Every finding on record at Henderson Health And Rehabilitation Center

Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders for 1 of 3 (Resident #13) sampled residents reviewed for Urinary Tract Infection. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician.verify dose.administer medication as ordered.Sign Mar [Medication Administration Record] after administered [medications]. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Uropathy, Benign Prostatic Hyperplasia, and Chronic Kidney Disease. Review of the Physician's Order dated 7/31/2025, revealed .Gentamicin Sulfate Solution [an antibiotic used to treat an infection] Inject 80 mg [milligrams] intramuscularly [IM] one time a day for UTI [Urinary Tract Infection] for 3 Days. Review of the Medication Administration Record for July 2025, revealed Gentamicin Sulfate Solution was not documented as administered on 7/31/2025. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 10, which indicated he was moderately cognitively impaired. During an interview on 11/19/2025 at 9:07 AM, the Director of Nursing (DON) was asked if a resident was ordered Gentamicin IM once a day for 3 days should they receive all 3 doses. The DON stated, Yes. The DON was asked should medications be documented when administered. The DON stated, Yes, they [medications] should be documented. The DON was asked if medications should be documented if not given or held. The DON stated, Yes it should have been documented if it was not given. The DON was asked if the Doctor should have been notified if a medication dose was missed. The DON stated, Yes, he [doctor] should have been notified.

Based on facility policy review, medical record review, observation, and interview, the facility failed to accurately assess nutritional status of residents, failed to follow the facility's policy for monitoring weights and failed to have a nutritional intervention provided timely for 2 of 4 (Resident #8 and #9) residents reviewed for nutrition. The findings include: 1. Review of the facility's policy titled, Weight System, revised 7/9/2025, revealed .Weekly weights are completed for.Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 months or 10% in 6 months.All weight changes are considered unplanned unless the MD [medical doctor] has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring.DON [Director of Nursing] or designee.will review monthly and weekly weights.Request reweights on a resident's weekly weight if a change greater than 2% change and on a resident's monthly weight if greater than 5%, 7.5% or 10% change is noted. DON or designee will also validate that monthly and weekly weights are recorded.Discuss all residents with significant weight change (gain/loss of 5% or more in 1 mo [month], 7.5 % or more in 3 mo., 10% or more in 6 mo.).At risk Meeting.Discuss residents with greater than 2% change in a week.discuss.until.resolved.Residents with significant weight loss or gain of 5% x [for] 1 month will be weighed every week for four weeks (or longer if not stable).Significant weight changes.should be referred to the RD [Registered Dietician].Residents with unstable weights should be discussed.until concern is resolved.Implement or request interventions as needed for residents with significant weight change.DON or designee to notify MD and resident representative of significant weight change and/or intervention in the EMR [electronic medical record]. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Encephalopathy, Dysphagia, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Resident #8 required total dependence for meals. Weight loss was coded as 5% in the last month and over 10% in last 6 months. Review of Resident #8's weights revealed on 4/2/2025, the resident weighed 119 pounds and on 5/7/2025, the resident weighed 106 pounds which was a 10.9 % loss in 35 days. During an interview on 11/18/2025 at 9:30 AM, the MDS Coordinator was asked what interventions were put into place after Resident #8's May 2025 weight loss. The MDS Coordinator stated, .on 8-9-2025, was an order for fortified food [foods with nutrients added to them] at dinner and add 120 ml [milliliter] house supplement at hs [bedtime] . Review of the Physician Order dated 8/9/2025, revealed, .fortified food [foods with nutrients added to them] at dinner and add 120 ml [milliliter] house supplement at hs [bedtime] . During an interview on 11/17/2025 at 2:41 PM, the Director of Nursing (DON) was asked if weight loss was identified and if an intervention should have been put into place prior to 8/9/2025. The DON stated, Yes Ma'am. 3. Review of medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 scored a 10 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of Resident #9's weights revealed on 10/05/2025, the resident weighed 145 pounds and on 11/4/2025, the resident weighed 131.2 pounds which was a 9.52% loss for 29 days. Review of Physician's orders dated 11/16/2025, revealed .High Calorie Boost twice daily two times a day for weight stabilization. During an interview on 11/19/2025 at 9:04 AM, the DON was asked if weight loss was identified on 11/4/2025, should the intervention have been implemented before 11/16/2025. The DON stated, Yes ma'am.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders, provide care and services regarding oxygen therapy, and failed to assess residents for the use of oxygen for 2 of 3 (Resident #42 and #75) sampled residents reviewed for respiratory care.The findings include: 1. Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Staff shall document the initial and ongoing assessments. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician.verify dose.administer medication as ordered.Sign Mar [Medication Administration Record] after administered [medications]. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Anemia, Atrial Fibrillation, and Alzheimer's. Review of the Physician's Orders dated 5/21/2024, revealed, .2 LITERS BY NASAL CANNULA [NC] FOR SHORTNESS OF BREATH PRN [as needed] as needed . