the puree onion rings and could provide reason for not notifying the RD.

Based on observations, staff interview, and record review, the facility failed to ensure the oxygen concentrator was clean per physician orders for one of 22 sampled Residents (R) (R7) reviewed for oxygen therapy. Findings include: Review of the physician orders for R7 with order date of 11/18/2023 revealed, charge nurse to clean O2 concentrator, change O2 tubing and humidifier bottle - date and place bag for storage weekly on Sundays night shift. Observations on 3/15/2024 at 9:25 am, 3/16/2024 at 3:40 pm, and 3/17/2024 at 10:10 am of R7 revealed she was lying in bed while oxygen was being administered and the exterior vent slates of the oxygen concentrator was covered with a thick layer of dust/lint. Interview and observation on 3/17/2024 at 10:10 am with the Director of Nursing (DON), confirmed that R7 oxygen concentrator exterior vent slates were covered with dust/lint. The DON revealed she expects nursing staff when they clean the oxygen machine to wipe it completely with sanitization wipes which includes wiping the vent slates to remove any debris. Review of the policy titled Oxygen Administration revealed it did not address cleaning of the oxygen concentrator.

Based on staff interviews, record review, and review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to perform a Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 22 sampled Residents (R) (R13) with a mental disorder This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: A review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, dated 12/19/022 under the section titled Policy Explanation and Compliance Guidelines revealed, Number 1. (b) PASARR Level II-a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has a MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Number 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring them to the appropriate authority. Number 9. Any resident who exhibited a newly evident or possible serious mental disorder would be referred promptly to the state mental health or intellectual disability for a level II resident review. Examples include: (c) a resident who was transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. A review of the R13's medical records revealed the resident was admitted to the facility on [DATE]. A review of the Diagnosis & DRG Bundle listed on R13's face sheet revealed new diagnosis of paranoid schizophrenia was added on 3/1/2022 after a transfer to a mental health facility related to psychiatric behaviors. A review of the most recent Annual Minimum Data Set (MDS) assessment dated [DATE] for Section A-Identification Information: revealed Level II PASARR had not evaluated the resident, and the resident did not currently have a Level II PASARR; Section C-Cognitive Pattern: revealed, the resident had a Brief Interview for Mental Status (BIMS) score of 15; Section E-Behaviors: revealed that R13 displayed behaviors of rejection of care that were necessary to achieve the resident's goals for health and well-being for one to three days during the assessment period and the behavior had worsened since the previous OBRA assessment (Quarterly Assessment 11/15/2023). A review of the medical record revealed a Level I PASARR for R13 dated 2/5/2021. A review of the Medical Doctor (MD) orders revealed an order for oxcarbazepine 300 mg to be administered by mouth twice per day for the treatment of paranoid schizophrenia. A review of the MD Visit Notes dated 3/1/2022 revealed that R13 had a new diagnosis of paranoid schizophrenia. A review of the nursing progress notes dated 3/1/2022 revealed that R13 was readmitted after mental health facility admission. A review of the medical record revealed that R13 received psych services on 3/16/2023, 5/4/2023, 7/20/2023, 9/7/2023, 11/16/2023, and 12/13/2023. During an interview with the Administrator on 3/16/2024 at 11:26 am, she stated the Social Worker (SW) was typically responsible for auditing the PASARRs in the facility, but the facility had actively been recruiting for the position of SW since July 2023. She stated that eight current residents with Level II PASARRs were admitted to the facility with Level II PASARRs, and the facility did not currently have a process to ensure Level II PASARR evaluations or audits for Level II PASARR services were conducted. She added that she was working on a process for PASARR evaluations and audits. The Administrator acknowledged that R13 was sent out to a mental health facility due to behaviors in July 2022 and was diagnosed with paranoid schizophrenia.

Based on staff interview, record review and review of the facility's policy titled, Electronic Transmission of the MDS, the facility failed to accurately code one out of 22 sampled Residents (R) (R18), Quarterly Minimum Data Set (MDS) assessment for urinary tract infection (UTI). Findings include: Review of the facility's policy titled, Electronic Transmission of the MDS dated [DATE] under Policy Interpretation and Implementation revealed, Number 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. Review of the Quarterly MDS assessment dated [DATE] for Section I: Active Diagnosis revealed R18 was assessed as having a UTI in the last 30 days. Review of R18's physician orders revealed no antibiotic ordered for a UTI within the 30 day look back period of the MDS assessment. Review of the nursing progress notes revealed no notation of R18 having a UTI during the 30 day look period of the Quarterly MDS assessment. Continued review of the nursing progress notes revealed that R18 had completed antibiotic therapy for UTI on 6/2/2023. During an interview on 3/16/2024 at 3:15 pm, the MDS Coordinator confirmed that Section I of the quarterly MDS assessment dated [DATE] was coded as R18 having a UTI. The MDS Coordinator confirmed that R18 did not have a UTI during the MDS look back period and revealed she failed to uncheck the indicator from the previous quarterly MDS assessment, and it should not have been checked. During an interview on 3/16/2024 at 3:15 pm, the MDS Coordinator confirmed that Section I of the quarterly MDS assessment dated [DATE] was coded as R18 having a UTI. The MDS Coordinator confirmed that R18 did not have a UTI during the MDS look back period and revealed she failed to uncheck the indicator from the previous quarterly MDS assessment, and it should not have been checked.

Based on observations, staff interviews, and review of the policy titled Quality of Life - Homelike Environment, the facility failed to ensure the packaged terminal air conditioner (PTAC) units in six of 19 resident rooms (rooms 6, 7, 8, 9, 10, and 11) on one of one hall were clean and free of dust buildup. In addition, the facility failed to ensure that the toilet tank lid was in place in a shared bathroom for rooms [ROOM NUMBERS]; failed to ensure the toilet and toilet seat were not loose and failed to ensure the top of the toilet was even and fitted securely to the toilet tank in a shared bathroom for room seven and nine. These failures had the potential to place residents residing in the rooms at risk of the use of unsanitary and unsafe equipment, placing the residents at risk for a diminished quality of life. The census was 42 residents. Findings include: A review of the facility-provided policy titled Quality of Life - Homelike Environment, revealed the Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. In the Policy Interpretation and Implementation section, line number 2 states: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects a personalized, home-like setting. These characteristics include a. Cleanliness and order. 1. Observations of resident rooms on 3/15/2024 from 9:28 am to 9:40 am revealed the following findings: room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. room [ROOM NUMBER]: The PTAC filter was observed to have a large buildup of dust. Observations on 3/16/2024 from 2:00 pm to 2:10 pm of the same resident rooms revealed the PTAC filters continued to have a large buildup of dust. Interview on 3/16/2024 at 3:15 pm with the Maintenance Director stated he had worked as the Maintenance Director for one year and was the only employee in the Maintenance Department. He stated he cleaned the PTAC units four times a year and that both himself and the Housekeeping Department were responsible for cleaning the PTAC filters in the resident rooms. The Director of Housekeeping and the Maintenance Director both stated there was no schedule for the cleaning of the filters or documentation of the filters being cleaned. Observations of the PTAC filters in rooms 6, 7, 8, 9, 10, and 11, with the Maintenance Director and the Housekeeping Supervisor verified the filters had a large build-up of dust. The Maintenance Director stated he would check and clean all filters in resident rooms. Interview on 3/16/2024 at 3:30 pm with the Administrator stated, her expectations were for the resident room heating and air unit filters to be cleaned regularly and for a schedule to be followed. 38988 2. Observation on 3/16/2024 at 10:15 am and 4:31 pm revealed in the shared bathroom in room [ROOM NUMBER] and 14, the toilet was missing the top tank lid/covering, with the flushing parts and water accessible to residents who reside in the two rooms. There was a black colored toilet plunger lying on the floor behind the toilet bowl. Observation on 3/16/2024 at 10:20 am and 4:18 pm revealed in the shared bathroom in room seven and nine, the toilet was loose and wabbly, the toilet seat was loose and movable, and the tank to the top of the toilet was uneven and didn't fit the toilet tank. In an interview on 3/17/2024 at 3:00 pm, concerns identified during the survey were verified with the Maintenance Director. He stated he had been gradually working on room improvements, and stated he did not know what happened to the missing tank top in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER]. During further interview, he stated he would replace the toilet seat and find a top to fit the toilet tank in room seven.

Based on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure the QAPI program effectively identified, developed and implemented appropriate action plans to meet the needs of six of 19 sampled residents (R) (R6, R10, R8, R14, R17, and R18). Specifically, the Quality Assurance Performance Improvement failed to protect R8, R14, R17, and R18 from abuse and failed to provide safety and oversight of the elopement prevention program for R6 and R10. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on [DATE] at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE] when the facility failed to protect four residents (R) (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on [DATE] when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of [DATE]. Findings include: Review of the policy titled Quality Assurance and Performance Improvement dated [DATE], revealed the policy is develop, implement, and maintain an effective, comprehensive, data driven Quality Assurance and Performance (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: Number 1: The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. Number 2c. Develop and implement appropriate plans of action to correct identified quality deficiencies. 2d. Regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements. Number 3. The QAPI plan will: a. Address design and scope of the facility's QAPI program. b. Policies and procedures for feedback, data collection systems, and monitoring. c. A systematic approach to determine when in-depth analysis and/or action is needed to ensure that improvements are realized and sustained. d. Prioritization of program activities that focus on high-risk, high volume, or problem-prone areas. Number 7. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. Adverse events will be monitored in accordance with established procedures for the type of adverse event. Review of the policy titled QAPI program dated [DATE] indicated the facility will maintain the QAPI program in such a way as to use it as a valuable tool for effecting positive changes for the facility, residents, and team members. The Guiding Principles of the QAPI Program are: Ensure that team members are informed and given opportunities to participate in the QAPI process. Measure the results of the activities and use those metrics to inform us as to the best way to continue improving services to the Residents and Team Members. Make decisions based upon the data which includes the input and experience of caregivers, residents, health care practitioners, families and other stakeholders. Support performance Improvement by encouraging team members to support each other as well as be accountable for their own professional performance and practice Maintain a culture that will encourage, rather than punish, employees who identify system breakdowns. View QAPI as a valuable tool in achieving our goal of continuous process improvement. Based upon the information and data that is shared by each department, the QAPI committee will make decisions regarding performance improvement plans (PIPs) that are needed for specific departments or process. Additionally, the QAPI Committee will be charged with performing Root Cause Analysis (RCAs) of adverse events that rise to a level of critical importance and have potential of affecting on-going operations of the facility. 1. Review of the facility policy titled Abuse Prohibition Policy and Procedures revised [DATE] revealed the facility believes that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. The facility failed to have an effective QA process to address failures in the facility including identifying and reporting allegations of Abuse. A total of 10 allegations of Abuse were documented in residents' electronic medical records (EMR's), but were not identified as potential Abuse, and not reported to State Agency or investigated by the facility. Review of the QAPI notes and Performance Improvement Plan (PIP) notes, there was no documented evidence indicating that the QAPI Committee had identified concerns of Abuse as an opportunity for improvement. Interview on [DATE] at 1:10 pm, the Administrator stated that the QAPI committee only briefly discussed Abuse and Neglect per the facility's QAPI calendar. The Administrator stated the committee did not identify abuse as a topic that warranted further discussion or process improvements. Interview on [DATE] at 12:30 pm, the Regional Administrator revealed the facility reported all the identified incidents from [DATE] to present to the SA. The Regional Administrator stated the self-reports had been called in on Friday, [DATE]. During further interview, he stated they had a much better plan to educate the staff on abuse, neglect, abuse prevention, including reporting and investigating allegations of abuse. 2. Record review of the undated facility policy last revised 2008, titled Elopements showed, staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse (CN) or the Director of Nursing (DON). When a departing individual returns to the facility, the DON or CN shall examine the resident for injuries, notify the attending physician, notify the residents legal representative of the incident, complete and file Report of Incident/Accident, and document the event in the resident's medical record. Interview on [DATE] at 11:25 am LPN AA revealed she was familiar with R6 and stated R6 was slick, sneaky, and understood what was going on. R6 was familiar with his surroundings and always looked for a way out. AA stated the current wander guard system was unsafe and placed residents at risk. Interview on [DATE] at 2:40 pm, the Maintenance Director revealed the front entrance was the only door equipped with an electronic alert system. He stated the sensor was supposed to beep when a resident with an electronic alert system gets close to the door. He revealed the rest of the facility exit doors were not equipped with the electronic alert system. The Maintenance Director revealed the facility installed all the exit doors with a mega lock system on [DATE], which requires an access code to be entered to exit the building. He stated he checked the mega lock system daily but does not check the electronic alert system. The Maintenance Director stated the facility relied on the mega lock system which, he stated did not have a sound feature to alert staff when a resident equipped with an electronic alert system exits the building. Interview on [DATE] at 4:45 pm, Administrator in Training (AIT) stated the previous administrator said a new system was to be installed and that never happened. The AIT stated the current electronic alert system was unsafe and explained if a resident walked behind a family member staff would not be able to detect and hear the alarm sound. Interview on [DATE] at 8:53 am, the previous administrator revealed she was unaware how R6 and R10 exited the building without staff noticing. She stated R6 and R10 were not adequately supervised, and the wander guard system did not sound the alarm when they exited. During further interview, she stated when R6 and R10 eloped from the facility, the doors were not equipped with the maglock system. She stated the maglock key codes are only given to staff members. She stated she expected staff to provide protective oversight for all residents. Interview on [DATE] at 9:51 am the DON shook her head no when asked if the nurses' input were considered for the QAPI meeting. When asked if the nursing department held departmental meetings, the DON shook no, The DON stated the Regional Nurse Consultant (RNC) just implemented a daily clinical meeting effective [DATE]. The DON was asked if the QAPI meetings were effective, the DON shook head no. The DON stated it was a waste of time and it feels like they are having a meeting just to have it. Interview on [DATE] at 8:33 am, the Regional Administrator stated the previous Administrator resigned on [DATE], effective immediately. He stated he was the Interim Administrator. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education on identifying, reporting, investigating, and implementing corrective actions to decrease the likelihood of alleged abuse using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. ([DATE]). 2. The Regional Nurse Consultant provided education on elopements using the Wandering and Elopements policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. ([DATE]). 3. Administrator, [NAME], resigned effective immediately on [DATE]. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on [DATE]. ([DATE]) 4. The Interim Administrator ([NAME], NHA 004705) reviewed and acknowledged the Administrator job description. ([DATE]) 5. The Regional [NAME] President provided education on the QAPI/QAA Improvement process to Department Managers: AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. ([DATE]). 6. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited [DATE] and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Care Plan policy was completed, and no policy changes were recommended. ([DATE]). 7. The identified progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] that contain allegations of abuse for R5 as the perpetrator have been reported, investigated, and corrective action implemented to decrease the likelihood of occurrence of the alleged abuse. ([DATE]). 8. R5 continues to reside at Heardmont Health and Rehab. R5 received inpatient geri-psych treatment from [DATE] - [DATE]. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning [DATE]. 9. The progress note dated [DATE] alleges physical abuse has been reported investigated, and corrective action implemented to decrease the likelihood of occurrence of alleged abuse for R3 and R8. ([DATE]). 10. The allegations of physical abuse of R8, R14, and R17 have been reported and investigated, and necessary corrective actions have been implemented to decrease the likelihood of the occurrence of alleged abuse. ([DATE]). 11. The allegations of sexual abuse for R8 and R17 have been reported and investigated, and necessary corrective actions have been implemented to decrease the likelihood of the occurrence of the alleged abuse. ([DATE]). 12. R8 continues to reside at this facility. The last allegation involving R8 and R5 together occurred on [DATE]. 13. R14 continues to reside at this facility. The last allegation involving R14 and R5 together occurred on [DATE]. 14. R17 continues to reside at this facility. The last allegation involving R17 and R5 together occurred on [DATE]. 15. The allegations of verbal abuse for R18 have been reported and investigated, and necessary corrective actions have been implemented to decrease the likelihood of the occurrence of the alleged abuse. ([DATE]). 16. R18 discharged from the facility [DATE]. 17. An audit was completed of Nurse's Notes dating back to [DATE] to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. ([DATE]). 18. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. ([DATE]). 19. A root cause analysis was completed, it was determined that a lack of thorough education related to the Abuse Prevention Program and a lack of training related to Wandering and Elopements was a factor. Education for all staff related to the Abuse Prevention Program and Wandering/Elopements was started on [DATE] and has continued through [DATE]. ([DATE]) 20. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy and the Wandering and Elopements policy for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% ([DATE]). 21. All facility staff not in-serviced on the Abuse, Neglect, and Exploitation Policy specific to identifying, reporting, investigating, and implementing corrective actions to decrease the likelihood of occurrence of alleged abuse will not be allowed to work until the education is completed. ([DATE]). The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. On [DATE] at 9:00 am - 9:45 am: Review of Immediate Jeopardy Findings AD HOC QAPI Meetings - presented by Regional Administrator. 10 employees (Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assist, MDS, DON, Housekeeping Supervisor, Human Resources) in addition to the Medical Director; signed on [DATE]. On [DATE] a QAPI meeting was conducted. The topics discussed: Wandering & Elopement policy and procedures, Grievance policy and procedures, stated reportables, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-of unknow origin. In attendance: Medical Director, Administrator AIT, DON, MDS, SSD/Human Resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, and Regional Nursing Consultant. 2. Evidence of the Wander Guard Training and in-services was verified in the inservice signup sheet dated [DATE] located in the binder provided by the facility and 23 staff were in- serviced. An inservice meeting verified an inservice meeting held on [DATE] was held regarding Maglock doors and how to check them. New Door codes. Door checks to ensure lock was engaged. The Wonder guard system. Providing security to at risk residents and using proper tools to check door bracelets and checking residents' bracelets. (23 staff were in-serviced). 3. This was verified as per observation [DATE] at 8:58 am and stated the administrator yesterday evening and that was accepted, and he will the acting administrator moving was forward. During an interview on [DATE] at 9:44 am the DON revealed there was an administrator change and added the Regional Administrator as the interim Administrator. When the staff are unable to reach the interim Administrator regarding reportable, they are required to report to her. 4. On [DATE] at 8:58 am the Regional Administrator stated he was the Acting Administrator going forward. The Regional Administrator stated the Administrator had resigned on [DATE]. The IJ Removal plan included the Administrator's job description with an interim hire date of [DATE]. 5. A review of the removal plan for QAPI/QAA Improvement process revealed the Regional Administrator provided education for the QAPI/QAA Improvement process. An interview on [DATE] at 1:15 pm with the current Interim Administrator, previously the Regional Administrator, confirmed that his other title was Regional Vice-President. 6. On [DATE] at 8:58 am the Regional Administrator stated he was the Acting Administrator going forward. The Regional Administrator stated the Administrator had resigned on [DATE]. [DATE] /ADHOC related to Complaint Survey review of wandering and elopement policy and procedure, Grievances policy and procedure, State reportables, Abuse policy and procedure (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury of unknown origin), and Abuse triggers. On [DATE] at 9:00 am - 9:45 am: Review of Immediate Jeopardy Findings AD HOC QAPI Meetings - presented by the Regional Administrator. 10 employees (Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assist, MDS, DON, Housekeeping Supervisor, Human Resources) in addition to the Medical Director; signed-in sheet on [DATE]. 7. An interview on [DATE] at 12:30 pm with the Regional Administrator revealed the facility had decided to go through the process of reporting all the incidents from [DATE] to present. The Regional Administrator stated they identified what should have been reported and reported it to the state. The Regional Administrator stated the self-reports had been called in on Friday. The facility reviewed the QAPI meetings, in-services, abuse prevention in-services and reviewed the care plans of R5 and R8. The Regional Administrator stated the Regional Nurses Consultant and the Director of Clinical Services conducted in-person in-services to 95% of the employees and would continue to complete the other 5% on [DATE]. The Regional Administrator stated part of the plan would be to interview residents with BIMS > eight and determine if there had been any concerns. The Regional Administrator stated they had a much better plan, going forward to educate all the nursing staff on abuse, neglect, and abuse prevention. Identified allegations of abuse about R5 a. [DATE] - reviewed FRI- Date reported is [DATE]. b. [DATE] - reviewed FRI- Date reported is [DATE]. c. [DATE] - reviewed FRI- Date reported is [DATE]. d. [DATE] - reviewed FRI- Date reported is [DATE]. e. [DATE] - reviewed FRI- Date reported is [DATE]. f. [DATE] - reviewed FRI- Date reported is [DATE]. g. [DATE] - reviewed FRI- Date reported is [DATE]. h. [DATE] - reviewed FRI- Date reported is [DATE]. 8. A record review of R5's psychiatric hospital visit revealed R5 was admitted on [DATE] due to combative behavior towards the staff. R5 was discharged from the hospital on [DATE]. On [DATE] the subjective observations revealed R5 was very confused. R5's thought process remained disorganized. R5 continued to require frequent behavioral re-direction but had not been combative. The objective observations revealed R5 had good grooming, normal speech, anxiousness, disorganized thought process, delusions, attention span/concentration was poor, poor memory, and poor functional capacity. On [DATE] the subjective observations revealed R5 had no new complaints, thought process remained disorganized, and R5 had reached a baseline that was compatible with outpatient care and discharge was anticipated. The objective observations revealed R5 had good grooming, normal speech, labile mood/affect, disorganized thought process, delusions, and poor attention span/concentration. The Clinical Treatment Plan: a. Benefit versus side effect profile to each medication had been reviewed. b. Patient continued to participate in group and individual therapy. R5 was admitted via the emergency room . R5 exhibited auditory and visual hallucinations, paranoid delusions, anger outbursts, and aggressive behaviors. R5 had multiple episodes of combative behaviors with staff. Initially, Depakote level was obtained. R5 was placed on Zyprexa 2.5 mg twice a day and Nuedexta ,d+[DATE] for pseudobulbar affect. R5 received Thorazine 50mg injection on [DATE]. R5's Zyprexa was increased to 5 mg twice a day on [DATE]. R5 improved over the period of the [DATE] to [DATE]. The hospital performed a Suicide risk assessment and determined R5 was safe to return to voluntary outpatient care. R5 was discharged on [DATE] with orders to follow-up with a local mental health authority in seven to nine days. 9. The facility provided the State Reportable Incident Log, which confirmed the incident between R3 and R8 had been reported on [DATE]. 10. The facility's Incident Reports revealed the facility processed investigations for R8, R14, and R17 on [DATE] and disposition was sent on [DATE]. 11. R8 Sexual abuse allegation was reported all though it was not reported until [DATE] per the previous Administrator, the date on the FRI stated [DATE]. The Compliance Specialist III stated someone must have started the incident report but did not finish the report to submit it on the 13th. The final report is due on [DATE]. 12. The review of the nurses' notes dated [DATE] at 12:10 am revealed R8 and R5 last incident had occurred on this date. 13. The review of the nurses' notes dated [DATE] revealed R14 and R5 last incident had occurred on [DATE]. 14. The review of the nurses' notes dated [DATE] revealed R17 moved from room [ROOM NUMBER]B to room [ROOM NUMBER]B. 15. The review of the nurses' notes dated [DATE] at 10:30 am revealed R18 expired on [DATE] when no pulse, no blood pressure, and no [NAME] sounds were noted. 16. The review of the nurses' notes dated [DATE] at 10:30 am revealed R18 expired on [DATE] when no pulse, no blood pressure, and no [NAME] sounds were noted. 17. An example of the Performance Improvement, dated [DATE], conducted by the DON and AIT, indicated the facility would review the nurses' notes for abuse and potential behavior events indicating if they were state reportable. The directions included: A member of the Performance Improvement Committee will review compliance. This review dates back to [DATE] to current. A 'Yes' response may indicate potential problems. The example also included the Abuse Questionnaire for Interviewable Residents. A review of the Abuse Questionnaire revealed the facility interviewed 19 residents to determine if there had been any problems or concerns with abuse/safety. 18. An example of the Performance Improvement, dated [DATE], conducted by the DON and AIT, indicated the facility would review the nurses' notes for abuse and potential behavior events indicating if they were state reportable. The directions included: A member of the Performance Improvement Committee will review compliance. This review dates back to [DATE] to current. A 'Yes' response may indicate potential problems. The example also included the Abuse Questionnaire for Interviewable Residents. A review of the Abuse Questionnaire revealed the facility interviewed 19 residents to determine if there had been any problems or concerns with abuse/neglect/safety. 19. [DATE] at 12:00 pm - 1:00 pm and 2:00 pm - 3:00 pm: In-service Freedom from Abuse and Neglect, Sexual Abuse was conducted by the Regional Nursing Consultant. 34 employees attended. [DATE] at 12:00 pm - 1:00 pm and 2:00 pm - 3:00 pm: In-service Freedom from Abuse and Neglect, Resident to Resident Physical Abuse was conducted by the Regional Nursing Consultant. 35 employees attended. [DATE] at 12:00 pm - 1:00 pm and 2:00 pm - 3:00 pm: In-service Abuse Prevention Program, Reporting/Investigating was conducted by the Director of Clinical Services. 34 employees attended. [DATE] at 10:30 am - 11:15 am: In-service Freedom from Abuse Neglect, Abuse Reporting, and Investigating Abuse was conducted by the Director of Clinical Services. 15 employees attended. [DATE] at 2:00 pm - 2:45 pm: In-service Freedom from Abuse Neglect, Abuse Reporting, and Investigating Abuse was conducted by the Regional Nursing Consultant. 12 employees attended. [DATE] at 2:00 pm: Verbal In-service Abuse, Wandering and Elopements was conducted. 23 employees attended. 20. An example of the Performance Improvement, dated [DATE], conducted by the DON and AIT, indicated the facility would review the nurses' notes for abuse and potential behavior events indicating if they were state reportable. The directions included: A member of the Performance Improvement Committee will review compliance. This review dates back to [DATE] to current. A 'Yes' response may indicate potential problems. The example also included the Abuse Questionnaire for Interviewable Residents. A review of the Abuse Questionnaire revealed the facility interviewed 19 residents to determine if there had been any problems or concerns with abuse/safety. 21. An interview on [DATE] at 9:45 am, with the Regional Administrator. The Regional Administrator provided a list of all the employees at the facility, each employee's hire date, and the date the employee had completed the in-service. The Regional Administrator stated that the last two staff listed on the employee list were RN Supervisors. The Regional Administrator stated they were PRN and will not be returning to the facility. The Regional Administrator stated a new employee was hired to take both of their place. 49477 49479 49687

Based on record review, interviews, and review of the Administrator's Job Description, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and ensuring proper functioning of the electronic alert system, failed to protect residents from abuse, failed to report allegations of abuse, and failed to thoroughly investigate allegations of abuse. Two Immediate Jeopardy situations were identified when two residents (R) (R6 and R10) eloped four times in a three-month period; abuse and allegations of abuse for four residents (R8, R14, R17, and R18) were not reported to the State Agency (SA); and 10 allegations of abuse were not thoroughly investigated. The sample size was 19. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/5/2022 when the facility failed to protect four residents (R) (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings included: Review of the document titled Administrator Job Description signed and dated 9/12/2018 by the previous Administrator, documented the summary of the position is to lead and direct the overall operation of the facility in accordance with the residents needs, government regulations, and company policies so as to maintain care for the residents. Essential job functions include: Directs and coordinates medical, nursing, and administrative staff and services Implements and communicates policies and procedures for various departments Conducts regular rounds to monitor delivery of nursing care. Conducts regular rounds to monitor for operation of support departments Conducts regular rounds to monitor residents needs are being met Maintains a working knowledge and ensures compliance with all governmental regulations 1. Review of the clinical record revealed that R6 was admitted to the facility on [DATE] with diagnoses including dementia, agitation, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99, indicating the resident had severe cognitive impairment. Section E revealed the resident exhibited wandering behaviors daily and the behaviors put the resident at significant risk of getting outside the facility. Section GG revealed resident ambulated independently. Review of the Facility Incident Report dated 7/14/2023 at 10:30 am revealed R6 eloped from the facility and was located approximately half mile from the facility. Resident was missing for approximately three hours. Review of the electronic medical record (EMR) revealed an Elopement Risk assessment dated [DATE] documented that R6 wanders aimlessly and verbally expresses a desire to leave the facility. An electronic alert system was applied to left wrist. Review of the Progress Note dated 7/2/2023 at 1:49 am written by Licensed Practical Nurse (LPN) HH, documented R6 was being monitored due to wandering and voiced the desire to go home and tried to find a way out, electronic alert system intact to left wrist. Review of the Progress Note dated 8/19/2023, written by LPN HH, documented on 8/18/2023 at 11:15 pm Certified Nursing Assistant (CNA) TT observed R6 going out the laundry door near the maintenance shed. Review of a handwritten statement dated 8/29/2023 written by CNA EE, documented R6 walked out through the back door, and she tried to redirect him back inside the building, but resident refused. She documented that R6 was not supposed to be outside, but he got out on his own. There is no evidence of documentation of this incident in the residents' electronic medical record. Interview on 11/27/2023 at 11:25 am, LPN AA revealed she was familiar with R6 and stated he was slick, sneaky, and understood what was going on. She stated R6 was familiar with his surroundings and always looked for a way out. LPN AA stated the current electronic alert system was unsafe and placed residents at risk. Interview on 11/28/2023 at 4:59 pm CNA FF revealed there was an electronic alert system at the front door, but stated the alarm sound was faint and it could not be heard. She revealed there was no electronic alert system on any of the other exit doors. She stated the residents had been able to get in and out of the facility before the maglocks were installed. Interview on 11/28/2023 at 9:43 am, LPN GG stated that R6 had attempted to leave the facility on multiple occasions. She revealed when R6 eloped on 7/14/2023, the facility doors stayed unlocked. During further interview, LPN GG stated she does not recall the incident which occurred on 8/29/2023, when R6 exited the building, and fell and hit his head. She stated it was impossible to monitor residents who were at risk for elopement on regular basis due to staffing concerns. 2. Review of the clinical record revealed that R10 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, hypertensive heart disease, and stage four chronic kidney disease (CKD). Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section E revealed the resident did not exhibit wandering behavior. Section GG revealed resident ambulated independently. Review of the Facility Incident Report dated 9/16/2023 at 10:30 am revealed R10 was noted missing in the facility. At 10:30 am the residents' family member called the facility informing staff that the resident stated earlier in the morning that he was leaving the facility. The resident was noted with superficial scratches to face and was sent to emergency room . Review of the electronic medical record (EMR) revealed an Elopement Risk assessment dated [DATE] revealed R10 wandering section was not completed, but indicated his photo was added to the wanderer list. Further review revealed resident has not shown any signs of leaving facility, and electronic alert system was removed. Review of a written statement from the Administrator in Training (AIT) dated 9/16/2023, the AIT documented at 10:55 am she drove and searched the area for R10. At 1:52 pm, the Activities Director (AD) called and stated R10 had been located. Review of the Progress Note revealed a late entry dated 9/16/2023 at 2:23 pm written by LPN GG, documented at approximately 10:20 am, she received a call from R10's representative. The representative stated R10 expressed the desire to leave the facility immediately. Staff were unable to locate R10 in the facility. Interview on 11/27/2023 at 2:40 pm, the Maintenance Director revealed the front entrance was the only door equipped with an electronic alert alarm sensor system. He stated the sensor system was supposed to beep when a resident with an electronic alert gets close to the door. He revealed the rest of the facility exit doors were not equipped with the electronic alert system. During further interview, he stated staff informed him the front door electronic alert system alarm was not loud enough. He stated the electronic alert system was discontinued and obsolete and could not be repaired. He revealed the facility installed all the exit doors with a mega lock system on 9/14/2023, which requires an access code to be entered to exit the building. He revealed he checked the mega lock system daily but does not check the electronic alert sensor system. He stated the facility relied on the mega lock system, but it did not have a sound feature to alert staff when a resident equipped with an electronic alert exits the building. Interview on 11/27/2023 at 4:07 pm, the Director of Nursing (DON) revealed she was aware the current electronic alert alarm system was not loud enough for staff to hear, and confirmed the front door was the only door fitted with the electronic alert system. The Maintenance Director was notified of the failure and is aware. Interview on 11/27/2023 at 4:45 pm, the AIT revealed the electronic alert system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the previous Administrator indicated a new system was to be installed, but that didn't happen. The AIT stated the current system was unsafe and explained if a resident walked out behind a family member, staff would not be able to detect and hear the alarm sound. Interview on 11/28/2023 at 8:53 am, the previous administrator revealed she was unaware how R6 and R10 exited the building without staff noticing. She stated R6 and R10 were not adequately supervised, and the electronic alert system did not sound the alarm when they exited. During further interview, she stated when R6 and R10 eloped from the facility, the doors were not equipped with the mega lock system. She stated the mega lock key codes are only given to staff members. She stated she expected staff to provide protective oversight for all residents. Interview on 12/5/2023 at 9:50 am, the DON revealed QAPI meetings were designed to discuss areas needed for improvement and to discuss residents who were potentially at risk. The DON concluded the meetings in QAPI are a waste of time, and added discussions are never put in practice. Cross Refer F656, F689 3. Review of the clinical record revealed that R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Review of the Progress Note dated 10/24/2022 revealed R3 grabbed R8's left upper arm and pushed R8 against the nursing station. The pushing caused R8 to hit the right side of her body against the nurses' station. Review of the Progress Note dated 11/14/2022 revealed several witnesses observed R3 approach another resident and without provocation, grabbed the female resident by the head and shook her head around. The female resident was in a geriatric chair, with her eyes closed, before R3 had grabbed her. R3 let go of the female resident when he was confronted by the staff. 4. Review of the clinical record revealed that R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating cognition could not be determined. Review of the Progress Note dated 7/5/2022 at 5:52 pm revealed R5 speaking loudly in his room. I enter room and he is standing over his roommate (R18) yelling cuss words and shaking his fist in the direction of the resident. Review of the Progress Note dated 11/29/2022 at 1:48 pm revealed that R5 entered R8's room and walked up to R8's bed, and she told him to leave. He then grabbed her wrist pushing on her. Review of the Progress Note dated 12/1/2022 at 2:23 am revealed that R5 was observed in another residents (R18) room, and both residents were hollering at each other - was able to redirect R5 back to his room and back to bed. Review of the Progress Note dated 1/6/2023 at 12:10 am revealed R5 entered into R8's room and was tugging at her hands. Staff redirected R5 out of R8's room. Review of the Progress Note dated 7/2/2023 at 1:58 am revealed on 7/1/2023 at 10:20 pm, R5 was up in his room when CNA entered the room, R5 noted holding roommate's (R17) leg while his roommate (R17) was in bed sleeping. Review of the Progress Note dated 7/2/2023 at 6:47 am revealed that R5 was observed in the bed with his roommate (R17). R5 had taken off all his clothes and threw his adult brief in the doorway. Review of the Progress Note dated 7/16/2023 at 6:40 am revealed that R5 was observed hitting his roommate (R17) in the arm and face with his bedroom shoe - roommate (R17) removed from the room for safety. Review of the Progress Note dated 9/22/2023 at 2:47 pm revealed that R5 slapped the other resident (R14) and pulled her hair. The other resident (R14) scratched at R5 and then the two were separated. Interview on 11/29/2023 at 9:07 am, CNA EE stated R3 and R5 had a history of hitting other residents and would become combative when their medications wore off. CNA EE stated the staff had tried to keep both residents from hitting and/or becoming combative with other residents, but it had been difficult. During further interview, she revealed everyone working at the facility knew R3 and R5 had been combative and had tendencies to hit other residents and staff. She stated there had not been any in-services on how to care for residents when aggressive behaviors were exhibited. 5. Review of the clinical record revealed that R8 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, anxiety, chronic obstructive pulmonary disease (COPD), and depression. Review of the admission MDS assessment dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. Review of a police report dated 11/13/2023 revealed R8 alleged a Contracted Physical Therapist had touched her inappropriately. This allegation of sexual abuse was not investigated by the facility. Interview on 11/29/2023 at 1:03 pm, Administrator and Business Office Manager (BOM) both stated R8 reported an allegation of sexual abuse to them on 11/13/2023. The BOM stated she referred R8 to the Administrator. The Administrator verified she received the allegation from R8 and did not do anything further. The Administrator confirmed that she considered this to be an allegation of abuse. She stated she was waiting to hear back from the police officer before doing anything further. 6. Review of the clinical record revealed that R14 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of four, indicating severe cognitive impairment. 7. Review of the clinical record revealed that R17 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, seizure disorder, traumatic brain injury, and depression. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating cognition could not be determined. 8. Review of the clinical record revealed that R18 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, congested heart failure (CHF), urinary tract infection (UTI), asthma, and depression. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Review of the facility's State Reportable Incident Log revealed that none of the above identified allegations were identified as State reportable, and therefore, were not reported to the State Agency. Interview on 11/29/2023 at 12:02 am, the DON revealed she was unsure who the abuse coordinator was. She stated, I will find out. The DON returned at 12:09 am and stated the Administrator is the Abuse Coordinator. Interview on 11/29/2023 at 1:30 pm, the Administrator/Abuse Coordinator confirmed that the allegations identified in the EMR progress notes were not reported or investigated. The Administrator's response to each identified entry was, I don't have that . that wasn't reported to me. Cross Refer F600, F609, F610 The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education related to the Wandering and Elopements policy, location of Elopement Binders, identifying residents at high risk for elopement, and Magnetic Door Lock Mechanism functionality to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director (12/06/2023). 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Care Plan policy was completed, and no policy changes were recommended. (12/12/2023). 3. Administrator, [NAME], resigned effective immediately on 12/05/2023. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on 12/06/2023. (12/06/2023) 4. The Interim Administrator ([NAME], NHA 004705) reviewed and acknowledged the Administrator job description. (12/06/2023) 5. All Residents were assessed using the Elopement Risk Assessment to determine residents at high risk for elopement. These assessments resulted in three (3) additional residents at high risk, bringing the facility total to five (5) residents at high risk for elopement. (11/30/2023) 6. Care Plans have been reviewed and updated for five Residents determined to be at High Risk for Elopement. (11/30/2023). 7. Five (5) residents determined to be at High Risk for Elopement have been updated in the Elopement Binder. All staff have been educated on the location of the Elopement Binder (Admin office, dietary (kitchen), and nurse's station. The elopement binders will be updated as any additional residents are identified as high risk for elopement. The Director of Nursing will be responsible for updating the elopement binder. (12/01/2023) 8. Resident R10 is no longer a Resident at this facility. (9/16/2023) 9. Resident R6 continues to reside at this facility and is being followed by contracted psych services. R6 was seen by psych services on: 8/10/2023, 9/7/2023, and 11/16/2023. R6 has no elopements since 8/29/2023. 10. Magnetic Door Locking mechanisms have been installed on all entry/exit doors that require a code for entry and exit. Staff members only are given the access code for the doors. (9/16/2023). 