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately cognitively impaired. Resident #42 was not coded for the use of oxygen. Review of the Progress Note dated 11/16/2025 at 7:27 PM, revealed, Vital signs obtained.BNC [binasal cannula] on 1 1/2 [1 and 1 half] liters. Review of the Medication Administration Record (MAR) dated 11/2025, revealed the facility failed to document the use of oxygen from 11/1/2025 to 11/18/2025. Observation in the dining room on 11/18/2025 at 10:26 AM, revealed Resident #42 was receiving 2 liters of oxygen via [by way of] a portable oxygen tank. During an interview on the 400 Hall on 11/19/2025 7:32 AM, Licensed Practical Nurse (LPN) B was asked what rate Resident #42's oxygen should be set at. LPN B stated, I believe 1 1/2 to 2 liters. LPN B was asked should oxygen usage be documented on the MAR. LPN B stated, Yes, ma'am it should be documented . 3. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Cervical Myelopathy, Pleural Effusion, and Emphysema. Review of the Physician's Orders dated 7/16/2025, revealed, .2 LITERS BY NASAL CANNULA FOR SHORTNESS OF BREATH AND COMFORT PRN every 1 hours as needed for SHORTNESS OF BREATH . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated severely cognitively impaired. Resident #75 was not coded for the use of oxygen. Review of the MAR dated 11/2025, revealed the facility failed to document the use of oxygen from 11/1/2025 through 11/18/2025. Observations in the resident's room on 11/17/2025 at 9:35 AM, and 11/18/2025 at 8:36 AM, revealed Resident #75 was receiving oxygen via BNC with the oxygen concentrator set at 1.5 liters per minute. During an observation and interview in Resident #75's room on 11/18/2025 at 8:37 AM, LPN C acknowledged Resident #75's oxygen concentrator was set incorrectly at 1.5 liters per minute and should be set at 2 liters per minute. LPN C was asked if prn medications should be documented on the Medication Administration Record. LPN C stated, Yes. During an interview on 11/18/2025 at 9:56 AM, the Director of Nursing (DON) confirmed Resident #75 should be receiving oxygen at 2 liters per minute. The DON was asked should prn medications be documented on the Medication Administration Record. The DON stated, Yes. During an interview on 11/19/2025 at 7:32 AM, LPN B was asked what Resident #75's oxygen concentrator should be set at. LPN B reviewed the Physician's Orders and stated, It should be 2 liters .

Based on policy review, manufacturer's guidelines review, maintenance history report review, observations, and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to label and date food stored in the cooler and dry storage, and failed to ensure food stored for resident consumption was not expired. The facility had a census of 92 residents with 91 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's undated policy titled, Sanitation Inspection, revealed, .policy of this facility . conduct inspections to ensure food service areas are clean, sanitary and in compliance .All food service areas shall be kept clean, sanitary .inspections to be conducted .Dry storage .Freezer .Refrigerator .Food preparation area .General dietary observations . The facility was unable to provide a dietary policy for food storage. 2. Review of the manufacturer's guidelines for the facility's ice machine dated 2018, revealed, .Cleaning/Sanitizing Procedure .This procedure must be performed a minimum of once every six months .ice machine and bin must be disassembled cleaned and sanitized . Review of the Work History Report for maintenance revealed, .Ice Machines/Ice Bins .sanitize interior .Marked as done .on [DATE] . Review of the Daily and Weekly Cleaning Schedule dated [DATE]-[DATE], revealed, .Ice Machine-Wipe/Sanitize Scoop [assigned daily] . No documentation of task being completed.Mixer [assigned daily] . Documentation of task completed 2 of 24 days. No assignment daily or weekly for the plate warmer cart. 3. Observation in the common area of ,d+[DATE] Hall and interview on [DATE] at 2:15 PM revealed a resident opened an ice storage chest and used the ice scoop to fill a water pitcher with ice then placed the scoop back in a container on top of the chest. The ice storage chest had multiple areas of green, red, black, and brown mildew/mold like substance on the outside and inside of the ice storage chest, where ice was stored for resident use. The plastic container on top of the chest storage chest had an ice scoop resting in a layer of white slimy substance on bottom. Licensed Practical Nurse (LPN) F observed the ,d+[DATE] Hall ice storage chest and stated the ice storage chest was dirty and should not be used to serve ice to the residents until cleaned. LPN F stated, .I will ask someone to come and get the cooler and clean it .I will get a new water cup for [Named Resident] . Observation on the ,d+[DATE] Hall, 500 Hall, 600 Hall, and interview on [DATE] beginning at 2:20 PM, revealed the ,d+[DATE] Hall ice storage chest still had the mold like substances inside and outside the chest was left unattended with the container holding the ice scoop resting on a layer of white slimy substance. An ice storage chest containing ice on 500 Hall had brown/black mildew/mold like substance on the outer and inside of the cover. A plastic container sitting on top of the ice storage chest held the ice scoop resting in a layer of a white slimy substance. An ice storage chest on the 600 Hall had brown/black mildew/mold like substance on the cover and inside the chest. A broken/cracked blue plastic container held an ice scoop resting in a layer of white slimy substance. The Assistant Director of Nursing (ADON) was present during the observations and confirmed the 3 ice storage chests containing ice were dirty and should not be used to deliver ice to the residents. The ADON touched the bottom of the containers holding the ice scoops and confirmed all 3 ice scoops, used to serve ice, were resting in a layer of slimy substance. Observation