11. Magnetic Door Locking mechanisms are monitored and checked for functionality daily by the Maintenance Director (Monday-Friday) and the Weekend RN Supervisor (Saturday-Sunday) using the Daily Door Lock Checks form. (12/04/2023). 12. The Main Entrance is equipped with a functioning Wander Guard system because all Visitors and Vendors are required to enter and exit at the Main Entrance. The Wander Guard system delivers an audible announcer if a Resident identified at High Risk for Elopement breaches the Main Entrance doorway with a Wander Guard intact device. (12/01/2023). 13. The Wander Guard devices on residents identified as high risk for elopement are monitored every 12 hours by a Nursing Manager using the handheld [NAME] Wander Guard Universal Tester noted in the electronic Medication Administration Record (MAR). The Universal Tester device was ordered and was delivered to the facility on [DATE]. All Staff are educated on 12/12/2023 on the use of the Universal Tester. (12/12/2023) 14. A root cause analysis was completed; it was determined that a lack of training related to Wandering and Elopements was a factor. Training for all staff related to Wandering and Elopements started on 11/30/2023 and has continued through 12/12/2023. (12/12/2023) 15. A Performance Improvement Plan related to Wandering and Elopements was developed and will be followed through the facility's QAPI process. (11/30/2023) 16. The Regional Nurse Consultant conducted training related to the Wandering and elopement policy, location of Elopement Binders, identifying residents at high risk for elopement, and Magnetic Door Lock Mechanism functionality for the following staff: a. 11of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff has received this training. d. 9 of 10 dietary staff members have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% (12/12/2023). 17. All facility staff not in-serviced on the Wandering and Elopements policy, location of Elopement Binders, identifying residents at high risk for elopement, and regarding Magnetic Door Lock Mechanism functionality will not work until the education is completed. (12/12/2023). The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. On 12/6/2023 at 9:00 am - 9:45 am: Review of Immediate Jeopardy Findings AD HOC QAPI Meetings - presented by [NAME], Regional Administrator. 10 employees (Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assist, MDS, DON, Housekeeping Supervisor, Human Resources) in addition to the Medical Director; signed on 12/12/2023. On 11/30/2023 a QAPI meeting was conducted. The topics discussed: Wandering & Elopement policy and procedures, Grievance policy and procedures, stated reportables, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-of unknow origin. In attendance: Medical Director, Administrator AIT, DON, MDS, SSD/Human Resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, Director of Clinical Services, and Regional Nurses Consultant. Phone interview on 12/15/2023 at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on 11/30/2023 and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. Interview on 12/15/2023 at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after 4/10/2022 were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicate there was a problem and a no indicated no problems were detected. For all the yes's, the group would discuss and review the notes and then a figure out who the other induvial named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 2. On 12/6/2023 at 8:58 am an interview with the Regional Administrator revealed he wound be the Acting Administrator going forward. The Regional Administrator stated the Administrator had resigned on 12/5/2023. 11/30/2023 /ADHOC related to Complaint Survey review of wandering and elopement policy and procedure, Grievances policy and procedure, State reportables, Abuse policy and procedure (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury of unknown origin), and Abuse triggers. On 12/6/2023 at 9:00 am - 9:45 am: Review of Immediate Jeopardy Findings AD HOC QAPI Meetings - presented by the Regional Administrator. 10 employees (Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assist, MDS, DON, Housekeeping Supervisor, Human Resources) in addition to the Medical Director; signed-in sheet on 12/12/2023. 3. On 12/6/2023 at 8:58 am the Regional Administrator stated he was the Acting Administrator going forward. The Regional Administrator stated the Administrator had resigned on 12/5/2023. The IJ Removal plan included the Administrator's job description with an interim hire date of 12/6/2023. 4. An interview on 12/6/2023 at 8:58 am with the Regional Administrator revealed he was the Acting Administrator going forward. The Regional Administrator stated the Administrator had resigned on 12/5/2023. The IJ Removal plan included the Administrator's job description with an interim hire date of 12/6/2023. 5. An interview on 12/5/2023 at 12:30 pm with the Regional Administrator, revealed the facility had decided to go through the process of reporting all the incidents from April 2022 to present. The Regional Administrator stated they identified what should have been reported and reported it to the state. The Regional Administrator stated the self-reports had been called in on Friday. The facility reviewed the QAPI meetings, in-services, abuse prevention in-services and reviewed the care plans of R5 and R8. The Regional Administrator stated the Director of Clinical Services and the Regional Nurses Consultant conducted in-person in-services to 95% of the employees and would continue to complete the other 5% on 11/30/2023. The Regional Administrator stated part of the plan would be to interview residents with BIMS > eight and determine if there had been any concerns. The Regional Administrator stated they had a much better plan, going forward to educate all the nursing staff on abuse, neglect, and abuse prevention. Identified allegations of abuse about R5 a. 9/22/23 - reviewed FRI- Date reported is 12/6/2023. b. 7/16/23 - reviewed FRI- Date reported is 11/29/2023. c. 7/2/23 - reviewed FRI- Date reported is 11/29/2023. d. 1/6/23 - reviewed FRI- Date reported is 12/7/2023. e. 11/29/22 - reviewed FRI- Date reported is 11/29/2023. f. 12/1/22 - reviewed FRI- Date reported is 12/1/2023. g. 7/5/22 - reviewed FRI- Date reported is 12/7/2023. h. 10/24/22 - reviewed FRI- Date reported is 12/1/2023. 6. Observation on 12/14/2023 at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on 12/15/2023 at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. R5 was assessed at Donalsonville Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated 9/1/23. A record review of R5's psychiatric hospital visit revealed R5 was admitted on [DATE] due to combative behavior towards the staff. R5 was discharged from the hospital on 9/15/2023. On 9/2/2023 the subjective observations revealed R5 was very confused. R5's thought process remained disorganized. R5 continued to require frequent behavioral re-direction but had not been combative. The objective observations revealed R5 had good grooming, normal speech, anxiousness, disorganized thought process, delusions, attention span/concentration was poor, poor memory, and poor functional capacity. On 9/14/2023 the subjective observations revealed R5 had no new complaints, thought process remained disorganized, and R5 had reached a baseline that was compatible with outpatient care and discharge was anticipated. The objective observations revealed R5 had good grooming, normal speech, labile mood/affect, disorganized thought process, delusions, and poor attention span/concentration. The Clinical Treatment Plan: a. Benefit versus side effect profile to each medication had been reviewed. b. Patient continued to participate in group and individual therapy. R5 was admitted via the emergency room . R5 exhibited auditory and visual hallucinations, paranoid delusions, anger outbursts, and aggressive behaviors. R5 had multiple episodes of combative behaviors with staff. Initially, Depakote level was obtained. R5 was placed on Zyprexa 2.5 mg twice a day and Nuedexta 20/10 for pseudobulbar affect. R5 received Thorazine 50mg injection on 9/7/2023. R5's Zyprexa was increased to 5 mg twice a day on 9/9/2023. R5 improved over the period of the 9/13/2023 to 9/15/2023. The hospital performed a Suicide risk assessment and determined R5 was safe to return to voluntary outpatient care. R5 was discharged on [DATE] with orders to follow-up with a local mental health authority in seven to nine days. 7. The facility provided the State Reportable Incident Log, which confirmed the incident between R3 and R8 had been reported on 12/6/2023. An interview on 12/15/2023 at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the DON had conducted a survey on whether R8 had any complaints or concerns about any allegations alleged concerning abuse towards the resident. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. 8. An example of the Performance Improvement, dated 11/30/2023, conducted by the DON and AIT, indicated the facility would review the nurses' notes for abuse and potential behavior events indicating if they were state reportable. The directions included: A member of the Performance Improvement Committee will review compliance. This review dates back to April 2022 to current. A 'Yes' response may indicate potential problems. The example also included the Abuse Questionnaire for Interviewable Residents. A review of the Abuse Questionnaire revealed the facility interviewed 19 residents to determine if there had been any problems or concerns with abuse/safety. The investigation that was identified on 12/1/2023; FRI revealed it was reported on 11/30/2023. An interview on 12/15/2023 at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated she understood that she had not been a registered nurse in years and would not attempt to redirect residents again. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. During an interview on 12/15/2023 at 5: 13 p.m., R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. During [TRUNCATED]

49479 49687 Based on record review, interviews, and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of sexual, physical and verbal abuse, were reported to the State Agency (SA) in a timely manner for four of 19 sampled residents (R) (R8, R14, R17 and R18). The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on [DATE] at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE] when the facility failed to protect four residents (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on [DATE] when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of [DATE]. Findings include: Review of the policy titled Abuse Prohibition Policy and Procedures revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R3 presented with a Brief Interview of Mental (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R5 presented with a BIMS score of 99, indicating severe cognitive impairment. 3. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, anxiety, chronic obstructive pulmonary disease (COPD), and depression. Review of the annual MDS assessment dated [DATE] revealed R8 presented with a BIMS score of nine, indicating moderate cognitive impairment. Review of the Progress Note dated [DATE] documented an allegation of physical abuse in which R3 grabbed R8's arm and pushed her into the nurses' station. The note indicated the action had caused R8 to hit the right side of her body against the nurses' station. Review of the Progress Note dated [DATE] at 1:48 pm documented that R5 entered (R8's room) and walked up to (R8), and (R8) told (R5) to leave. (R5) then grabbed (R8's) wrist pushing on (R8). Review of the Progress Note dated [DATE] at 12:10 am documented that R5 wandered into (R8's Room) - heard residents (in the room) hollering out, and when staff entered the room, noted R5 and female resident holding each other's hands tugging on each other - was able to redirect R5 with much encouragement back to his room, but he was very agitated and cursing. Review of a police report dated [DATE] of an allegation of sexual abuse revealed R8 had reported an alleged sexual abuse allegation by a Contracted Physical Therapist, that was not investigated. Interview on [DATE] at 12:15 pm with R8 confirmed the allegation that a Contracted Physical Therapist had made sexual comments to her and touched her inappropriately. Interview on [DATE] at 1:03 pm, the Administrator confirmed R8 made an allegation of abuse to her and to a police officer on [DATE]. The Administrator stated she did not report this allegation of abuse to the State Agency and verified that she should have reported the allegation of abuse but was unable to state the reason she had not reported the incident. 4. Review of the clinical record revealed R14 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R14 presented with a BIMS score of four, indicating severe cognitive impairment. Review of the Progress Note dated [DATE] at 2:47 pm documented that R5 slapped the other resident (R14) and pulled her hair. The other resident (R14) scratched at R5 and then the two were separated. 5. Review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, seizure disorder, traumatic brain injury, and depression. Review of the quarterly MDS assessment dated [DATE] revealed R17 presented with a BIMS score of 99, indicating cognition could not be determined. Review of the Progress Note dated [DATE] at 1:58 am documented that on [DATE] at 10:20 pm, R5 was up in his room when Certified Nursing Assistant (CNA) entered the room, she noted R5 holding roommate (R17) leg while his roommate (R17) was in bed sleeping. Review of the Progress Note dated [DATE] at 6:47 am documented that R5 was observed in the bed with his roommate (R17). R5 had taken off all his clothes and threw his adult brief in the doorway. Review of the Progress Note dated [DATE] at 6:40 am revealed that R5 became very agitated while CNA' were changing him due to he was incontinent of urine- resident was fighting/and slapping/scratching staff and cursing and name calling staff vulgar names and kicked one of the CNA's in the stomach - difficulty to redirect - left room to allow resident to calm down, but about five minutes later, R5 was observed hitting roommate in the arm and face with his bedroom shoe - roommate (R17) removed from the room for safety. Interview on [DATE] at 3:30 pm, the AIT confirmed that the altercations on [DATE], on [DATE], and on [DATE] was between R5 (perpetrator) and R17 (victim). 6. Review of the clinical record revealed R18 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, congested heart failure (CHF), urinary tract infection (UTI), asthma, and depression. Review of the Progress Note dated [DATE] at 2:23 am documented that R5 was observed in another residents room (R18), and both residents were hollering at each other - was able to redirect R5 back to his room and back to bed. Review of the Progress Note dated [DATE] at 5:52 pm documented that R5 was speaking loudly in his room. I enter the room and he is standing over his roommate (R18) yelling cuss words and shaking his fist in the direction of the resident. I entered the room and tried to get between the two residents. Review of the facility's State Reportable Incident Log revealed that none of the nine identified allegations above were identified as State reportable, and therefore, were not reported to the State Agency. Interview on [DATE] at 11:30 am with the Administrator/Abuse Coordinator revealed that allegations identified in the progress notes were not reported or investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. Interview on [DATE] at 1:53 pm, the Administrator acknowledged, If I didn't know about it, I didn't do an investigation, in reference to the allegations of sexual, physical, and verbal abuse that has been documented in the progress notes. Interview on [DATE] at 9:07 am, CNA EE revealed R3 and R5 had been combative in the past towards the other residents. She stated the staff had tried to keep them from hitting and/or becoming combative with other residents, but it had been difficult to do, when their medicine wore off. CNA EE stated she had reported the aggressive behaviors of R3 and R5 to three different nurses: LPN AA, LPN BB and LPN GG. She stated the nurses documented the incidents in the nurses' notes as behavioral problems. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education on timely reporting of allegations of abuse using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited [DATE] and reviewed facility findings and plans and made no recommendations. During this meeting, a review of the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse was conducted, and no policy changes were recommended. 3. Administrator, [NAME], resigned effective immediately on [DATE]. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on [DATE]. 4. The identified residents, R8, R14, R17, and R18, with allegations of abuse with R5 as the perpetrator, have been reported to the Department of Community Health Complaint Division. 5. R8 continues to reside at this facility. The last allegation involving R8 and R5 together occurred on [DATE]. 6. R14 continues to reside at this facility. The last allegation involving R14 and R5 together occurred on [DATE]. 7. R17 continues to reside at this facility. The last allegation involving R17 and R5 together occurred on [DATE]. 8. R18 discharged from the facility [DATE]. 9. R5 continues to reside at facility. R5 received inpatient geri-psych treatment from [DATE] - [DATE]. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning [DATE]. 10. The allegation of sexual abuse for R8 has been reported to the Department of Community Health Complaint Division. 11. R8 continues to reside at this facility and was included in the Interviews conducted of residents with BIM of 8 or higher and voiced no new concerns during this interview. 12. An audit was completed of Nurse's Notes dating back to [DATE] to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. 13. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. 14. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on [DATE] and has continued through [DATE]. 15. A Performance Improvement Plan related to Abuse Prevention Program was developed and will be followed through the facility's QAPI process. 16. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. g. 3 of the 3 administrative staff members have received this training. Total Education: 45 of 47 Staff Members have received this training: 96%. 17. All facility staff not in-serviced on the Abuse, Neglect, and Exploitation Policy specific to timely reporting of abuse allegations will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Inservice topic: Pre IJ inservice -QAPI meeting [DATE]: Topics discussed include the following: Wondering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping supervisor, Activities director, Regional Manager, Pasty RN, [NAME], RN. Adhoc QAPI meetings - Review of immediate jeopardy findings. Verbal presentation 9am to 9:45am by RA [NAME] on [DATE]. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on [DATE]. Phone interview on [DATE] at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on [DATE] and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. The RNC continued with stated the meeting discussing the IJs basically was a summary of abuse allegation were not getting reported. The RNC also stated that the RNC initiated a daily clinical meeting to be done prior ot the morning meetings. The clinical meetings require the MDS coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 2. Inservice topic: Adhoc QAPI meetings - Review of immediate jeopardy findings. All the IJs identified on [DATE] were reviewed. Verbal presentation 9am to 9:45am by RA [NAME] on [DATE]. a. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on [DATE]. b. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering. Interview on [DATE] on 9:23 am, The Regional Administrator stated a QAPI meeting was held about the immediate jeopardy finding. The RA stated that the medical director was not in person there, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on [DATE] and signed the sign in sheet. Phone interview on [DATE] at 4:47 pm with the Regional Nurse Consultant (RNC) continued with stated the meeting discussing the IJs basically was a summary of abuse allegation were not getting reported. The RNC also stated that the RNC initiated a daily clinical meeting to be done prior ot the morning meetings. The clinical meetings require the MDS coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 3. Upon arrival to the facility on [DATE] on 8:58am, The Administrator's door was closed. This was unusual as the door had been upon since entry of the facility on [DATE]. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator (RA) stated she resigned yesterday evening, and we accepted it. I will be the acting administrator for this facility moving forward. Anything you need you can ask me. The administrator was not seen on the premises since that notification. RA signed an Administrator job description for [DATE]. Interview on [DATE] at 4:08pm with the Regional Administrator (RA), the previous Administrator's resignation was verbal. The verbal resignation was accepted effective [DATE]. 4. The facility Incident report indicates the following incidents were reported. a. [DATE] - reviewed FRI- Date reported is [DATE]. b. [DATE] - reviewed FRI- Date reported is [DATE] c. [DATE] - reviewed FRI- Date reported is [DATE] d. [DATE] - reviewed FRI- Date reported is [DATE] e. [DATE] - reviewed FRI- Date reported is [DATE] f. [DATE] - reviewed FRI- Date reported is [DATE] g. [DATE] - reviewed FRI- Date reported is [DATE] h. [DATE] - reviewed FRI- Date reported is [DATE] Interview on [DATE] at 9:23 am with the Regional Administrator (RA) revealed that the outcomes of these investigations were based on what was noted in the nurses' notes proceeding these events. Examples of the interventions that were implemented include the of room changes for R5 and Psych evaluations. The RA stated they did what could be done with the information they had and due to the time, that has lapsed between the potential allegation to current. The outcomes of the investigations. 5. Record review of FRI confirms that the incident for [DATE] was reported Date of [DATE]. Observation on [DATE] at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. Observation on [DATE] at 9:25 am, R8 was observed in her room, alert and orientated. R8 keeps to self and eats several meals in R8's room. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. 6. Observation on [DATE] at 2:44 pm, R14 was observed interacting with the Activities director. R14 was alert and orientated with no behaviors noted. Observation on [DATE] at 11:55 am, R14 was observed in R14's room, laying in R14's bed. Review of the FRI documents a reported date of [DATE]. The resident is still in the facility. 7. Record review of FRI confirms that the incident for [DATE] was reported on [DATE]. Observation of ,d+[DATE]/ 2023 at 11:50 am, R17 was observed in R17's room. R17 was in bed, asleep and appears clean. 8. Per the resident's MDS and Discharge sheet, R18 is deceased . 9. Observation on [DATE] at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. R5 was assessed at Donalsonville Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated [DATE]. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and social services discharge assessment were performed. (Hospital) A Master treatment plan for R5 was reviewed. R5 had daily progress notes from [DATE] through [DATE]; his discharge on [DATE]. Subjective observations and objective observations were performed in addition ot physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history past medical history, current outpatient medications, allergies and social history were noted. 10. The facility Incident report form indicates this incident [DATE] - reviewed FRI- Date reported is [DATE]. Per [NAME] it appears someone had started the report. 11. R8 has been observed in R8's room through the survey and during the IJ period. The resident keeps to self and eats several of her meals in R8's room. R8 was observed in her room at 9:25am on [DATE]. R8 participated in the abuse questionnaire for interview-able residents on [DATE]. R8 was noted to have BIMS of 9. No additional allegations were noted. Some of R8's answers included refusal to answer. The activities director conducted the interview. 12. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS coordinator. for this tool was the DON beginning on [DATE]. 6 pages are doesn't have accessors name or date on there. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on [DATE] at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after [DATE] were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicate there was a problem and a no indicated no problems were detected. For all the yes's, the group would discuss and review the notes and then a figure out who the other induvial named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 13. Record review of resident BIMS Audit dates [DATE]. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on [DATE] at 12:15pm. An abuse questionnaire for the interview able resident's. was included. a. The questionnaires were conducted by [NAME] the Activities director on [DATE]. b. 19 name questionnaires were found. c. Investigation that was identified for [DATE]. The FRI provided shows a reported date of [DATE]. Interview on [DATE] at 5:10 pm with R19 revealed that the activity director did ask R19 a bunch of question about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member during R25's diaper change. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the activity director made notes of R19's Statement. Interview on [DATE] at 5:20 pm with R25 revealed that the activity director did speak with R25. R25 stated that the activity director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on [DATE] at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on [DATE] at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on [DATE] at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on [DATE] regarding another resident popping the top of her hand while playing cards. She stated the administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 14. Plan was identified as the following. a. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was [DATE] with an ongoing completion date. Team leader for this plan was [NAME] Interim Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The Point people were the DON, the Regional Administrator, the MDS coordinator and the AIT. were a plan of attack was of how to conduct. b. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. c. Actions to be taking for a for F600, a full house audit was conducted [DATE] - [DATE] review the nurse notes dated back to [DATE] to current. Additional actions were outlined in the facility action place/continuous quality improvement plan. d. Persons responsible were identified at DON, AIT, Maintenance, Social Services Designee, and the Administrator. 15. QAPI meeting [DATE] i. topics discussed include the following: Wondering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping supervisor, Activities director, Regional Manager, Pasty RN, [NAME], RN A performance improvement project worksheet was reviewed. The project title is F-tag 600 freedom from abuse; F tag 610 failure to investigate, report, prevent and correct alleged abuse. Plan: The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date for this project is [DATE] with the completion date is ongoing. The Regional Administrator is leading the charge. A root cause analysis was conducted to develop and approach the problem. The implement the approaches or the plan include at the following. A full house audit was conducted between [DATE] through [DATE] of the nurses' notes dates back to the prior survey [DATE] to current. Any identified allegations of abuse will be reported. Education will be provided to the employees except two as they will not be returning to work Abuse education will be provided upon hire and on throughout the calendar year. The administrator or designee will take care of the investigations and report in the time frame required. Individuals identified to be responsible for these efforts was the MDS coordinator, AIT, DON and Regional Administrator. 16. Per the Regional Administrator (RA) the log of individuals names and their dates of participation of the in- services are included. Signatures of the services were used to confirm. During the confirmation period on [DATE] at 10:30am. There was a discrepancy in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is at follows. Interview on 11:08am on [DATE] with the RA confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary Staff have received this training. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. 2 of the 2 Administrative Staff have received this training. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse, Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering Inservice's provided. Inservice was presented verbally. [DATE] at 2pm - Abuse and wondering/elopements. 23 individuals were noted to have attended (signed) Inservice topic F600- Freedom from abuse neglect, 610- Investigation abuse, 609 abuse reporting. Start time was at 10:,d+[DATE]:15pm and 2pm - 2:45 pm o Verbal presentation by [NAME] on [DATE] o 15 attended the 10:30am class and 12 attended the 2pm o Inservice topic 689 accidents-elopements; F656- Care plans provided at 10:30am-11:15am and 2:00pm -2:45pm Presented verbally on [DATE]. 15 attended the 10:30am class and 12 attended the 2pm Inservice topic: Wondering/elopement plan; abuse prevention program plan. Started 9am presented verbally. Presented by [NAME], Regional administrator on [DATE]. 10 attended the 9am presentation and 13 attended the 10:30am Inservice topic was Wondering/elopement, Abuse prevention program plan. Provided by [NAME] RN. Paper and verbally presented at 9:00am to 9:35 am with 10 people in attendance on [DATE] Inservice topic: Freedom from abuse and neglect- sexual abuse. Provide on [DATE] at 12pm and 2pm provided by [NAME] RN, RNC, 34 staff in attendance via signatures. Freedom from abuse and neglect- resident to resident physical abuse. Start ti [TRUNCATED]

49479 49687 Based on record review, interviews, and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to investigate, correct, and prevent allegations of abuse for four of 19 sampled residents (R) (R8, R14, R17, and R18) with multiple documented incidences of physical, sexual, and verbal abuse by R3, R5, and a Contracted Physical Therapist. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on [DATE] at 3:45 pm. The noncompliance related to the IJ was identified to have existed on [DATE] when the facility failed to protect four residents (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A second IJ was identified to have existed on [DATE] when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of [DATE]. Findings included: Review of the policy titled Abuse Prohibition Policy and Procedures revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed that R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R3 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed that R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed that R5 presented with a BIMS score of 99, indicating the resident was not able to cognitively be screened due to impairment. 3. Review of the clinical record revealed that R8 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, anxiety, chronic obstructive pulmonary disease (COPD), and depression. Review of the admission MDS assessment dated [DATE] revealed that R8 presented with a BIMS score of nine, indicating moderate cognitive impairment. 4. Review of the clinical record revealed that R14 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and dementia. Review of the admission MDS assessment dated [DATE] revealed that R14 presented with a BIMS score of four, indicating severe cognitive impairment. 5. Review of the clinical record revealed that R17 was admitted to the facility on [DATE] with diagnoses including coronary artery disease (CAD), seizure disorder, traumatic brain injury, and depression. Review of the admission MDS assessment dated [DATE] revealed that R17 presented with a BIMS score of 99, indicating the resident was not able to cognitively be screened due to impairment. 6. Review of the clinical record revealed that R18 was admitted to the facility on [DATE] with diagnoses including CAD, congested heart failure (CHF), urinary tract infection (UTI), asthma, and depression. Review of the admission MDS assessment dated [DATE] revealed that R8 presented with a BIMS score of 12, indicating moderate cognitive impairment. During a review of the clinical records, it was noted there was five documented incidences involving R5 for potential physical abuse, two incidences of potential verbal abuse, and one incident of potential sexual abuse: * On [DATE], R5 was standing over his roommate (R18) yelling and cursing while shaking his fist at R18. * On [DATE], R5 wandered into R8's room and as R8 was telling him to leave, R5 grabbed R8's wrist and started pushing her. * On [DATE], R5 was in R18's room yelling at him. Staff redirected R5 from R18's room. * On [DATE], R5 wandered into R8's room and was yelling at her and pulling on her hands. R5 was very agitated and cursed at staff as he was redirected from R8's room. * On [DATE], staff observed R5 holding his roommate (R17) leg, while R17 was in bed sleeping. * On [DATE], R5 was observed in bed with his roommate (R17). R5 had taken off all his clothes and threw the pull-up in the doorway. * On [DATE], R5 became very agitated and was fighting/slapping/cursing at staff while providing activities of daily living (ADL) care. He kicked one staff member in the abdomen. Staff left the room and approximately five minutes later, R5 was observed hitting his roommate (R17) in the face and arm with his bedroom shoe. R17 removed from room for his safety. * On [DATE], R5 slapped R14 and pulled her hair. During a review of the clinical records, it was noted there was two documented incidences involving R3 for potential physical abuse: * On [DATE], R3 grabbed R8's arm and pushed her into the nurse's station, causing R8 to hit the right side of her body against the nurses' station. * On [DATE], R3 grabbed a defenseless female resident by the head and shook her head around, before being confronted by staff, and then let go of the residents head. During a review of the clinical records, it was noted there was one incident for potential sexual abuse by a Contracted Physical Therapist: * On [DATE], R8 reported an allegation of potential sexual abuse by a Contracted Physical Therapist, to the Business Office Manager, the Administrator, and the Police Department. Review of the facility's State Reportable Incident Log revealed that none of the 11 identified allegations were identified as State reportable, and therefore, were not reported to the State Agency (SA), nor investigated by the facility. Interview on [DATE] at 11:30 am with the Administrator, who serves as the facility's Abuse Coordinator, revealed that the allegations identified in the progress notes were not reported to the SA and was not investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. Interview on [DATE] at 12:41 pm, the Administrator revealed there had not been any difference between a Grievance and a Facility Reported Incident. Interview on [DATE] at 1:53 pm, the Administrator stated, If I didn't know about it, I didn't do an investigation. This was in reference to sexual, physical and verbal abuse that have been documented in the progress notes. Interview on [DATE] at 9:07 am, Certified Nursing Assistant (CNA) EE stated R3 and R5 had been combative in the past, and had tendencies to hit other residents, and even staff members. She stated the staff tried to keep R3 and R5 from hitting and/or becoming combative with other residents, but it had been difficult, especially when their medications wore off. CNA EE stated the last incident involving R5 was approximately two weeks ago, when staff heard yelling and screaming and went to R8's room, and noted R5 grabbing R8 by both shoulders, shaking the resident and yelling at her. During further interview, CNA EE stated there had not been any in-services on how to care for R3 or R5 when the aggressive behaviors were exhibited. CNA EE stated she had reported aggressive behaviors to three different nurses: Licensed Practical Nurse (LPN) AA, LPN BB and LPN GG. Interview on [DATE] at 1:03 pm, the Administrator confirmed that R8 made an allegation of abuse to herself and the police officer on [DATE]. The Administrator stated she did not report this allegation of abuse to the SA. The Administrator stated she should have investigated the allegation of abuse and was unable to state the reason she had not investigated the incident. Interview with the Administrator on [DATE] at 1:30 pm, it was revealed that the Business Office Manager accompanied R8 to the Administrators office regarding the alleged sexual abuse by the Contracted Physical Therapist. When asked what the Administrator did with this information, the Administrator did not provide a response. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education on thorough investigations and corrective action implementation to decrease the likelihood of alleged abuse using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited [DATE] and reviewed facility findings and plans and made no recommendations. During this meeting, a review of the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse was conducted, and no policy changes were recommended. 3. Administrator, [NAME], resigned effective immediately on [DATE]. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on [DATE]. 4. The allegations of physical abuse of R8, R14, and R17 have been investigated, and necessary corrective actions have been implemented. 5. The allegations of sexual abuse for R8 and R17 have been investigated, and necessary corrective actions have been implemented. 6. The allegations of verbal abuse for R18 have been investigated, and necessary corrective actions have been implemented. 7. R8 continues to reside at this facility. The last allegation involving R8 and R5 together occurred on [DATE]. 8. R14 continues to reside at this facility. The last allegation involving R14 and R5 together occurred on [DATE]. 9. R17 continues to reside at this facility. The last allegation involving R17 and R5 together occurred on [DATE]. 10. R18 discharged from the facility [DATE]. 11. R5 continues to reside at the facility. R5 received inpatient geri-psych treatment from [DATE] - [DATE]. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning [DATE]. 12. An audit was completed of Nurse's Notes dating back to [DATE] to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. 13. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. 14. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on [DATE] and has continued through [DATE]. 15. A Performance Improvement Plan related to Abuse Prevention Program was developed and will be followed through the facility's QAPI process. 16. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy specific to thorough investigations and corrective action implementation to decrease the likelihood of occurrence of alleged abuse for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 17. All facility staff not in-serviced on the Abuse, Neglect, and Exploitation Policy specific to thorough investigations and corrective action implementation will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Inservice topic/ adhoc QAPI meetings - Review of immediate jeopardy findings a. Verbal presentation 9am to 9:45am by RA [NAME] on [DATE] b. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on [DATE]. QAPI meeting [DATE]. c. Topics discussed include the following: Wondering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping Supervisor, Activities director, Regional Manager, Pasty RN, [NAME], RN Observation on [DATE] at 2:25 pm, several staff members were gathered in the dining room as an inservice was being presented. The surveyor heard the Regional Nurse Consultant presenting the inservice. Phone interview on [DATE] at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on [DATE] and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. 2. Inservice topic/ adhoc QAPI meetings - Review of immediate jeopardy findings. All the IJs identified on [DATE] were reviewed. a. Verbal presentation 9am to 9:45am by RA [NAME] on [DATE] b. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on [DATE]. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering. Interview on [DATE] on 9:23 am, The regional administrator stated a QAPI meeting was held on about the immediate jeopardy finding. The RA stated that the medical director was not there in person, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on [DATE] and signed the sign in sheet. 3. Upon arrival to the facility on [DATE] on 8:58am, The Administrator's door was closed. This was unusual as the door had been upon since entry of the facility on [DATE]. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator (RA) stated she resigned yesterday evening, and we accepted it. I will be the acting administrator for this facility moving forward. Anything you need you can ask me. The administrator was not seen on the premises since that notification. RA signed an Administrator job description for [DATE]. Interview on [DATE] at 4:08pm with the Regional Administrator (RA), the previous Administrator's resignation was verbal. The verbal resignation was accepted effective [DATE]. 4. The following allegations of physical abuse were investigated and with necessary correction actions implemented. [DATE] at 02:47 pm (R5 and R14): Both residents were assessed, and no injuries occurred. R5's medication regimen was reviewed by the medical doctor. It was determined that R5 will be followed by psych services that will be candied in person at the facility. [DATE] at 6:40 am (R5 and R17): The outcome of the investing was that R17 was moved to another room for safety after several attempts were made to redirect R5. On call Physician was notified and new orders medication (IM injection). Staff continue to monitor. [DATE] at 01:58 am (R5 and R17). The outcome of the investigation was that R17 was moved to a different room while R5's medication had changed per MD orders. [DATE] at 12:10am - (R5 and R8): Since the incident occurred, R5 has been on medication reviewed by the Medical Director/PCP. A room change was initiated and R5 received Inpatient psych services related to behaviors. [DATE] at 01:48 pm - (R5 and R8)- the final investigation was submitted on [DATE]. R5's medication has changed since the incident occurred per doctor's orders. Staff will continue to redirect R5 while in the facility. [DATE]. (R3 and R8): The outcome of this investigation was that per nurses notes, the Medical Director was contacted in regard to resident R3's behaviors with order to transfer resident to ER if R3 continued with aggression. Interview on [DATE] at 9:23 am the regional administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 5. The following allegations of sexual abuse were investigated and with necessary correction actions implemented. [DATE] at 06:47 am - (R17 and R5) Outcome of the investigation was that a room change was initiated on [DATE]. [DATE] (R8 and physical therapist/contract employee UU): Outcome included the review of other female residents the Physical therapist/Contract employee UU case load were interviewed. Physical Therapist/Contract employee UU was banned from the facility. Interview on [DATE] at 9:23 am the regional administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 6. The following allegations of verbal abuse were investigated and with necessary correction actions implemented. [DATE] at 02:23 am - (R18 and R5) The LPN that made this nurse note entry is no longer employed at the facility and R18 is now deceased as of [DATE]. R5 is continued to be seen by psych services. [DATE] at 05:52 pm - (R18 and R5): Outcome of the investigation is that there were no injuries. Room changes for R5 was initiated, medication for R5 was reviewed. R5 is still a resident at the facility however, R18 is now deceased as of [DATE]. Interview on [DATE] at 9:23 am the Regional Administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 7. Record review of FRI confirms that the incident for [DATE] was report date of [DATE]. Observation on [DATE] at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. Observation on [DATE] at 9:25 am, R8 was observed in her room, alert and orientated. R8 keeps to self and eats several meals in R8's room. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. 8. Observation on [DATE] at 2:44 pm, R14 was observed interacting with the Activities director. R14 was alert and orientated with no behaviors noted. Observation on [DATE] at 11:55 am, R14 was observed in R14's room, laying in R14's bed. Review of the FRI documents a reported date of [DATE]. The resident is still in the facility. 9. Record review of FRI confirms that the incident for [DATE] was reported on [DATE]. Observation of ,d+[DATE]/ 2023 at 11:50 am, R17 was observed in R17's room. R17 was in bed, asleep and appears clean. 10. Per the resident's MDS and Discharge sheet, R18 is deceased . 11. Observation on [DATE] at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. R5 was assessed at Donalsonville Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated [DATE]. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and social services discharge assessment were performed. Master treatment plan for R5 was reviewed. R5 had daily progress notes from [DATE] through [DATE]; his discharge on [DATE]. Subjective observations and objective observations were performed in addition ot physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history past medical history, current outpatient medications, allergies and social history were noted. 12. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS coordinator. for this tool was the DON beginning on [DATE]. Six pages doesn't have accessors name or date on there. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on [DATE] at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after [DATE] were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicate there was a problem and a no indicated no problems were detected. For all the yes's, the group would discuss and review the notes and then a figure out who the other induvial named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 13. Record review of resident BIMS Audit dates [DATE]. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on [DATE] at 12:15pm. An abuse questionnaire for the interview able resident's. was included. a. The questionnaires were conducted by [NAME] the Activities director on [DATE]. b. 19 name questionnaires were found. c. Investigation that was identified for [DATE]. The FRI provided shows a reported date of [DATE]. Interview on [DATE] at 5:10 pm with R19 revealed that the activity director did ask R19 a bunch of question about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member during R25's diaper change. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the activity director made notes of R19's Statement. Interview on [DATE] at 5:20 pm with R25 revealed that the activity director did speak with R25. R25 stated that the activity director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on [DATE] at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on [DATE] at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on [DATE] at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on [DATE] regarding another resident popping the top of her hand while playing cards. She stated the administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 14. Plan was identified as the following. a. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was [DATE] with an ongoing completion date. Team leader for this plan was [NAME] Interim Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The Point people were the DON, the Regional Administrator, the MDS coordinator and the AIT. were a plan of attack was of how to conduct. b. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. c. Actions to be taking for a for F600, a full house audit was conducted [DATE] - [DATE] review the nurse notes dated back to [DATE] to current. Additional actions were outlined in the facility action place/continuous quality improvement plan. d. Persons responsible were identified at DON, AIT, Maintenance, Social Services Designee, and the Administrator. 15. QAPI meeting [DATE]. i. Topics discussed include the following: Wondering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping Supervisor, Activities director, Regional Manager, Pasty RN, [NAME], RN A performance improvement project worksheet was reviewed. The project title is F-tag 600 freedom from abuse; F tag 610 failure to investigate, report, prevent and correct alleged abuse. Plan: The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date for this project is [DATE] with the completion date is ongoing. The Regional Administrator is leading the charge. A root cause analysis was conducted to develop and approach the problem. The implement the approaches or the plan include at the following. A full house audit was conducted between [DATE] through [DATE] of the nurses' notes dates back to the prior survey [DATE] to current. Any identified allegations of abuse will be reported. Education will be provided to the employees except two as they will not be returning to work. Abuse education will be provided upon hire and on throughout the calendar year. The administrator or designee will take charge of the investigations and report in the time frame required. Individuals identified to be responsible for these efforts was the MDS coordinator, AIT, DON, and Regional Administrator. 16. Per the Regional Administrator (RA) the log of individuals names and their dates of participation of the in- services are included. Signatures of the services were used to confirm. During the confirmation period on [DATE] at 10:30 am. There was a discrepancy. in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is at follows. Interview on 11:08 am on [DATE] with the RA confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary Staff have received this training. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. 2 of the 2 Administrative Staff have received this training. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse, Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering Inservice's provided. Inservice was presented verbally. [DATE] at 2pm - Abuse and wondering/elopements. 23 individuals were noted to have attended (signed) Inservice topic F600- Freedom from abuse neglect, 610- Invest [TRUNCATED]