in the kitchen and interview on [DATE] at 2:30 PM, revealed the ice machine door had rust like debris on the hinges above the bin containing ice. The inside back wall had a large area of black powdery mold like substance at and below the level of ice in the bin and the inside right wall of the ice machine bin had multiple small spots of black powdery mold like substance below the level of ice in the bin. The ADON was asked to use a paper towel to wipe over the black powdery mold like substance on the inside wall and rust like substance on the hinges, and verified the substance was removable to touch. An uncovered container sitting beside the ice machine held two ice scoops resting on a layer of clear slimy substance. There were black/brown areas of dried debris in several spots on the inside wall of the ice scoop container. The ADON confirmed the ice machine used to prepare and store ice for food preparation and resident consumption, and the scoop used in the ice machine were not clean and sanitary. Observation in the dining room and interview on [DATE] at 2:38 PM, revealed 4 tray carts used to transport meal trays to residents. All 4 tray carts had dried brown, white, beige debris scattered in multiple areas and on the tray rails. The Dietary Manager (DM) stated the carts were held in the dining room and had been cleaned after use today. The DM stated the dried areas were rust spots and would not come off with cleaning. The DM was then asked to scrape some of the dried debris off. The DM was able to successfully scrape off two areas chosen for demonstration. The ADON confirmed the tray carts were used to transport meal trays and should be clean and free from debris. During an interview on [DATE] at 2:48 PM, the DM verified there was a cleaning schedule for daily and weekly cleaning tasks. The DM provided the cleaning schedule for [DATE] and February 2025 and confirmed the ice machine cleaning task had not been documented as completed for January and February 2025. 4. Observation in the kitchen and interview on [DATE] at 3:30 PM, revealed the DM confirmed the following observations: The water cups/pitchers with open lids, to be distributed to residents by nursing staff, were stored on a table with dust and dried debris present. A chest type cooler contained Fourteen (14) 8-ounce (oz) glasses with an unidentified liquid that was unlabeled and undated, 1 opened and undated 46 oz carton of Apple juice, 1 opened and undated carton of nectar thick dairy milk, One (1) 8 oz Styrofoam cup of buttermilk undated, a 1 gallon (gal.) plastic pitcher of undated lemonade. There was a large area of an orange substance spilled on the bottom of the cooler. Walk-in cooler contained an opened jar of ready-made pizza sauce with a dried black substance around the mouth of the jar, dated [DATE], 1 partially used bottle of steak house type, honey mustard salad dressing, no open date, 1 partially used open bag of chocolate chips, no open date, 1 undated 10-pound (lbs.) box of uncooked sausage patties, 1- partially used container of Italian salad dressing, expiration date [DATE], 1 undated 4 oz plastic container of beets. Loose and dried debris behind moveable shelves on both sides of cooler. The Dry storage area contained, 1 expired 16 oz bottle of ground [NAME] seasoning, open date [DATE], 1 expired 16 oz. bottle of ground Cloves, open date [DATE], 1 expired 15 oz. bottle of ground Cumin, open date [DATE], 1 expired 16 oz. bottle of mild Chili powder, open date [DATE], 1 expired 32 oz container of Celery Salt, open date [DATE], 1expired 1 oz container of chopped Chives, open date [DATE], 1 undated 6 oz. opened bottle of rubbed Sage, 1 expired 5 oz. bottle of Dillweed, open date [DATE], 1 expired 21 oz. package (pkg) of [NAME] Gravy mix, open date [DATE], 1 expired 14 oz. bottle of Coriander, open date [DATE],1 expired 4 oz. bottle of leaf Tarragon, open date [DATE], 1 expired pkg of Bay Leaves, open date [DATE], 1 open bag of Coconut Flakes, expired [DATE], 1 open bottle of pancake syrup, expired [DATE], 1 expired 11 oz. bottle of Parsley Flakes, open date [DATE], 1 expired bottle of Onion powder, open date [DATE], 1 gal. bottle of open Soy Sauce-refrigerate after opening, 1 expired container of Cocoa, open date [DATE], 1 undated 11 lb. bag of Grits, open tear in plastic bag, 1 undated bag of rolls, 1 undated 40 quart (qt) plastic container of Ziti pasta with brown dried debris on the lid, 1 undated 20 qt. plastic container of elbow pasta, expired corn flakes cereal in plastic container, dated [DATE], expired Cheerios cereal in 6 qt plastic container, dated [DATE], expired Raisin Bran cereal in plastic container, dated [DATE], and expired [NAME] Crispies cereal in plastic container, dated [DATE], and an uncovered container of cooking utensils and a plastic mixing bowl on a shelf with loose and dried debris on them. The Floor Mixer had a black grease like substance oozing out of control knob located over the mixing bowl. The Mixer stand and table had dried brown/beige debris scattered in multiple areas. The Plate warmer case had dried brown debris over the outside case. 5. During an interview on [DATE] at 5:21 PM, the Infection Preventionist (IP) stated, .An infection control audit form should be completed by the dietary manager .Infection Control monitors the form quarterly .The monitoring would include making sure the cleaning schedule was completed . When asked to provide the audit documentation for the previous year, the IP responded, .I have not completed the audit in approximately 1 year .I spoke to nursing staff about the dirty ice chests used to fill water pitchers in January [2025] .I in-serviced the staff .voiced concerns to the Administrator and Director of Nursing . The IP was unable to provide documentation of the previous in-service. The IP provided a visual presentation of infection tracking and denied any outbreak/occurrence of foodborne illness for ,d+[DATE]. During an interview on [DATE] at 5:59 PM the Maintenance