Based on observations, record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered the facility failed to develop and implement the person- centered care plan that focused on risks for wandering and elopement for two residents (R) (R6 and R10) from a sample of 19 residents. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/5/2022 when the facility failed to protect four residents (R) (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the policy titled Care Plans, Comprehensive Person- Centered revised December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: number 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Number 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Number 8. The comprehensive person-centered care plan: g. incorporates identified problem areas. H. incorporates risks factors associated with identified problems. 1. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses including dementia, agitation, and depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99, indicating the resident had severe cognitive impairment. Section E revealed the resident exhibited wandering behaviors daily and the behaviors put the resident at significant risk of getting outside the facility. Section GG revealed resident ambulated independently. Review of the Elopement Risk assessment dated [DATE] revealed R6 wanders aimlessly and verbally expresses a desire to leave the facility. A wander guard was applied to left wrist. Review of R6's comprehensive care plan initiated on 7/9/2023 and revised on 10/4/2023 revealed resident is at risk for wandering/elopement due to attempting to exit the building. Interventions to care include provide distraction, provide simple commands, and promptly checking exit doors when the alarm sounds. Interventions added after the 7/14/2023 elopement include assess residents whereabouts every 15 minutes and check residents wander guard at each exit to ensure it is functioning properly each shift. There is no evidence of interventions added for the 8/18/2023 or the 8/29/2023 elopements. Review of the Progress Note dated 7/2/2023 at 1:49 am written by Licensed Practical Nurse (LPN) HH, documented R6 was being monitored due to wandering and voiced the desire to go home and tried to find a way out, wander guard intact to left wrist. Review of the Progress Note dated 7/14/2023 at 4:22 pm written by the Administrator in Training (AIT), documented at 10:30 am Activities Director (AD) answered the phone with a woman stating she saw a man in a light blue shirt walking on the highway. Review of the Progress Note dated 8/19/2023, written by LPN HH, documented on 8/18/2023 at 11:15 pm Certified Nursing Assistant (CNA) TT observed R6 going out the laundry door near the maintenance shed. Review of a handwritten note dated 8/29/2023 written by CNA EE, documented R6 walked out through the back door, and she tried to redirect him back inside the building, but resident refused. There is no documentation in the resident electronic medical record regarding this incident. Interview on 11/27/2023 at 10:59 am, the Activities Director (AD) stated the facility doors used to stay unlocked all the time. She stated residents were able to go in and out. The AD stated R6 was missing from the facility for approximately one hour. During continued interview, she stated lock pads were installed to the doors on 9/14/2023. Interview on 11/27/2023 at 4:07 pm, the Director of Nursing (DON) revealed interventions on care plans were communicated to all staff by word of mouth. According to the DON, the facility had not been initiating quarterly elopement assessments as required by facility policy. She stated elopement assessments were only being completed on admission. During further interview, the DON stated she expects the care plan coordinator to document residents identified as risk for elopement. The DON stated care plan interventions are mostly carried out to staff by word of mouth, and that interventions are to be developed and implemented after each elopement. Interview on 11/27/2023 at 4:45 pm, the AIT said the wander guard system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the Maintenance Director was made aware, but nothing has changed. During further interview, she stated the current system was unsafe and explained if a resident walked out behind a family member staff would not be able to detect and hear the alarm sound. She stated care plans should be updated after each elopement. Interview on 12/15/2023 at 9:04 am, LPN AA revealed care plans should be updated to include the interventions specifically related to wandering. She verified the wandering interventions for R2 on his care plan, and confirmed there were no additional interventions added for the 8/16/2023 and 8/29/2023 incidents when R2 was found outside the facility. 2. Review of the clinical record revealed R10 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, hypertensive heart disease, and stage four chronic kidney disease (CKD). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section E revealed the resident did not exhibit wandering behavior Section GG revealed resident ambulated independently. Review of the Elopement Risk assessment dated [DATE] for R10 revealed section for wandering was not completed, but indicated his photo was added to the wanderer list. Further review revealed resident has not shown any signs of leaving facility, and wander guard was removed. Review of R10's comprehensive care plan initiated on 7/31/2023 and revised on 9/7/2023 revealed resident is at risk for wandering/elopement with wander guard in place. Interventions to care include photo taken and placed in designated areas, diversional activities to reduce wander/elopement behavior, observe for wander/elopement behavior, psych consult as needed, and notify physician (MD) as needed (PRN). The goal was for R10 not to exit the facility unplanned and or unattended. Review of Progress Note revealed a late entry dated 9/16/2023 at 2:23 pm written by LPN GG, documented at approximately 10:20 am, she received a call from R10's representative. The representative stated R10 expressed the desire to leave the facility immediately. Review of Progress Note dated 9/16/2023 at 2:15 pm written by DON documented R10 was found safe by the sheriff department on the highway around 1:50 pm. Further review revealed documentation that resident will not be returning to the facility due to safety hazard. Interview on 11/27/2023 at 4:07 pm, the DON revealed care plan interventions were communicated to all staff by word of mouth. She stated the interventions were not supported by documentation, and revealed the wander guards are monitored once a month. The DON stated staff are expected to take residents equipped with the wander guard to the exit doors and test if the system responded as required and expects staff to document in the nursing notes that they monitored the wander guard. During further interview, she stated the facility had not been completing quarterly elopement assessments as required by facility policy. She stated elopement assessments were only done on admission. She stated she expected the care plan coordinator to document residents identified as risk for elopement. Interview on 11/27/2023 at 4:45 pm, the AIT revealed the wander guard system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the current system was unsafe and explained if a resident walked out behind a family member, staff would not be able to detect and hear the alarm sound. She stated care plans should be updated after each elopement. She confirmed the care plan was not updated after the elopement for R10, because he was not returning to facility. Observation on 11/27/2023 at 4:50 pm, the AIT tested the wander guard system with a wander guard bracelet in her hand, and the door opened. The audible alarm sound was faint. The AIT stated, the door should not have opened, and the alarm sound could barely be heard. The alarm system was not detected, and the sound was faint. Interview on 12/5/2023 at 9:50 am, the DON indicated that the Quality Assurance and Performance Improvement (QAPI) meetings were designed to discuss areas needed for improvement and to discuss residents who were potentially at risk. The DON concluded the meetings in QAPI are a waste of time, and added discussions are never put in to practice, such as the discussions about care plan interventions. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Care Plan policy was completed, and no policy changes were recommended. 2. Administrator, [NAME], resigned effective immediately on 12/5/2023. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on 12/6/2023. 3. All Residents were assessed using the Elopement Risk Assessment to determine residents at high risk for elopement. These assessments resulted in three (3) additional residents at high risk, bringing the facility total to five (5) residents at high risk for elopement. 4. Care Plans have been reviewed and updated for five Residents determined to be at High Risk for Elopement. 5. Five (5) residents determined to be at High Risk for Elopement have been updated in the Elopement Binder. All staff have been educated on the location of the Elopement Binder (Admin office, dietary (kitchen), and nurse's station. The elopement binders will be updated as any additional residents are identified as high risk for elopement. The Director of Nursing will be responsible for updating the binders. 6. Resident R6 Care Plan review was completed, and appropriate updates were made specific to the risk for wandering/elopement and specific to suicidal ideations. 7. R6 continues to reside at the facility and is being followed by contracted psych services. R6 was seen by psych services on:8/10/2023, 9/7/2023, and 11/16/2023. R6 has no elopements since 8/29/2023. 8. Resident R10 is no longer a Resident at this facility, d/c date of 9/16/2023. 9. The Wander Guard devices on residents identified as high risk for elopement are monitored every 12 hours by a Nursing Manager using the handheld [NAME] Wander Guard Universal Tester noted in the electronic Medication Administration Record (MAR). The Universal Tester device was ordered and was delivered to the facility on [DATE]. All Staff are educated on 12/12/2023 on the use of the Universal Tester. 10. A root cause analysis was completed; it was determined that a lack of training related to Wandering and Elopements was a factor. Training for all staff related to Wandering and Elopements started on 11/30/2023 and has continued through 12/12/2023. 11. A Performance Improvement Plan related to Wandering and Elopements was developed and will be followed through the facility's QAPI process. 12. The Corporate MDS consultant provided education to the DON, MDS/AIT, and the MDS. The Regional Nurse Consultant conducted training related to Care Plan updates specific to those residents determined to be at high risk for elopement and for residents with suicidal ideations for the following staff: a. 11 of 12 licensed staff members have received this training. Total Education: 11 of 12 Staff Members have received this training: 92% 13. All Licensed staff not in-serviced on Care Plan updates specific to wandering/elopement will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A QAPI meeting was held on 12/06/2023 from 9:00 am and ended at 9:45 am the following staff attended the QAPI meeting- Business Office Manager, Maintenance, Director, Dietary Manager, Administrator in Training AIT/MDS, Risk Manager Activity Assistant, MDS, Director of Nursing, House Keeping and Human Resource Director. The QAPI meeting was held for the following Tags F835, F867, F689 and F689. And signatures were documented regarding completion of the inservice. 2. This was verified as per observation 12/6/2023 at 8;58 am and stated the administrator yesterday evening and that was accepted, and he will the acting administrator moving was forward. The following interview verified the above information: During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held regarding elopement, wandering and abuse. Abuse should be reported within 2 hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The care plans DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance. 3. Residents R6, R10, R19, R20, and R21, and R 22 are assessed for elopement risks. 4. Residents R6, R10, R19, R20 and R21, and R 22 care plans updated for elopement risks. During an interview on 12/15/2023 at 9:14 am LPN RR revealed I work the first shift, we did in-service about elopement and facility identified additional residents and added wander guards to the residents. The sound of alarms its audible it can be heard from the nurse's station, and they sound we the wander guards are checked once a shift, the residents are checked hourly only th staff have the access codes to the door. The elopement book has all the intervention at the nurses and all staff have access to the book. During an interview on 12/15/2023 at 9:27 am CNA EE revealed the inservice discussed elopement and abuse. And what to do when a resident elopes. EE stated facility identified six residents as risk for elopement and the identified residents all have wander guards on, they have ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. During an interview on 12/15/2023 at 9:34 am CNA-SS revealed the in-service was done regarding elopement during the in-service and that it should be reportable to the administrator immediately. We do check on the resident that have been identified every few fifteen minutes. R6 is alert and oriented now we are doing regular checks, and we are checking more residents, we do check the wander guards every morning the rest have wander guard on the wrist. The alarm sounds can be heard from the hallway when the sound is heard you go and investigate. Observations on 12/14/2023 at 11:30 am showed Residents R6, R10 R19, R20 and R21- and R 22 had wander guards on their wrist and the wander guard functioned as required. 5. Observations on 12/14/2023 at 11:30 am showed Residents R6, R10 R19, R20, and R21- and R 22, had wander guards on their wrist and the wander guard functioned as required. During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held and additional residents identified as at risk for elopement were identified regarding elopement, wandering. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The care plans DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance. 6. Documentation revealed R6's care plan was updated and showed specific interventions related to wandering/elopement and specific to suicidal ideations 12/6/2023. Record review showed facility implemented specific intervention in R6's care plan and documented directions. Record review showed facility reassessed R6 elopement risk assessment on 11/27/2023. The following interviews verified the care plan was updated. During an interview on 12/15/2023 at 9:04 am LPN AA revealed she had done inservice regarding elopement and care plans were updated to include the interventions specifically related to wandering. We are now residents with bracelets before they have a tester, now it has a high pitch sound and its loud and clear I feel. The elopement book is accessible to all can and they can access it for certain measures. measures will help. The care plans are now updated to indicate they are at risk for elopement on the care plan they will be interventions all can are conveyed verbally through communications on what interventions are in place. All wander guards are checked on the MAR. During an interview on 12/15/2023 at 9:14 am LPN RR revealed I work the first shift, we did inservice about elopement and abuse and when observed abuse that is reported to the administrator. Additional residents were identified. They added wander guards to the fixed they sound alarm its audible it can be heard from the nurse's station, and they sound we the wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses and all staff have access to the book. 7. Record review showed psych services were established for the resident and R6 had no observed or recorded elopements since 8/29/20203. During an interview on 12/15/2023 at 6:45 am, LPN BB revealed knowledge of the six identified residents for risk of elopement. BB stated she in-serviced regarding abuse and elopement. BB explained codes were changed for the front door and will be changed daily. BB stated the alarm was loud enough for staff to hear when inside the facility. Observations on 12/14/2023 at 11:30 am showed Residents R6, had wander guards on their wrist and the wander guard functioned as required. 8. Record review and interviews showed R10 was discharged from the facility on 9/16/2023. 9. According to the daily door lock checks, documentation showed checks were started on 12/4/Door daily checks were started on 12/4/2023. The following interviews were conducted and verified the above information: During an interview on 12/15/2023 at 6:45 am, LPN BB revealed knowledge of the six identified residents for risk of elopement. BB stated she in-serviced regarding abuse and elopement. BB explained codes were changed for the front door and will be changed daily. BB stated the alarm was loud enough for staff to hear when inside the facility. During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held regarding elopement, wandering and abuse. Abuse should be reported within 2 hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The care plans DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance. Observations on 12/14/2023 at 11:30 am showed Residents R6, had wander guards on their wrist and the wander guard functioned as required 10. A full house audit was conducted on 11/30/2023 and continued through 12/12/2023. Documentation showed five additional residents were identified as Risk for Elopement. 11. Record review showed on 11/30/2023 a full house audit was conducted and a total of five residents were identified for potential risk for elopement. The elopement Binder was updated with pictures of those residents. A list would be kept in the elopement binder with expiration dates of the devices for replacement. Education was provided to all staff regarding the elopement wandering policy and process. The care plans were updated to reflect elopement risk. The clinical team will ensure the orders are on the Medication Administration Record (MAR). The families were notified of the assessment results and informed that a wander guard bracelet would be replaced. The Mag locks are to be checked for placement by the nurse on every shift and additional wander guards were ordered fir additional residents and were placed on the residents. 12. a.11 of 12 licensed staff members have received this training. b. 14 of 14 CNA's CAN's a have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 administrative staff members have received this training. Evidence of the inservice showed that on 12/6/2023 at 12:00 pm to 1:00 pm and from 1:00 pm to 2:00 pm regarding Wandering, Elopement and Resident Safety and was dated on 11/30/2023 in all a total of thirty-six (36) staff were in serviced signed on the inservice sheet. Another inservice sheet was completed on 12/01/2023 at 9:00 am ten staff (10) and on 12/01/2023 at 10:30 am a total of (13) thirteen. Total Education: 11 of 12 Staff Members have received this training: 92% 13. Interview with the administrator revealed that all staff had been in serviced regarding wandering and elopement. Interviews with staff showed inservice was completed regarding wandering and elopement, the DON supported with the following interview: During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held regarding elopement, wandering and abuse. Abuse should be reported within 2 hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The care plans DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance During an interview on 12/15/2023 at 6:55 am CNA LL revealed am stealing and sexual inappropriate touching, mental and restraint is considered abuse and reportable to the administrative immediately and all is reported when the administrator is not available, she would report to the DON. If a resident combative I would report first and then check on them, we have six residents with wander guards. We check on those residents every two hours. I completed elopement in services, abuse, and all types and how to report. We were told if the wander guard resident exited it would sound an alarm. I was not here when they did the demonstration about sounding the alarm. If a resident disappears, we search the area and call 911. 12/15/2023 at 7:04 am, CNA MM abuse can be mental physical and dignity and if observed I would report, if I would notify the charge nurse if observed abuse, I would calm the residents down, we completed the F tags, abuse and elopement, we are supposed to make rounds making sure residents are in their rooms the ones that have wander guard. Always check the residents throughout the nights. We have six residents with wander guards. The alarm is loud enough to be heard. Interview on 12/15/2023 at 7:13 am, CNA KK we have learned abuse topic and forms of abuse and what to do when it occurs. Physical mental isolation financial verbal and I will inform the charge nurse if I observe the staff stealing money, the administration is the abuse coordinator, during care when a resident becomes combative, I will separate them so they can calm down. I came in on one with the administrator, we talked about the elopement and were told to search all the rooms when they are missing contact the police and the administrator The maintenance guy sounded the alarm, and it could be heard and was loud. During an interview, 12/15/2023 at 7;23 am. CNA, DD we have learned all types of abuse including financial administration is the abuse coordinator and any abuse would be reported to him immediately if he not here DON would be the next person to report to. We talked abuse and elopement we now have six identified elements. That alarm sounding was demonstrated, I am not able to hear the alarm. Resident cant gets out because we have mega locks and codes. The resident does know the codes. During an interview 12/15/2023 at 7:24 Dietary Aide, NN we learned about abuse and that it was reportable to the administrator immediately. Including verbal abuse which is reportable to the administrator. Elopement we were told when the alarm sounds the patient is trying to get, the alarm sound can be heard while I am in the kitchen.

Based on record review, interviews, and review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure that four of 19 sampled residents (R) (R8, R14, R17, and R18) were free from physical, verbal, and sexual abuse. The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/5/2022 when the facility failed to protect four residents (R) (R8, R14, R17 and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the facility policy titled Abuse Prohibition Policy and Procedures revised January 2017 revealed the facility believes that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R3 presented with a Brief Interview of Mental (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R5 presented with a BIMS score of 99, indicating severe cognitive impairment. Review of the electronic medical records (EMR) revealed documentation of 13 allegations of potential physical, sexual, and verbal abuse as follows: 1. Progress Note dated 7/5/2022 at 5:52 pm documented that R5 speaking loudly in his room. I enter room and he is standing over his roommate (R18) yelling cuss words and shaking his fist in the direction of the resident. I entered the room and tried to get between the two residents. 2. Progress Note dated 10/24/2022 documented an allegation of physical abuse in which R3 grabbed R8's arm and pushed her into the nurses' station. The note indicated the action had caused R8 to hit the right side of her body against the nurses' station. 3. Progress Note dated 11/5/2022 documented R3 had to be constantly redirected from going into other residents' rooms. The notes documented R3 had become combative towards the staff and other residents. 4. Progress Note dated 11/14/2022 documented several witnesses observed R3 approach a defenseless female resident and without provocation, grabbed the female resident by the head and shook her head around. The female resident was in a geriatric chair, with her eyes closed, before R3 had grabbed her. R3 let go of the female resident when he was confronted by the staff. 5. Progress Note dated 11/27/2022 documented R3 entered another resident's room (R8) and tried to take her belongings. The CNA tried to redirect R3, but he hit the CNA in the face. The nurse escorted R3 out of R8's room and administered a PRN (as needed) medication. 6. Progress Note dated 11/29/2022 at 1:48 pm documented that R5 entered (R8) room, walked up to the bed, and (R8) told him to leave. He then grabbed her wrist pushing on her. 7. Progress Note dated 12/1/2022 at 2:23 am documented that R5 was observed in another residents room (R18), and both residents were hollering at each other - was able to redirect R5 back to his room and back to bed. 8. Progress Note dated 1/6/2023 at 12:10 am documented that R5 wandered into (R8) room - heard residents in the room hollering out, and when staff entered the room, noted R5 and female resident (R8) holding each other's hands tugging on each other - was able to redirect R5 with much encouragement back to his room but he was very agitated and cursing. 9. Progress Note dated 7/2/2023 at 1:58 am documented that on 7/1/2023 at 10:20 pm, R5 was up in his room when CNA entered the room, she noted R5 holding roommate (R17) leg while his roommate (R17) was in bed sleeping. 10. Review of the Progress Note dated 7/2/2023 at 6:47 am documented that R5 was observed in the bed with his roommate (R17). R5 had taken off all his clothes and threw his adult brief in the doorway. 11. Review of the Progress Note dated 7/16/2023 at 6:40 am revealed that R5 became very agitated and was fighting/slapping/cursing at staff while providing activities of daily living (ADL) care. He kicked one staff member in the abdomen. Staff left the room and approximately five minutes later, R5 was observed hitting his roommate (R17) in the face and arm with his bedroom shoe. R17 removed from room for his safety. 12. Review of the Progress Note dated 9/22/2023 at 2:47 pm documented that R5 slapped the other resident (R14) and pulled her hair. The other resident scratched at R5 and then the two were separated. Interview on 11/28/2023 at 3:53 pm, the Administrator acknowledged that If I didn't know about it, I didn't do an investigation in reference to the physical, sexual, and verbal abuse allegations that have been documented in the EMR. 13. Review of a Police Report dated 11/13/2023 documented an allegation of sexual abuse which R8 reported was perpetrated by a Contracted Facility Staff. R8 alleged the Contracted Male Therapist asked her if she had ever had sexual relations with a man before. She stated that on another day he had offered to give her a back massage after she had complained about her back to him. R8 stated that while rubbing her back the perpetrator's hand traveled inside her buttock cheeks and near her anus. R8 indicated the Contract Male Therapist was constantly staring at her and adjusting his penis from outside his pants. She claimed the incident happened three - or - four weeks ago. The alleged sexual abuse allegation was not investigated. Review of R8's EMR revealed no documentation of the allegation of abuse by the Contracted Facility Staff. Interview on 11/29/2023 at 9:07 am, CNA EE stated R3 and R5 had a history of hitting other residents and would become combative when their medications wore off. CNA EE stated the staff had tried to keep both residents from hitting and/or becoming combative with other residents, but it had been difficult. During further interview, she stated everyone working at the facility knew R3 and R5 had been combative and had tendencies to hit other residents and staff. She stated she had reported aggressive behaviors, at different times, to three different nurses: LPN AA, LPN BB and LPN GG. Interview on 11/29/2023 at 12:15 pm with R8, stated a Physical Therapist had touched her inappropriately during a therapy session. Interview on 11/29/2023 at 12:54 pm with the police officer, he reiterated his statement of the 11/13/2023 police report. Interview on 11/29/2023 at 1:03 p.m., the Administrator revealed that the Business Office Manager accompanied R8 to the Administrators office regarding the alleged sexual abuse by the Contracted Physical Therapist. When asked what the Administrator did with this information, the Administrator did not provide a response. Interview on 11/29/2023 at 1:30 pm, the Administrator confirmed that she did not report or investigate the allegation of sexual abuse between R8 and the Contracted Facility Staff to the State Agency (SA). Review of the facility document titled State Reportable Incident Log revealed that none of the allegations of physical, sexual, and verbal abuse were identified by the facility as a reportable offense to the State Agency. Interview on 11/29/2023 at 1:30 pm the Administrator/Abuse Coordinator confirmed that the allegations identified in the EMR progress notes were not reported or investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education specific to identifying resident-to-resident physical abuse, specific to determining resident-to-resident sexual abuse, and specific to identifying sexual abuse from contracted facility staff using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director (12/06/2023). 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and made no recommendations. The Abuse, Neglect, and Exploitation policy was reviewed during this meeting, and no policy changes were recommended. (12/12/2023). 3. Administrator, [NAME], resigned effective immediately on 12/05/2023. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on 12/06/2023. (12/06/2023) 4. The identified progress notes dated 9/22/2023, 7/16/2023, 7/02/2023, 1/06/2023, 11/29/2022, 12/01/2022, 7/05/2022, 10/24/2022 that contain allegations of abuse for R5 as the perpetrator have been reported to the Department of Community Health Complaint Division. (12/06/2023) 5. R5 continues to reside at Heardmont Health and Rehab. R5 received inpatient geri-psych treatment from 9/01/2023 - 9/14/2023. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning 12/13/2023. (12/13/2023) 6. The allegation of sexual abuse for R8 has been reported to the Department of Community Health Complaint Division. (11/29/2023). 7. An audit was completed of Nurse's Notes dating back to April 2022 to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. (12/06/2023). 8. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. (12/01/2023). 9. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on 11/30/2023 and has continued through 12/12/2023. (12/12/2023) 10. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 11. All facility staff, including PRN staff, not in-serviced on the Abuse, Neglect, and Exploitation Policy will not work until the education is completed. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Inservice topic Pre IJ inservice -QAPI meeting 11/30/23: Topics discussed include the following: Wondering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping supervisor, Activities director, Regional Manager, Pasty RN, [NAME], RN Adhoc QAPI meetings - Review of immediate jeopardy findings. Verbal presentation 9am to 9:45am by RA [NAME] on 12/6/23. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on 12/12/23. Phone interview on 12/15/2023 at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on 11/30/2023 and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. The RNC continued with stated the meeting discussing the IJs basically was a summary of abuse allegation were not getting reported. The RNC also stated that the RNC initiated a daily clinical meeting to be done prior ot the morning meetings. The clinical meetings require the MDS coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 2. Inservice topic: Adhoc QAPI meetings - Review of immediate jeopardy findings. All the IJs identified on 12/5/2023 were reviewed. Verbal presentation 9am to 9:45am by RA [NAME] on 12/6/23 a. Attendance included Maintenance dir., dietary manager, Business office manager, AIT/MDS, Risk manager, activity assist, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on 12/12/23. b. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering. Interview on 12/14/23 on 9:23 am, The Regional Administrator stated a QAPI meeting was held about the immediate jeopardy finding. The RA stated that the medical director was not personally there, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on 12/12/23 and signed the sign in sheet. Phone interview on 12/15/2023 at 4:47 pm with the Regional Nurse Consultant (RNC) continued with stated the meeting discussing the IJs basically was a summary of abuse allegation were not getting reported. The RNC also stated that the RNC initiated a daily clinical meeting to be done prior ot the morning meetings. The clinical meetings require the MDS coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 3. Upon arrival to the facility on [DATE] on 8:58am, The Administrator's door was closed. This was unusual as the door had been upon since entry of the facility on 11/27/23. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator (RA) stated she resigned yesterday evening, and we accepted it. I will be the acting administrator for this facility moving forward. Anything you need you can ask me. The administrator was not seen on the premises since that notification. RA signed an Administrator job description for 12/6/23. Interview on 12/15/2023 at 4:08pm with the Regional Administrator (RA), the previous Administrator's resignation was verbal. The verbal resignation was accepted effective 12/6/2023. 4. The following Identified allegations of abuse about R5 a. 9/22/23 - reviewed FRI- Date reported is 12/6/23. b. 7/16/23 - reviewed FRI- Date reported is 11/29/23 c. 7/2/23 - reviewed FRI- Date reported is 11/29/23 d. 1/6/23 - reviewed FRI- Date reported is 12/7/23 e. 11/29/22 - reviewed FRI- Date reported is 11/29/23 f. 12/1/22 - reviewed FRI- Date reported is 12/1/23 g. 7/5/22 - reviewed FRI- Date reported is 12/7/23 h. 10/24/22 - reviewed FRI- Date reported is 12/1/23 Interview on 12/14/2023 at 9:23 am with the Regional Administrator (RA) revealed that the outcomes of these investigations were based on what was noted in the nurses' notes proceeding these events. Examples of the interventions that were implemented include the room changes for R5 and Psych evaluations. The RA stated they did what could be done with the information they had and due to the time, that has lapsed between the potential allegation to current. The outcomes of the investigations 5. Observation on 12/14/2023 at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on 12/15/2023 at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. R5 was assessed at Donalsonville Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated 9/1/23. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and social services discharge assessment were performed. Documents were provided of a visit to Donalsonville Hospital. A Master treatment plan for R5 was reviewed. R5 had daily progress notes from 9/1/2023 through 9/14/2023; his discharge on 9/15/2023. Subjective observations and objective observations were performed in addition ot physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history past medical history, current outpatient medications, allergies and social history were noted. 6. R8 Sexual abuse allegation was reported on 11/29/2023. Interview on 12/5/2023 at 12:30 pm with the previous Administrator confirmed the report was submitted to the State Agency after being questioned about the incident between R8 and the Contract employee. Interview on 12/5/2023 at 11:45 am The Regional Administrator confirmed that after the interview with the Administrator asking about the incidents R5 that were not reported, RA decided an audit of all the nurses' notes since the last survey. The RA notified the regional Director of an influx of state reportable will be coming through the pipeline. 7. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS coordinator. for this tool was the DON beginning on 11/30/23, [NAME] on 11/30/23. 6 pages are doesn't have accessors name or date on there. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on 12/15/2023 at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after 4/10/2022 were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicate there was a problem and a no indicated no problems were detected. For all the yes's, the group would discuss and review the notes and then a figure out who the other induvial named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 8. Record review of resident BIMS Audit dates 11/30/23. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on 11/30/23 at 12:15pm. An abuse questionnaire for the interview able resident's. was included. a. The questionnaires were conducted by [NAME] the Activities director on 12/1/23. b. 19 name questionnaires were found. c. Investigation that was identified for 12/1/23. The FRI provided shows a reported date of 11/30/2023. Interview on 12/15/2023 at 5:10 pm with R19 revealed that the activity director did ask R19 a bunch of question about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member during R25's diaper change. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the activity director made notes of R19's Statement. Interview on 12/15/2023 at 5:20 pm with R25 revealed that the activity director did speak with R25. R25 stated that the activity director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on 12/15/2023 at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on 12/15/2023 at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. An interview on 12/15/2023 at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on 12/15/2023 at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on 9/27/2023 regarding another resident popping the top of her hand while playing cards. She stated the administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 9. Plan was identified as the following. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was 11/30/23 with an ongoing completion date. Team leader for this plan was [NAME] Interim Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The Point people were the DON, the Regional Administrator, the MDS coordinator and the AIT. were An plan of attack was of how to conduct. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. Actions to be taking for a for F600, a full house audit was conducted 11/30/23 - 12/1/23 to review the nurse notes dated back to April 2022 to current. Additional actions were outlined in the facility action place/continuous quality improvement plan. Persons responsible were identified at DON, AIT, Maintenance, Social Services Designee and the Administrator. 10. Per the Regional Administrator (RA) the log of individuals names and their dates of participation of the in- services are included. Signatures of the services were used to confirm. During the confirmation period on 12/15/23 at 10:30am. There was a discrepancy. in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is at follows. Interview on 11:08am on 12/15/2023 with the RA confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary Staff have received this training. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. 2 of the 2 Administrative Staff have received this training. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specify types of abuse, Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procures and wondering Inservice's provided. Inservice was presented verbally. 12/11/23 at 2pm - Abuse and wondering/elopements. 23 individuals were noted to have attended (signed) Inservice topic F600- Freedom from abuse neglect, 610- Investigation abuse, 609 abuse reporting. Start time was at 10:30-11:15pm and 2pm - 2:45 pm o Verbal presentation by [NAME] on 12/6/23 o 15 attended the 10:30am class and 12 attended the 2pm o Inservice topic 689 accidents-elopements; F656- Care plans provided at 10:30am-11:15am and 2:00pm -2:45pm Presented verbally on 12/6/23. 15 attended the 10:30am class and 12 attended the 2pm Inservice topic: Wondering/elopement plan; abuse prevention program plan. Started 9am presented verbally. Presented by [NAME], Regional administrator on 12/1/23. 10 attended the 9am presentation and 13 attended the 10:30am Inservice topic was Wondering/elopement, Abuse prevention program plan. Provided by [NAME] RN. Paper and verbally presented at 9:00am to 9:35 am with 10 people in attendance on 12/2/23 Inservice topic: Freedom from abuse and neglect- sexual abuse. Provide on 11/30/23 at 12pm and 2pm provided by [NAME] RN, RNC, 34 staff in attendance via signatures. Freedom from abuse and neglect- resident to resident physical abuse. Start time was 12pm and 2pm. Verbal presentation by RNC on 11/30/23 with 35 in attendance. Inservice topic- Abuse prevention program- Reporting/investigation. Verbal presentation provided at 12pm and 2pm by [NAME] RNC on 11/30/23 with 34 people in attendance. To certify that all staff were educated, the surveyor team interviewed a sample of staff within each department. Each shift; first, second and third shifts; were included in the interviews. Interview on 12/15/2023 with following employees revealed they received education: 6:43 am LPN BB; 6:56 am C.N.A LL; 7:00 am C.N.A MM; 7:09 am C.N.A KK; 7:20 am C.N.A DD; 7:34 am Dietary aide NN; 7:42 am Dietary aide OO; 7:50 am Laundry FF; 8:17 am Housekeeping PP; 8:24 am Dietary Manager; 9:04 am LPN AA; 9:15 am LPN RR; 9:27 am C.N.A EE; 9:34 am C.N.A SS; 9:44 am Director of Nursing (DON); 2:01 pm Administrator in Training (AIT); 2:09 pm MDS coordinator; 2:27 pm Housekeeping Supervisor; 2:34 pm Business Office Manager; 2:45 pm Human Resource Manager; 3:40 pm Dietary aide VV; 3:45pm C.N.A II; and 3:53 pm C.N.A WW. 11. Interview on 12/14/23 at 9:45am, the Regional Administrator (RA) provided a list of all the employees at the facility, next to the employee's names, the RA included the dates of when each employee was in-serviced The RA stated that the last two staff listed on the employee list are RN Supervisor. They were PRN and will not be returning to the facility. A new employee was hired to take both of their place. 49477 49479