Director verified the ice machine should be cleaned and sanitized every 6 months and confirmed the ice machine located in the kitchen had not been cleaned and sanitized per schedule, for at least 1 year. The Maintenance Director verified the black substance oozing out of the control knob on the floor mixer was grease/lubricant. During an interview on [DATE] at 6:09 PM, the Administrator stated the maintenance on the ice machine in the kitchen had not been performed in 2024. The Administrator stated he expected the ice machines to be cleaned and sanitized every six months, according to manufacturing guidelines. The Administrator confirmed dietary staff should complete daily cleaning and inspection of all areas of food preparation and storage. During an interview on [DATE] at 6:18 PM, Certified Nursing Assistant (CNA) D stated she usually works 3 PM to 11 PM shift. CNA stated, .We usually take the ice [chest] coolers and fill them up in the kitchen .No cleaning schedule that I know of until now .I have never washed out the ice coolers .We take the coolers down the hall and pass ice with water to the residents . During an interview on [DATE] at 6:26 PM, CNA E stated, .Usually the night shift cleans the ice [chest] coolers .I have taken the coolers to the kitchen and filled them with ice .we use the ice from the coolers on each hall to pass ice and water for the residents twice a day and when they ask for more . During an interview on [DATE] at 4:07 PM, the Dietary [NAME] stated ice from the kitchen ice machine was used to pack around milk, juice, and any cold foods prepared for resident meals. The Dietary [NAME] confirmed ice from the kitchen ice machine was served to the residents in drinks prepared for meals. During an interview on [DATE] at 4:10 PM, Dietary Staff G stated she uses ice from the kitchen ice machine to pack around cold foods, milk, and serves ice from the machine in drinks for the resident's meals. Dietary Staff G acknowledged refrigerated foods and dry storage foods should be labeled and dated when opened to prevent them from being served after they have expired. During a telephone interview on [DATE] at 4:17 PM, the Registered Dietician (RD) stated, . Dietary staff complete a cleaning schedule, and I audit the schedule to ensure they are completed timely .The last audit I completed was in January [2025] . When asked if the cleaning schedule included the ice machine, the RD replied, Yes. The RD stated she was not aware of the 1 year lapse in cleaning and sanitizing the ice machine. When asked if ice from the kitchen ice machine was used to prepare and serve food to the residents, the RD replied, Yes. The RD expressed she expected dietary staff to throw away expired foods, label and date food that has been opened or prepared for future use, and prepare, serve, store food in a sanitary manner. During a return telephone interview on [DATE] at 11:30 AM (an attempt was made during the survey prior to exit), the Assistant Director of Environmental Health for the State of Tennessee stated the black/pink/green substances found around wet areas such as ice machines was often found to be mildew. The Assistant Director concluded any form of contamination to ice/water served for consumption was subject to cause gastrointestinal (stomach) upset. The Assistant Director stated it was imperative to dispose of expired foods, label and date all foods that have been opened and stored for future consumption to monitor for bacteria growth and food spoilage.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 7 of 15 staff members (Certified Nursing Assistants (CNA) I,K,M,N,S, Licensed Practical Nurse (LPN) H, and Registered Nurse (RN) E) failed to knock and/or announce self when entering resident rooms and failed to use courtesy titles when addressing residents during dining. The findings include: 1. Review of the undated facility's policy titled, Courtesy Titles Policy, revealed .employees should be constantly cautious to avoid using first names when addressing residents regardless of how familiar they may become .Always use Mr. and Mrs. and do not use first names or nicknames .exceptions made .if the resident makes a special request .shall be documented in the medical record . 2. Observation during dining on 7/29/2024 at 11:58 AM, revealed CNA I placed the tray on Resident #71's bedside table and said, .Here darling . Observation during dining on 7/29/2024 at 12:00 PM, revealed CNA S placed the tray on Resident #53's over bed table and said, .here honey . Observation during dining on 7/29/2024 at 12:07 PM, revealed LPN H placed the tray on Resident #63's over the bed table and said .here's your food, sweetheart . Observation during dining on 500 HALL on 7/29/2024 at 12:12 PM, revealed CNA N said, .feeders . At 12:22 PM, CNA N again said, .feeders . Observation during dining on 600 Hall on 07/29/2024 at 12:26 PM, revealed CNA S was carrying a tray down the hall and said, .feeders . Observation during dining on 7/29/24 at 11:52 AM, revealed CNA M called Resident #26, .sweet pea . Observation during dining on 7/29/2024 at 12:13 PM, revealed CNA S said, .hey baby . to Resident #35. Observation during dining on 7/29/24 at 12:14 PM, revealed CNA S entered the room of Resident #64, and said, .hey baby, here's lunch . Observation during dining on 7/29/2024 at 12:14, revealed CNA S called Resident #68, .honey . Observation during dining on 400 Hall on 7/30/2024 at 7:41 AM, revealed CNA K said .feeders . Observation during dining on 7/30/2024 at 7:44 AM, revealed CNA K called Resident #25, .honey . Observation during dining on 7/30/2024 at 8:03 AM, RN E failed to knock prior to entering Resident #17's room and did not announce self until already in the room. During an interview on 07/31/24 at 11:41 AM, the DON was asked if staff should refer to residents as feeders or call them honey and baby. The DON stated, No they should not. The DON confirmed that staff should always knock or announce themselves when entering a resident room.

Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate respiratory care and services consistent with professional standards of practice for 2 of 2 nurses (Registered Nurse (RN) F and Licensed Practical Nurse (LPN) C) observed for tracheostomy care, and failed to obtain a physician's order for 1 of 3 (Resident #36) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility's policy titled, TRACHEOSTOMY CARE, dated 10/21/2022, revealed The facility will ensure that residents who need respiratory care, including tracheostomy [a surgically created opening into the trachea that allows the person to breathe through a tube inserted into the opening] care .is provided such care consistent with professional standards of practice .The facility will provide necessary respiratory care and services, such as oxygen therapy . tracheostomy care .Tracheostomy care will be provided according to physicians orders .Maintain .an Ambu bag [a hand held device used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately] easily accessible for immediate emergency care .The facility will ensure staff responsible for providing tracheostomy care .are trained and competent according to professional standards of practice .Procedure .Perform hand hygiene per facility policy .Suction tracheostomy per facility policy .Remove old dressing .Perform hand hygiene .Prepare equipment on bedside table .Change trach [tracheostomy] ties/tube holder when soiled or wet .Perform hand hygiene .Document procedure . Review of the facility's undated policy titled Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .This applies to all staff working in all locations within the facility .Conditions [for performing hand hygiene] .Between resident contacts .After handling contaminated objects .Before performing invasive procedures .Before and after handling clean or soiled dressings .Before performing resident care procedures .Before and after providing care to residents in isolation .After handling items potentially contaminated with blood, body fluids, secretions, or excretions . Review of the facility's undated policy titled Oxygen Administration, revealed .Oxygen is administered under orders of a physician .The resident's care plan shall identify the interventions for oxygen therapy . Review of the facility's undated policy titled Medication Administration, revealed .Compare .MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time .Administer medication as ordered .Sign MAR after administered . 2. Review of the medical record revealed Resident #276 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, and Respiratory Failure. Review of the Physician's Order dated 7/11/2024, revealed .Perform trach care as needed AND every shift . Review of the July 2024 Treatment Administration Record (TAR) revealed .trach [tracheostomy] care performed every shift starting on 7/11/2024 at 7:00 PM . May suction mouth and trach . Review of the Care Plan dated 7/12/2024, revealed .The resident has a tracheostomy .Trach care per md [medical doctor] order/ facility protocol .Use UNIVERSAL PRECAUTIONS as appropriate . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #276 was cognitively intact. Observation of trach care and interview in the Resident's room on 7/31/2024 at 3:14 PM, revealed RN F donned gloves without performing hand hygiene and performed trach care. Resident #276 had mucus outside of the trach, onto the trach collar, and onto the towel that was lying on the Resident's chest. RN F failed to clean the mucous from the Resident's trach, trach collar, and remove soiled towel from Resident's chest. RN F removed the soiled gloves and exited the Resident's room without performing hand hygiene. RN F was asked if he should have performed hand hygiene after completion of care. RN F stated, Yes. Observation of trach care and interview in the Resident's room on 8/1/2024 at 10:11 AM, LPN C left a box fan blowing at the Resident's bedside facing the Resident. LPN C placed a barrier and supplies on Resident's abdomen. LPN C removed the soiled cannula, doffed gloves. Resident placed his hand on the barrier touching the clean gloves to keep the barrier from blowing off. LPN C donned the gloves from the barrier without performing hand hygiene. During an interview on 8/1/2024 at 4:00 PM, the Director of Nursing (DON) confirmed that staff should perform hand hygiene before and after donning and doffing gloves. The DON confirmed that trach care should include cleaning of the trach site. 3. Review of the medical record showed Resident #36 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Abnormal findings of the Lung Field, Anxiety Disorder, and Senile Degeneration of Brain. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #36 was severely cognitively impaired. Resident was not assessed for oxygen use. Review of the Care Plan revised 7/29/2024, revealed .Resident is at risk for Shortness of breath and/or respiratory distress. Oxygen per MD [physician's] order . Observation in Resident #36's room on 7/29/2024 at 9:57 AM and on 7/29/2024 at 12:22 PM, revealed the Resident was wearing a face mask connected to an oxygen concentrator set at 5.5 Liters/minute (l/min). During an observation and interview in the Resident's room with LPN T on 7/29/2024 at 3:29 PM, revealed Resident #36 was wearing a face mask connected to an oxygen concentrator set at 5.5 l/min. LPN T verified the oxygen rate was at 5 Liters. LPN T stated that she was going to go look at the order. Review of the Physician Orders revealed there were no orders for oxygen. During an interview on 7/29/2024 at 3:36 PM, LPN T stated that she just put in the order for oxygen into the medical record. LPN T stated that it was supposed to have been added over the weekend and did not get put in the medical record. LPN T confirmed that there should have been an order in the MAR. During an interview on 07/31/2024 at 11:37 AM, the DON was asked if physicians orders should be followed. The DON stated, Yes. During an interview on 8/01/2024 at 4:01 PM, the DON confirmed that no oxygen should be administered without a physician's order.