Based on observations, record review, interviews, document review, and review of the facility policy titled Elopements, the facility failed to provide adequate monitoring and protective oversight of the elopement prevention program and failed to ensure the mechanisms of the electronic alert system was functioning properly to prevent residents at risk for elopement to exit the facility undetected. In addition, the facility failed to have a process in place for the four remaining exit doors not equipped with the electronic alert system. Specifically, resident (R) R6 and R10, both wearing electronic alert system devices, eloped from the facility for approximately three hours, before being spotted by local citizens, and reported to the facility that they were missing. The sample size was 19. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator, Director of Nursing (DON) and Regional Nurse Consultant were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/5/2022 when the facility failed to protect four residents (R) (R8, R14, R17 and R18) from physical, verbal, and sexual abuse. A second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the policy titled Elopements revised 2008, indicated staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or the Director of Nursing (DON). When a departing individual returns to the facility, the DON or Charge Nurse shall examine the resident for injuries, notify the attending physician, notify the residents legal representative of the incident, complete and file Report of Incident/Accident, and document the event in the resident's medical record. 1. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses including dementia, agitation, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99, indicating the resident had severe cognitive impairment. Section E revealed the resident exhibited wandering behaviors daily and the behaviors put the resident at significant risk of getting outside the facility. Section GG revealed resident ambulated independently. Review of the Elopement Risk assessment dated [DATE] documented the following: --Is the resident cognitively impaired with poor decision-making skills? (i.e., intermittent confusion, cognitive- staff documented Yes and documented the resident had dementia, agitation, and confusion. --Does the resident verbally express the desire to go home? Staff documented, yes. --Does the resident wander aimlessly? staff documented, Yes and documented frequently wandering- wander guard intact to left wrist. Review of R6's care plan revised on 10/4/2023 documented R6 was at risk for wandering/elopement due to attempting to exit the building. The care plan directed staff to provide distraction, provide simple commands and promptly check exit doors when the alarm sounds. Interventions added after the 7/14/2023 elopement include assessing resident whereabouts every 15 minutes and check residents wander guard at each exit to ensure it is functioning properly each shift. There is no evidence of interventions added for the 8/18/2023 or the 8/29/2023 elopements Review of the Progress Note dated 7/2/2023 at 1:49 am written by Licensed Practical Nurse (LPN) HH, documented R6 was being monitored due to wandering and voiced the desire to go home and tried to find a way out, wander guard intact to left wrist. Review of the Progress Note dated 7/14/2023 at 4:22 pm written by the Administrator in Training (AIT), documented at 10:30 am Activities Director (AD) answered the phone with a woman stating she saw a man in a light blue shirt walking on the highway. Staff started looking throughout the building. The AD walked down the road and found resident approximately a mile and a half a mile from the facility. Resident was returned to the facility; assessment was completed, and no injuries noted. Resident had electronic alert system device intact and functioning properly upon re-entry to the facility. Review of the weather status in the area, according to Accuweather.com, showed the temperature on 7/14/2023 ranged from 71 degrees Fahrenheit (F) to 91 degrees F. Review of the Follow-up Report dated 7/21/2023 revealed on 7/14/2023, the AD received a call to the facility at approximately 10:30 am from an outside caller stating, she believed we might have a resident in a light blue shirt on the highway by her house. R6 had an electronic alert system device in place on the right wrist. Facility findings of the investigation showed the electronic alert system alarm on the back door was noted not functioning properly. The back gate by the broiler was not functioning properly and was replaced immediately. Review of the Progress Note dated 8/19/2023, written by LPN HH, documented on 8/18/2023 at 11:15 pm Certified Nursing Assistant (CNA) TT observed R6 going out the laundry door near the maintenance shed. CNA TT approached R6 to redirect him back into the facility and he stated, he was going to kill himself and end it and added, he didn't know he was going to be at the facility forever. R6 stated he didn't want to be at the facility. Resident was redirected back into the facility and later that afternoon, he tried to go out the front door when staff were trying to leave. LPN HH redirected resident back to his room and allowed him to vent his feelings. Resident showed no harm or threat to himself and will continue to monitor closely with 15-minute visual/safety checks. Review of a handwritten statement dated 8/29/2023 written by CNA EE, documented R6 walked out through the back door, and she tried to redirect him back inside the building, but resident refused. She documented that R6 was not supposed to be outside, but he got out on his own. CNA EE attempted to lead R6 back to the facility and R6's foot went off the concrete sidewalk and R6 fell and hit his head. She notified LPN GG. There is no evidence of documentation of this incident in the residents' electronic medical record (EMR). Interview on 11/27/23 at 10:59 am, the AD revealed on 7/14/2023, she received a phone call from a local resident, who suspected a resident from the facility was walking along the highway. The AD asked the caller about the residents' description, and she concluded the description fitted that of R6. She stated she walked towards the highway and located R6 a mile and half from the facility. She notified the facility and the AIT drove to the location and transported R6 back to the facility. The AD stated the facility doors used to stay unlocked all the time, and residents were able to get in and out. She stated the lock pads were installed on 9/14/2023. Interview on 11/27/2023 at 11:25 am, LPN AA revealed she was familiar with R6 and stated he was slick, sneaky, and understood what was going on. She stated R6 was familiar with his surroundings and always looked for a way out. LPN AA stated the current electronic alert system was unsafe and placed residents at risk. Interview on 11/28/2023 at 9:43 am, LPN GG stated that R6 had attempted to leave the facility on multiple occasions. She revealed at that time when R6 eloped, the facility doors stayed unlocked. During further interview, LPN GG stated she does not recall the incident which occurred on 8/29/2023, when R6 exited the building. She stated it was impossible to monitor residents who were at risk for elopement on regular basis due to staffing concerns. Interview on 11/28/2023 at 4:59 pm, CNA FF revealed that R6 had attempted to leave the facility on several occasions. She revealed there was no wander guard alarm system on any of the doors, except the front door, but that alarm sound was faint and could not be heard. During further interview, she stated residents had been able to get in and out of the facility before the maglocks were installed. 2. Review of the clinical record revealed R10 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, hypertensive heart disease, and stage four chronic kidney disease (CKD). Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section E revealed the resident did not exhibit wandering behavior. Section GG revealed resident ambulated independently. Review of the Elopement Risk assessment dated [DATE] documented the following: --Is the resident cognitively impaired with poor decision-making skills? (i.e., intermittent confusion, cognitive- staff documented Yes and documented the resident had dementia, agitation, and confusion. --Does the resident verbally express the desire to go home? Staff documented, No. --Does the resident wander aimlessly? staff documented, No. Resident re-evaluated and noted to no longer be an elopement risk as he has shown no signs of leaving the facility with wander guard removed. Review of the care plan for R10 revised on 9/7/2023 revealed resident was at risk for elopement/wandering with electronic alert system device in place. The goal was for R10 not to exit the facility unplanned and or unattended. The care plan directed staff to use diversional activities and to observe wandering and elopement behavior. Review of the Follow-up Report dated 9/22/2023 revealed on 9/16/2023, LPN GG received a call from R10's sister stating resident called her earlier saying he was going to leave the facility and go home. After the call ended, LPN GG went to the residents room and resident was not in his room. She alerted the staff of Code Pink and staff began looking in the facility and on the facility grounds, but resident was not located. Local authorities were notified, including the Administrator. Resident responded to facility via phone call and mobile text messages, and resident was located approximately two miles from the facility. Resident was noted to have superficial scratches to face from briars, but no complaints of pain. Emergency Medical Services (EMS) dispatched and transported R10 to the hospital for evaluation. Resident left the hospital against Medical Advice (AMA) after having eloped from the ER and being returned by local police department. Facility findings of the investigation revealed that resident had been pacing outside the facility in the smoking area. Smoke breaks are now scheduled and supervised by staff during set times throughout the day, door locks checked every shift. Review of a written statement from the AIT dated 9/16/2023, the AIT documented at 10:55 am she drove and searched the area for R10. At 1:52 pm the AD called and stated R10 had been located and was seated in AD's personal car. Record review of the weather status in the area, according to Accuweather.com, showed the temperature on 9/16/2023 ranged from as low as 61 degrees Fahrenheit (F) to 78 degrees F. Record review of R10's progress notes showed a late entry dated 9/16/2023 at 2:23 pm LPN GG documented, at approximately 10:20 am, she received a call from R10's representative. The representative stated R10 expressed the desire to leave the facility immediately. LPN GG told R10's representative she last saw R10 at 10:00 am walking down the hall. She was unable to locate R10, after a parameter search around the facility, LPN GG notified the supervisor R10 was missing. Entire staff searched the facility and were unable to locate R10 and GG notified the police department. Review of a hand written statement from LPN GG dated 9/16/2023, revealed she spoke with residents sister at 10:20 am, who was concerned because R10 called her and stated he was going to leave the facility. LPN GG went to residents room and the smoking area and was unable to locate the resident. Staff started searching the surrounding woods and the highway. Called and texted resident encouraging him to return to the facility. Resident stated he did not want to return to the facility. LPN GG continued to communicate with R10 until 1:19 pm. Review of Progress Note dated 9/16/2023 at 2:15 pm written by the DON, documented R10 has was found safe by the sheriff's department on the highway around 1:50 pm. EMS arrived at the scene and transported R10 to the hospital for evaluation. DON notified representative that resident had been found and documented R10 will not be returning to the facility due to safety concerns. Interview on 11/27/2023 at 2:40 pm, the Maintenance Director revealed the front entrance was the only door equipped with an electronic alert system. He stated the sensor system was supposed to beep when a resident with an electronic alert system device gets close to the door. He revealed the rest of the facility exit doors were not equipped with the electronic alert system. During further interview, he stated staff informed him the front door electronic alert system alarm was not loud enough. He stated the electronic alert system was discontinued, obsolete and could not be repaired. The Maintenance Director revealed the facility installed all the exit doors with a mega lock system on 9/14/2023, which requires an access code to be entered to exit the building. He stated he checked the mega lock system daily but does not check the electronic alert system. He stated he relied on the mega lock system which, he stated did not have a sound feature to alert staff when a resident equipped with an electronic alert system device exits the building. Interview on 11/27/23 at 4:07 pm, the DON stated staff are expected to take residents equipped with the electronic alert system device to the exit doors and test if the system responded as required. The system was supposed to sound an alarm, when a resident equipped with an electronic alert system device moved closer to the door. She stated she expected staff to document in the nursing chart that they monitored the wander guard. The DON confirmed the front door was the only door fitted with the electronic alert system and verified the current alarm system was not loud enough for staff to hear. During further interview, she stated prior to 9/13/2023, the rear doors stayed unlocked during the day. According to the DON, facility staff were supposed to review current procedures after each elopement and the resident is supposed to be sent out for evaluation. For the 7/14/2023 elopement, R6 was not sent out for evaluation, but staff monitored R6 every fifteen minutes. The fifteen-minute monitoring checks were discontinued, but she did not recall when and why the monitoring was discontinued. The DON stated elopement assessments were only done on admission, and not quarterly, as required by facility policy. Interview on 11/27/2023 at 4:45 pm, the AIT revealed the electronic alert system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the current system was unsafe and explained if a resident walked out behind a family member, staff would not be able to detect and hear the alarm sound. Observation on 11/27/2023 at 4:50 pm, the AIT tested the wander guard system with an electronic alert system bracelet in her hand, and the door opened. The audible alarm sound was faint. The AIT stated, the door should not have opened, and the alarm sound could barely be heard. The alarm system was not detected, and the sound was faint. Interview on 11/28/2023 at 8:53 am, the previous Administrator revealed she was unaware how R6 and R10 exited the building without staff noticing. She stated R6 and R10 were not adequately supervised, and the wander guard system did not sound the alarm when they exited. During further interview, she stated when R6 and R10 eloped from the facility, the doors were not equipped with the maglock system. She stated the maglock key codes are only given to staff members. She stated she expected staff to provide protective oversight for all residents. Interview on 12/5/2023 at 9:50 am, the DON revealed QAPI meetings were designed to discuss areas needed for improvement and to discuss residents who were potentially at risk. The DON concluded the meetings in QAPI are a waste of time, and added discussions are never put in practice. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education related to the Wandering and Elopements policy, location of Elopement Binders, identifying residents at high risk for elopement, and Magnetic Door Lock Mechanism functionality to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Wandering and Elopement policy was completed, and no policy changes were recommended. 3. Administrator, [NAME], resigned effective immediately on 12/05/2023. Regional Administrator, [NAME] (NHA004705) assumed the role of Interim Administrator on 12/06/2023. 4. All Residents were assessed using the Elopement Risk Assessment to determine residents at high risk for elopement. These assessments resulted in three (3) additional residents at high risk, bringing the facility total to five (5) residents at high risk for elopement. 5. Care Plans have been reviewed and updated for five Residents determined to be at High Risk for Elopement. 6. Five (5) residents determined to be at High Risk for Elopement have been updated in the Elopement Binder. All staff have been educated on the location of the Elopement Binder (Admin office, dietary (kitchen), and nurse's station. The elopement binders will be updated as any additional residents are identified as high risk for elopement. 7. Magnetic Door Locking mechanisms have been installed on all entry/exit doors that require a code for entry and exit. 8. Magnetic Door Locking mechanisms are monitored and checked for functionality daily by the Maintenance Director (Monday-Friday) and the Weekend RN Supervisor (Saturday-Sunday) using the Daily Door Lock Checks form. 9. The Main Entrance is equipped with a functioning Wander Guard system because all Visitors and Vendors are required to enter and exit at the Main Entrance. The Wander Guard system delivers an audible announcer if a Resident identified at High Risk for Elopement breaches the Main Entrance doorway with a Wander Guard intact device. 10. The Wander Guard devices on residents identified as high risk for elopement are monitored every 12 hours by a Nursing Manager using the handheld [NAME] Wander Guard Universal Tester noted in the electronic Medication Administration Record (MAR). The Universal Tester device was ordered and was delivered to the facility on [DATE]. All Staff are educated on 12/12/2023 on the use of the Universal Tester. 11. A root cause analysis was completed; it was determined that a lack of training related to Wandering and Elopements was a factor. Training for all staff related to Wandering and Elopements started on 11/30/2023 and has continued through 12/12/2023. 12. A Performance Improvement Plan related to Wandering and Elopements was developed and will be followed through the facility's QAPI process. 13. The Regional Nurse Consultant conducted training using the Wandering and Elopements policy, locations of the Elopement Binders, identifying residents at high risk for elopement, and regarding Magnetic Door Lock mechanism functionality for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 administrative staff members have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 14. All facility staff not in-serviced on the Wandering and Elopements Policy, location of elopement binders, and identifying residents at high risk for elopement will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Evidence of the Wander Guard Training and in-services was verified in the inservice signup sheet dated 12/12/2023 located in the binder provided by the facility and 23 staff were in serviced. An inservice meeting verified an inservice meeting held on 12/12/2023 was held regarding Maglock doors and how to check them. New Door codes. Door checks to ensure lock was engaged. The Wonder guard system. Providing security to at risk residents and using proper tools to check door bracelets and checking residents' bracelets. (23 staff were in serviced). Observations on 12/14/2023 at 10:30 am showed the mega locks was installed with new door codes and the wander guard sound was audible and loud enough for staff to hear from all angles of the facility. 2. Evidence of the inservice showed that on 12/6/2023 at 10:30 am fifteen (15) staff were in serviced regarding Accidents and Elopements and care plans. On 12/6/2023 at 2:00 pm fourteen (14) staff were in serviced regarding Accidents and Elopements and care plans. A QAPI meeting was held on 12/06/2023 from 9:00 am and ended at 9:45 am the following staff attended the QAPI meeting- Business Office Manager, Maintenance, Director, Dietary Manager, Administrator in Training AIT/MDS, Risk Manager Activity Assistant, MDS, Director of Nursing, House Keeping and Human Resource Director. The QAPI meeting was held for the following Tags F600, F609, F610, F835, F867, F689, F689 and F635. And signatures were documented regarding completion of the inservice. A defined reassessment showed five residents were identified on the Elopement Risk assessment dated [DATE]. During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held regarding elopement, wandering and abuse. She verified all abuse should be reported within 2 hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI, inservice starts the same day if possible. DON is responsible for in-services. CNA's can access the elopement book. In the book, they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance. 3. This was verified as per observation 12/6/2023 at 8:58 am and stated the administrator yesterday evening and that was accepted, and he will the acting administrator moving forward. During an interview on 12/15/2023 at 9:44 am the DON revealed there was an administrator change and the Regional Admibistrator was now the interim Administrator. When staff are unable to reach him regarding reportable, they are required to report to her. Observations on 12/14/2023 at 10:30 through 10;40 am revealed the administrator- [NAME] was not in the office. 4. Evidence of the inservice showed that on 12/6/2023 at 12:00 pm to 1:00 pm and from 1:00 pm to 2:00 pm regarding Wandering, Elopement and Resident Safety and was dated on 11/30/2023 in all a total of thirty-six (36) staff were in serviced signed on the inservice sheet. Another inservice sheet was completed on 12/01/2023 at 9:00 am ten staff (10) and on 12/01/2023 at 10:30 am a total of (13) thirteen. The following interviews verified interventions were in place: During an interview on 12/15/2023 at 9:14 am LPN RR revealed I work the first shift, we did inservice about elopement and facility identified additional residents and added wander guards to the residents. The sound of alarms its audible it can be heard from the nurse's station, and they sound we the wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses and all staff have access to the book. During an interview on 12/15/2023 at 9:27 am CNA EE revealed the inservice discussed elopement and abuse. And what to do when a resident elopes. EE stated facility identified six residents as risk for elopement and the identified residents all have wander guards on, they have ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. During an interview on 12/15/2023 at 9:34 am CNA-SS revealed the inservice was done regarding elopement during the inservice and that it should be reportable to the administrator immediately. We do check on the resident that have been identified every few fifteen minutes. R6 is alert and oriented now we are doing regular checks, and we are checking more residents, we do check the wander guards every morning the rest have wander guard on the wrist. The alarm sounds can be heard from the hallway when the sound is heard you go and investigate. Observations on 12/14/2023 at 11:30 am showed Residents R6, R10, R19, R20 and R21, and R 22 had electronic alert devices on their wrist and the electronic alert system functioned as required. Care plans have been reviewed and updated fir five residents determined to be at High Risk for Elopement. Documentation showed care plans were updated for residents identified as elopement risk and was reviewed and interventions were put in place. The following interviews verified the interventions were conducted and were in place: During an interview on 12/15/2023 at 9:04 am LPN AA revealed she had done inservice regarding elopement and that if anything that we were not sure should be reported to the administrator including all types of abuse. We are now residents with bracelets before they have a tester, now it has a high pitch sound and its loud and clear I feel. The elopement book is accessible to all can and they can access it for certain measures. measures will help. The care plans are now updated to indicate they are at risk for elopement on the care plan they will be interventions all can are conveyed verbally through communications on what interventions are in place. All wanderers are checked on the MAR. During an interview on 12/15/2023 at 9:14 am LPN RR revealed I work the first shift, we did inservice and care plans were updated for five additional residents identified as risk for elopement. Wander guards were added to the residents they sound an alarm, which is audible it can be heard from the nurse's station, and they sound we the wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses and all staff have access to the book. During an interview on 12/15/2023 at 9:27 am CNA EE revealed the inservice discussed elopement and abuse. And what to do when a resident elopes, when residents are fighting, we would separate, we have now six elopements elopement residents they all have wander guards on they have ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. 5. Residents R6, R10, R19, R20 and R21, and R 22 were identified to be at risk for elopement. Observations on 12/15/2023 at 11:50 am showed an elopement book at the nurses station and staff verified the resident were being monitored. 6. Documentation showed that the Magnetic Locking Mechanisms was installed on 9/14/2023. Observations from 11/29/2023 through 12/14/2023 revealed the Magnetic Locking Mechanisms worked as required. 7. According to the daily door lock checks, documentation showed checks were started on 12/4/Door daily checks were started on 12/4/2023. Observations on 12/15/2023 at 11: 05 am showed that the magnetic locking mechanism was functioning as required. 8. Documentation showed the system was ordered on 12/07/2023 from Securitas Healthcare and was installed on 12/12/2023. During an interview with the administrator on 12/12/2023 at 1:05 pm, a Wander Guard Universal Tester was ordered and was received by facility on 12/12/2023. 9. During an interview on 12/15/2023 at 9:44 am the DON revealed that in services were held regarding elopement, wandering and abuse. Abuse should be reported within 2 hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The care plans DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book they are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the maintenance. During an interview, 12/15/2023 at 7;23 am [NAME]. CNA, DD we have learned all types of abuse including financial administration is the abuse coordinator and any abuse would be reported to him immediately if he not here DON would be the next person to report to. We talked abuse and elopement we now have six identified elements. That alarm sounding was demonstrated, I am not able to hear the alarm. Resident cant gets out because we have mega locks and codes. The resident does know the codes. During an interview 12/15/2023 at 7:24 [NAME] (Dietary Aide), NN we learned about abuse and that it was reportable to the administrator immediately. Including verbal abuse which is reportable to the administrator. Elopement we were told when the alarm sounds the patient is trying to get, the alarm sound can be heard while I am in the kitchen. 10. During an interview on 12/15/ [TRUNCATED]

Based on observations, resident and staff interviews, record review and review of the facility's policies entitled Return to Work Guidance After COVID-19 Illness or Exposure and COVID-19 Emergency Preparedness Policy Plan, the facility failed to follow their COVID-19 return to work policy when a staff member (the Minimum Data Set Coordinator (MDS)/Infection Control Preventionist (IP)), continued to work in the facility and have direct contact with 40 residents currently residing in the facility after testing positive for COVID-19. In addition, the facility failed to isolate one (1) resident (Resident #6), after exposure to his roommate, who tested positive for COVID-19. Further, the facility was unable to provide policies and procedures that addressed the following: 1. Isolation/cohorting to prevent the spread of COVID-19 related to residents with known exposure to COVID-19; 2. Positive residents who left the facility for routine or emergent appointments and 3. Appropriately quarantine staff and residents that prevented the increased risk of transmission of COVID-19. This resulted in an Immediate Jeopardy. On 09/02/20 at 10:00 PM, the Administrator was notified of the immediate jeopardy at F880 (Infection Control) related to the facility's failure to ensure one staff member who tested positive for COVID-19 on 08/27/20 was not working in the facility in direct contact with all 40 residents in the facility; the facility's failure to ensure isolation/quarantine policies were in place and followed for residents who had known exposure to residents who tested positive for COVID-19 and for residents who left the facility for routine or emergent appointments. The facility provided an acceptable removal plan for the immediate jeopardy at F880 on 09/03/20 at 6:45 PM. The removal plan indicated that the staff member who tested positive for COVID 19 was placed on leave and could not return to work. The removal plan included testing of all staff and residents in the facility for COVID-19 and the appropriate placement and quarantining of residents based on test results. The facility's COVID-19 Response Policy was updated to include measures for quarantining residents with known exposure to residents who tested positive for COVID-19 and for residents who left the facility for routine and emergency care. The facility designated a unit which was called Presumptive Positive Unit (PUI) and staff was in-serviced on the policy changes as well as updated on changes in resident status. The removal plan was validated by the surveyor through observations, staff interviews, record review and review of the facility's revised policies and procedures. Observations verified that residents and staff were being tested for the COVID 19 virus and that the revised COVID 19 Policy was being followed in response to testing results, residents leaving the facility and residents who were placed on the PUI unit. The surveyor notified the Administrator that the immediate jeopardy was removed on 09/03/20 at 7:00 PM. The deficient practice was lowered to an F (widespread scope and severity with a potential for more than minimum harm) following the removal of the immediate jeopardy. Based on observation and interview, the facility failed to ensure that staff, Certified Nurse Assistant (CNA) #2, adhered to the facility's policy and procedure regarding the gowning of appropriate Personal Protective Equipment (PPE). The findings include: 1. During the tour of the facility, which included the COVID-19 and Non-COVID-19 Units, on 09/02/20 between 11:40 AM and 1:40 PM, the MDS Coordinator/IP was observed in direct contact with multiple staff and residents on both units, including Certified Nursing Assistant (CNA #1), CNA #2, the Housekeeping Supervisor, Housekeeper (HK #1), Licensed Practical Nurse (LPN #1), and Registered Nurse (RN #1). The MDS Coordinator/IP remained with the surveyor during the entire tour and was within less than 2 feet of these staff members during interviews at approximately 11:45 AM with CNA #1, 12:00 PM with CNA #2, 12:15 PM with the Housekeeping Supervisor, 12:30 PM with HK #1, 1:20 PM with LPN #1, and 1:35 PM with RN #1. During the interviews with CNA #2, the Housekeeping Supervisor, and RN #1, all three stated they had job responsibilities in both the COVID-19 Unit and the Non-COVID Unit and provided direct care or were within close proximity (less than 6 feet) of all residents in the facility on a routine basis. In addition, the Dietary Manager (DM) was observed in the MDS Coordinator/IP's office asking work related questions (within two feet of each other) on 09/02/20 at approximately 11:00 AM and 2:10 PM. The Social Worker was observed in the MDS Coordinator/IP's office discussing work related issues (within two feet of each other) on 09/02/20 at approximately 2:00 PM and approximately 2:30 PM. CNA #3 was observed in the MDS Coordinator/IP's office asking work related questions (within 2 feet of each other) on 09/02/20 at approximately 3:00 PM. The MDS/Coordinator was wearing her N95 mask during these observations, however, the DM, Social Worker, and CNA3 were observed to be wearing only cloth masks at the time of the observations. The MDS Coordinator/IP also escorted the surveyor to Resident #6's room for an interview on 09/02/20 at approximately 5:30 PM. The MDS Coordinator/IP entered the resident's room during the interview and was standing within 2 feet of Resident #6 during the entire interview (approximately 10 minutes). The MDS Coordinator/IP was wearing her N95 mask during the interview, however Resident #6 was not wearing a mask. During an interview with the MDS Coordinator/IP on 09/02/20 at 3:45 PM, she stated he Director of Nursing (DON) had become ill and tested positive for COVID 19 on 08/27/20, the same day the MDS Coordinator/IP also tested positive for COVID. She stated she was aware of the facility's policy that indicated she was to be quarantined for a period of 10 days after testing positive. She stated she was immediately sent home after the positive result but was directed by the Administrator to return to work the following day on 08/28/20 and was told to quarantine herself in her office. She also indicated she had been working her full-time schedule since she tested positive and in addition she had also picked up a shift as the charge nurse on the COVID-19 Unit on 08/30/20. According to the MDS/IP nurse, although administration was aware of her results, she had been directed by the corporate office to report back to work. Review of the MDS Coordinator/IP's work schedule from 08/27/20 through 09/02/20 revealed she had been in the facility and had worked her regular 8-hour day shifts (as MDS Coordinator/IP) on 08/28/20, 08/31/20, 09/01/20, and 09/02/20. In addition, the schedule she filled in as the charge nurse and provided direct care to residents on the COVID-19 Unit from 7:00 AM to 7:00 PM on 08/30/20. According to the Employee COVID Testing List, the MDS Coordinator/IP tested positive for COVID-19 on 08/27/20. During an interview with the Administrator on 09/02/20 at 4:00 PM, she stated the MDS Coordinator/IP was needed to work as a charge nurse on 8/30/20, and that, to her knowledge, she just kept coming to work after that date through the survey date. She was unable to recall why the MDS Coordinator/IP worked in the facility on the other dates and stated her job did not require her to be in the facility. The Administrator acknowledged she was aware of the facility's Return to Work Guidance After COVID-19 Illness or Exposure Policy and that it indicated staff was not to return to work after a positive COVID-19 test result until at least 10 days after the positive test result and the staff member was symptom free. She acknowledged the policy had not been followed. During an interview with the Medical Director on 09/02/20 at 6:15 PM, he stated he was aware that there were cases of COVID 19 in the facility, but he was not aware that the MDS Coordinator/IP had tested positive and continued to work in the facility with direct contact with all residents and staff. He stated the MDS Coordinator/IP should have been isolated/quarantined at home for 14 days before being allowed to return to work. Review of the facility's policy entitled, Return to Work Guidance After COVID-19 Illness or Exposure dated 07/21/20 revealed, The following guidance should be used to make decisions about return to work for employees and Symptom based strategies for determining return to work, and Asymptomatic HCPs (Health Care Partners) with confirmed COVID-19 can use the time based strategy and return to work after: (1) at least 10 days have passed since the positive laboratory test and the HCP remains asymptomatic. (2) Note, asymptomatic HCPs who test positive and later develop symptoms should follow the guidance for symptomatic HCPs. 2. According to the facility's Census List dated 09/02/20, there were a total of 19 residents in the facility who tested positive and were resided in the COVID-19 Unit and 21 residents on the Non-COVID-19 Unit. Five (5) additional residents were hospitalized for [REDACTED]. An updated facility Census List dated 09/03/20 revealed 26 residents on the COVID-19 positive unit, 10 residents on the PUI unit for isolation, and two (2) residents resided on the Non-COVID-19 Unit. Seven residents were hospitalized for [REDACTED]. 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS dated [DATE], indicated the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) Score of 3. Resident #6 was independent with ambulation and only required supervision of staff to walk about the facility. Review of Resident #6's COVID-19 Care Plan dated 06/18/20, indicated the resident was at risk for developing COVID 19 due to risk for non-compliance with precautions. The planned approaches included monitoring for signs and symptoms of COVID-19, encouraging the resident to socially distance himself from others, wear a mask in common areas, and to follow appropriate cough etiquette and hand washing, and preventative COVID-19 isolation as ordered after hospital returns. Review of the Departmental Notes, indicated Resident #6 had been out of the facility on 08/04/20, 08/19/20, and 09/02/20 for routine visits with his oncologist. The facility Census List dated 09/02/20 indicated Resident #6 resided on the Non-COVID Unit as of 08/26/20 and through the exit date of the survey. Prior to 08/26/20, Resident #6 was a roommate with Resident #9 (who tested positive for COVID-19). Resident #9 was moved to the COVID Unit, but Resident #6 remained on the Non-COVID Unit and moved into the room with Resident #7. On 09/02/20 at 5:30 PM, during an observation and resident interview in the resident's room, he stated he was able to ambulate in his room independently. He also stated he had just returned from an appointment with his doctor, wasn't in any kind of isolation and he could walk around the facility freely as long as he wore a mask. The MDS Coordinator/IP was present at the time of the interview and verified the resident's statements were accurate. During an interview with the MDS Coordinator/IP on 09/02/20, at 5:40 PM, she stated the facility had not previously quarantined or cohorted any residents after known exposure to positive roommates. She further stated that residents, who had been out of the facility to appointments had not been isolated/quarantined to ensure COVID-19 was not spread throughout the facility. There was no policy to address these issues, and that she had not thought about the possibility of spreading [MEDICAL CONDITION] this way. She stated no further testing had been done on residents who had prior negative COVID-19 results unless residents were showing signs of the disease. During an interview with the Medical Director on 09/02/20 at 6:16 PM, he stated he had been made aware of the COVID-19 outbreak in building the previous week and had not received any updates since that time. He stated he asked what was being done and was told the facility was geographically separating residents and had different nursing staff caring for the different populations. He stated residents with known exposure to COVID-19 or who had been out of the building for any reason were to be isolated for 14 days, and that residents with known COVID-19 exposure should not be sharing rooms with residents with no known COVID-19 exposure. During an interview with the Administrator on 09/02/20 at 8:00 PM, she stated that the facility did not have a specific policy to address the issue of isolating residents with known exposure to COVID-19 or residents who needed to travel outside of the facility for appointments. The facility presented an acceptable removal plan for the Immediate Jeopardy on 09/03/20 at 6:45 PM that read: Regarding the MDS/IP working in the facility with a positive test for COVID-19: a) As of 09/02/20, the IP coordinator will not return to work until the Work Restriction Criteria has been met according to the corporate policy that coincides with CDC recommendations. Regarding isolation/cohorting of residents to prevent the spread of COVID-19 related to Residents with known exposure to COVID-19: a) Facility-wide testing (09/0/2020) via licensed nurse; for both residents and staff with the remaining supply of the BO Sofia2 (COVID [MEDICATION NAME] test) POC device. 100% of resident will be tested today, excluding the twenty-five existing positive residents on isolation. A total of twelve residents were tested today. Six residents tested negative, and six tested positive. The facility currently has a total of thirty-one positive residents and thirteen negative residents. The facility has fifty-three employees. 100% of the staff will be tested . Twenty-one staff were tested today with eleven tested as positive, and ten tested negative. The remaining staff wil be tested within the next two days before the beginning of their shift. B) Residents currently on the designated positive unit will be tested last, and current negative residents will be tested first priority today (09/03/2020) with the current in-house POC device and supplies to ensure appropriate interventions and unit designation. c) Immediate actions will be taken (09/03/2020) for resident/staff resulting in a CoV-2 positive result such as Work Restriction and or appropriate placement of the resident to prevent the transmission of CoV-2 virus. According to CDC guidelines. d) Residents with known positivity based on the last testing results will remain on the designated unit unless the Medical Director request retesting; encouraging to follow CDC guidelines for isolation discontinuation via symptom strategy methodology. E) Residents #6, #7, #8, #9 will be included in the priority of testing today, 09/03/2020, to ensure appropriate placement on the designated units. {late entry, resident #6) tested negative and will be placed in the quarantine unit due to scheduled appointments related to Dx. CA treatments. f) The Medical Director will be consulted today {09/03/2020} for a standing order to perform testing on residents. Regarding positive residents who require quarantine and/or leave the facility for routine or emergent appointments: a) The facility will construct a movable barrier wall today (09/03/220) to implement a quarantine unit between the designated positive & negative units. The quarantine unit will house hospital returns with known negatives or persons under investigation (Put) and residents that frequently have scheduled appointments such as [MEDICAL TREATMENT] and chemo treatments. b) Any resident identified to require scheduled appointments will be appropriately care planned, designated to the unit according to the last test results. Refer to the transport of residents with a known [DIAGNOSES REDACTED]. The care plan will be altered to encompass appropriate steps to be taken for staff awareness. c) Existing policies revised to reflect resident isolaton procedures related to COVID 19 exposures while out of the facility and the policy to address isolation procedures related to residents who need to leave the facility for appointments or who previously resided with/have had close contact with residents who have tested positive for COVID 19. 4. CNA #2 was observed working on the facility's COVID-19 Unit on 09/02/20 between 11:40 AM and 1:20 PM. During continuous observations of CNA #2 during this time period, she wore an orange one-piece jumpsuit. The CNA entered and exited residents' rooms to provide personal care and assistance to several different residents on the unit. She did not don (put on) a new gown prior to entering each resident's room to provide care, instead she wore the orange jumpsuit continuously while on the COVID Unit. During an interview with CNA #2 on 09/02/20 at approximately 1:10 PM, she stated she had been provided with the jumpsuit quite a while ago by the facility, and that she had been wearing the suit for several days. She stated she did not don a gown prior to entering individual resident rooms, only wearing the jumpsuit over her regular clothing throughout her shift for extra protection. CNA #2 stated that she did not remove the jumpsuit prior to leaving the facility at the end of her shift, instead she removed the jumpsuit once she returned home on her porch, prior to entering her home. CNA #2 stated she cleansed the jumpsuit with Lysol spray, donned the jumpsuit again the next day before leaving her home for her next shift at the facility. CNA #2 did not remember being educated related to proper use of PPE while working with COVID-19 positive residents in the facility. Review of CNA #2's Employee In-service documentation revealed that she received in-service training related to PPE for COVID-19 Care on 07/13/20. The training documentation did not provide specifics related to the content of the training. During an interview with the MDS Coordinator/IP on 09/02/20 at approximately 1:50 PM, she stated CNA #2 should wear a separate gown each time she entered a different resident's room, and that she should not wear the orange jumpsuit in and out of resident rooms all day and then home from the facility at the end of her shift. During an interview with the Medical Director on 09/02/20 at 6:15 PM, he stated, All staff should be wearing appropriate PPE, and should take their PPE off before leaving the unit/facility. No one should be wearing PPE home. Review of the facility's COVID-19 Emergency Preparedness Policy Plan dated 03/18/20 revealed, All staff and new hires will receive training in proper hand hygiene and use of PPE, Sanitization of reusable (PPE) according to manufacturer recommendations.