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 3 of 6 Medication (Med) Storage Areas (501-506 Hall Cart, 507-514 Hall Cart, and 400 Hall Cart) and for 8 of 8 (Resident #14, #28, #30, #39, #67, #227, #277 and #376) random medication observations. The findings include: 1. Review of the facility's undated policy titled, Controlled Substance Accountability, revealed It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record . 2. Observation and interview at the 400 Hall Med Cart on 7/31/2024 at 10:54 AM, with LPN A, to review Resident #14's narcotic reconciliation, revealed the following: Review of Resident #14's Controlled Drug Record revealed, .Morphine Sulfate [used to treat severe pain] .GIVE 0.25 ML [Milliliters] 5mg [Milligram] .Amount Remaining .30 ML The Morphine was delivered to the facility on [DATE] with documentation that 30ML was received and signed for by Registered Nurse on duty. Observation of Resident #14's prescription bottle containing the labeled Morphine, that was delivered on 7/26/2024, revealed there was greater than the documented 30ML liquid in the bottle. The liquid was a clear liquid substance in the bottle labeled Morphine. In an interview, LPN A was asked about the difference in the color of the liquid in the prescription bottle compared to the other liquid Morphine bottles with blue liquid made by the same manufacturer. LPN A stated she had not noticed before now. LPN A confirmed that the Controlled Drug Record dated 7/26/2023, revealed that no doses had been administered to Resident #14. Observation and interview on 7/31/2024 at 11:12 AM, revealed the Director of Nursing (DON) was informed of the findings related to Resident #14's Morphine Sulfate with the clear liquid noted in bottle. The DON opened the Morphine bottle and confirmed there was no seal noted on the bottle. The DON smelled the clear liquid substance in the Morphine bottle and took the medication with her. During a phone interview on 7/31/2024 at 3:13 PM, the Pharmacist confirmed that only bottle labeled Morphine, was a blue solution, that had been dispensed for Resident #14's Morphine Sulfate. 3. Observation and interview at the 501-506 Hall Med Cart on 7/31/2024 at 11:44 AM, LPN B was asked to verify Resident #28's Diazepam (used to treat anxiety) 2 mg card with various kinds of tape on the back of the bubble pack with doses opened and taped closed. LPN B confirmed that doses should probably be wasted instead of taped. During an interview on 7/31/2024 at 11:55 AM, the DON confirmed that medication cards should not be taped closed, and medications should be wasted if opened accidentally or otherwise. 4. Observation and interview at the 507-514 Hall Med Cart on 7/31/2024 at 11:26 AM, revealed the following: Review of the Controlled Drug Record for Resident #30 revealed, .LYRICA [used to treat nerve pain] 100MG CAPSULE .Amount Remaining .27 . Review of Resident #30's controlled drug card revealed 26 Lyrica remained on the card, resulting in a 1 capsule discrepancy in the reconciliation of the Lyrica. LPN B was asked to verify the discrepancy for Resident #30's Lyrica count. LPN B stated that she had not signed out any controlled medication that she administered this morning. 5. Review of the Controlled Drug Record for Resident #30 revealed, .HYDROCODONE-ACET [Acetaminophen] (used to treat pain) 7.5-325MG TABLET .Amount Remaining .26 . Review of Resident #30's controlled drug card revealed 25 Hydrocodone 7.5/325mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Hydrocodone. 6. Review of the Controlled Drug Record for Resident #39 revealed, .GABAPENTIN (used to treat nerve pain) 100MG 2 TABLETS .Amount Remaining .24 . Review of Resident #39's controlled drug card revealed 22 Gabapentin 100mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Gabapentin. 7. Review of the Controlled Drug Record for Resident #67 revealed, .ALPRAZOLAM (used to treat anxiety) 1MG TABLET .Amount Remaining .16 . Review of Resident #67's controlled drug card revealed 15 Alprazolam 1mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Alprazolam. 8. Review of the Controlled Drug Record for Resident #227 revealed .ALPRAZOLAM 0.5MG TABLET .Amount Remaining .12 . Review of Resident #227's controlled drug card revealed 11 Alprazolam 0.5mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Alprazolam. 9. Review of the Controlled Drug Record for Resident #277 revealed .HYDROCODONE-ACET 7.5-325MG TABLET .Amount Remaining .17 . There was no documentation a nurse verified and signed that the documented quantity of doses, and date received was correct. Review of Resident #277's controlled drug card revealed 16 Hydrocodone 7.5/325 mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Hydrocodone. . 10. Review of the Controlled Drug Record for Resident #376 revealed .GABAPENTIN 800MG CAPSULE .Amount Remaining .12 . Review of Resident #376's controlled drug card revealed 11 Gabapentin 800mg remained, resulting in a 1 tablet discrepancy in the reconciliation of the Gabapentin. 11. During an interview on 7/31/2024 at 4:00 PM, the DON confirmed that Resident #14's Morphine bottle did not have a seal and the liquid was odorless. The DON confirmed that nursing staff should document controlled substance administration on the controlled drug records after administration.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 3 of 4 (Licensed Practical Nurse (LPN) B, C, and Registered Nurse (RN) E) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 10 errors were observed out of 29 opportunities, resulting in a medication error rate of 34.48%. The findings include: 1. Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in manner to prevent contamination or infection .Administer medication as ordered .Wash hands using facility protocol and product .If medication is a controlled substance, sign narcotic book . Review of the facility's undated policy titled, Medication Administration via Enteral Tube, revealed It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines .Each medication will be administered separately, or will [be] administered per physician order . Review of the facility's policy titled, Parenteral Intravenous Therapy, dated 10/21/2022, revealed The facility will adhere to accepted standards of practice regarding infusion practices .Review and verify physician's order for infusion solution or medication, dose, frequency, and route of administration . 2. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Asthma, Meningococcal Infection, Dysphagia, and Hypertensive Heart Disease. Review of the Physician's Order dated 7/1/2024, revealed .Heparin Sodium [used to keep intravenous catheters open]100 Units/ML .injection .use 5 milliliters intravenously every 4 hours for IV [intravenous] antibiotics flush 5ml heparin after infusion and after 10ml saline . Review of the Physician's Order dated 7/1/2024, revealed .Normal Saline Flush Intravenous Solution .Use 5ml intravenously every 4 hours for IV antibiotics flush 5ml saline before infusion . Review of the Physician's Order dated 7/15/2024, revealed .Ampicillin [used to treat infection] .Use 2 gram intravenously every 4 hours for meningitis . Observation and interview in the Resident's room on 7/30/2024 at 12:34 PM, RN E entered Resident #71's room to administer Ampicillin via right upper arm PICC (Peripherally Inserted Central Catheter) line. RN E flushed Resident #71's PICC line with Heparin 5ml flush prior to starting the Ampicillin IV infusion at 100ml/hr (milliliters per hour). RN E was asked, when should an intravenous line be flushed with Normal Saline. RN E stated at the end of the infusion. RN E failed to administer the Normal Saline 5ml flush before the infusion, and administered Heparin 5ml flush before the infusion, resulting in 2 medication errors. 3. Review of the medical record revealed Resident #326 was admitted to the facility on [DATE], with diagnoses including Right Foot Ulcer, Sepsis, Diabetes, and Methicillin Susceptible Staphylococcus Aureus Infection. Review of the Physician's Order dated 7/18/2024, revealed .Zosyn [used to treat infection] .Use 3.375 gram intravenously .every 6 hours . Review of the Physician's Order dated 7/18/2024, revealed .Normal Saline Flush Intravenous Solution .0.9% [Percent] .Use 10ml intravenously every 6 hours for flush before infusion .Use 10ml intravenously .after infusion . Review of the Physician's Order dated 7/26/2024, revealed .Heparin Sodium Lock Flush .100unit/ML . Heparin flush should follow a NS [Normal Saline] flush every IV fusion . Observation in the Resident's room on 7/30/2024 at 1:41 PM, revealed LPN C flushed PICC line with Normal Saline 10ml. LPN C failed to flush Resident's right upper arm PICC line with Heparin after flushing with Normal Saline, resulting in 1 medication error. LPN C confirmed that the Physician's order stated to flush with Normal Saline and Heparin after every IV infusion. 4. Review of the medical record revealed Resident #276 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Diabetes, Depression, and Respiratory Failure. Review of the Physician's Orders dated 7/11/2024, revealed the following 7 medications: a.Amlodipine [used for blood pressure] .Tablet .5 MG .Give 1 tablet via [by way of] PEG [Percutaneous Endoscopic Gastrostomy] . b.Citalopram [used for depression] 20mg .Give 1 tablet via PEG . c.Fludrocortisone [used for breathing] 0.1mg .Give 0.5 tab via PEG . d.Quetiapine [used for mood] 50mg .Give 1 tab via PEG . e.Sodium Chloride [supplement] 1 gram .Give 1 tab via PEG . f.Aspirin [used for heart health] 81mg .Give 1 tab via PEG . g.Lansoprazole [used for acid reflux] 30mg . Give 1 tab via PEG . Observation in the resident's room on 7/31/2024 at 8:41 AM, revealed LPN B crushed each medication separately, placed each crushed medication in the same medication cup, and mixed meds with 30ml of water, cocktailing (to combine the medications together and administer) the medications. LPN B then administered the following medications via Peg tube per gravity, and flushed Peg tube with 30ml of water afterwards: a. Amlodipine b. Citalopram c. Fludrocortisone d. Quetiapine e. Sodium Chloride f. Aspirin g. Lansoprazole Review of the Physician's orders revealed there was no order to cocktail the medications for administration. The administration of these 7 medications cocktailed together without a physician's order, resulted in 7 medication errors. 5. During an interview on 8/1/2024 at 4:00 PM, the Director of Nursing (DON) confirmed that nurses should follow Physician's orders regarding administration of medications and performing flushing IVs with Heparin and Normal Saline. The DON confirmed that medications should not be cocktailed when administering via Peg tubes without a Physician's order to cocktail the medications.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 15 staff members (Certified Nursing Assistant (CNA) L, N, and O) observed during dining failed to perform hand hygiene, and when 1 of 6 staff members (Licensed Practical Nurse (LPN) C) failed to observe Enhanced Barrier Precautions for 1 of 6 (Resident #326) sampled residents and 2 of 4 (LPN B and C) nurses failed to clean reusable equipment during medication administration. The findings include: 1. Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .This applies to all staff working in all locations within the facility .Conditions [for performing hand hygiene] .Between resident contacts .After handling contaminated objects . Review of the facility's undated policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Multiple-resident use equipment shall be cleaned and disinfected after each use . Review of the facility's undated policy titled, Enhanced Barrier Precautions, revealed .Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . 2. Observation in Resident #56's room on 7/30/2024 at 7:37 AM, revealed Certified Nursing Assistant (CNA) L failed to perform hand hygiene after handling items in the environment and before handling the straw and setting up the tray. Observations in Resident #46's room on 7/30/2024 at 7:39 AM, revealed CNA L failed to perform hand hygiene between setting up residents' trays in the same room. Observations in Resident #47's room on 7/30/2024 at 7:41 AM, revealed CNA L failed to perform hand hygiene between rooms and after handling the remote to raise the bed and handling the curtain at the end of the bed before setting up the tray. Observations in Resident #14's room on 7/30/2024 at 7:43 AM, revealed CNA L failed to perform hand hygiene between roommates and handling the remote to raise bed before handling the straw to place it in a glass. Observation in Resident #26's room on 7/30/2024 at 7:53 AM, revealed CNA N pulled the curtain, adjusted the Resident, picked up the biscuit with her bare hand, cut it, picked up the sausage, and placed it on the biscuit. CNA N raised the Resident's head of bed and picked up the sausage biscuit and placed it to resident's lips. CNA N did not perform hand hygiene after touching items in the environment. Observation in Resident #60's room on 7/30/2024 at 8:15 AM, revealed CNA N picked up the Resident's biscuit with her bare hands, cut it, picked it back up and put jelly on it. Observation in Resident #39's room on 7/30/2024 at 8:15 AM, revealed CNA O touched the biscuit with her bare hand to cut, set it down, opened the jelly and touched the biscuit again with bare hands to put the jelly on it. During an interview on 7/30/2024 at 8:18 AM, CNA N was asked if she should touch resident's foods with her bare hand. CNA N stated, I thought so because we can't feed with gloves on. During an interview on 7/30/2024 at 2:05 PM, CNA O was asked if she should have worn gloves when touching a resident's food with her bare hands. CNA O stated, she should have put on gloves when touching a resident's food. During an interview on 07/31/2024 at 11:41 AM the DON was asked should staff touch residents' food with bare hands. The DON stated .Probably should wear gloves but I don't know I would have to look at the policy. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Meningococcal Infection, and Hypertension. Observation and interview in the Resident's room on 7/30/2024 at 12:34 PM, revealed RN E failed to perform hand hygiene when changing gloves during IV (intravenous) medication administration. RN E confirmed that hand hygiene should be performed when donning and doffing gloves and when performing resident care. Review of the medical record revealed Resident #326 was admitted to the facility on [DATE], with diagnoses including Right Foot Ulcer, Sepsis, Diabetes, and Methicillin Susceptible Staphylococcus Aureus Infection. Review of the Physician's Order dated 7/29/2024, revealed .Enhanced Barrier Precautions r/t [related to] IV and wounds. Gown and gloves must be worn when performing high-contact resident care . Observation and interview in the Resident's room on 7/30/2024 at 1:41 PM, revealed LPN C failed to apply PPE (Personal Protective Equipment) for Resident #326, who was in Enhanced Barrier Precautions during IV medication administration. LPN C was asked when PPE should be worn. LPN C confirmed that PPE should be worn when providing direct care and administering medications. 4. Review of the medical record revealed Resident #276 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Diabetes, Depression, and Respiratory Failure. Review of the Physician's Order dated 7/11/2024, revealed Check tube placement by auscultation . Review of the Physician's Order dated 7/29/2024, .Enhanced Barrier Precautions r/t [related to] indwelling medical devices, peg [percutaneous endoscopic gastrostomy a tube used for nutrition and medications], trach[tracheostomy] until resolves. every shift for peg, trach . Observation in the Resident's room on 7/31/2024 at 8:41 AM, revealed LPN B checked PEG tube placement by placing the stethoscope on the resident's abdomen during medication administration, and failed to clean stethoscope before or after use on Resident #276. 5. Observation in the Resident's room on 7/30/2024 at 12:42 PM, revealed during medication administration LPN C listened for PEG tube placement by placing the stethoscope on the resident's abdomen, and did not clean before or after use on Resident #327. During an interview on 7/30/2024 at 12:51 PM, LPN C was asked if she should have cleaned her stethoscope before or after using on Resident #327. LPN C stated, Yes, most definitely. Observation on 8/1/2024 at 8:00 AM, revealed LPN B checked Resident #66's blood pressure. LPN B placed the electronic blood pressure reader on the Resident's leg and placed the cuff around Resident's arm. LPN B didn't clean or disinfect the blood pressure cuff before or after use on Resident #66. During an interview on 8/1/2024 at 4:00 PM, the DON was asked if reusable equipment should be cleaned between use on residents. The DON stated, Yes. The DON confirmed that staff should perform hand hygiene before and after donning and doffing gloves, PPE should be worn with enhanced barrier precautions with all direct care on residents with tubes, artificial lines, wound, or openings.

Based on policy review, observation, and interview the facility failed to ensure that medications were properly and securely stored when 2 of 4 nurses (Licensed Practical Nurse (LPN) B and C) left medications unattended and unsecured on the 400 Hall and 600 Hall Medication Carts. The findings include: 1. Review of the undated facility policy titled, Medication Storage revealed .All drugs and biologicals will be stored in locked compartments (i.e. [that is], medication carts .During medication pass, medications must be under the direct observation of the person administering medications or locked in the medications storage area/cart . 2. Observation outside of Resident #327's room on 7/30/2024 at 12:33 PM, revealed LPN C left the medication cup with crushed Baclofen (treatment of muscle pain) on the 600 Hall Medication Cart unattended and unsecured while donning Personal Protective Equipment (PPE). Observation in Resident #327's room on 7/30/2024 at 12:42 PM, revealed LPN C went to wash hands in the bathroom while the medications were on the overbed tray outside the bathroom at the resident's bedside. During an interview on 7/30/2024 at 12:51 PM, LPN C confirmed medications should not be left unattended and unsecured. 3. Observation on the 400 Hall on 8/1/2024 at 8:00 AM, revealed LPN B left a medication cup with Bupropion (antidepressant) on the 400 Hall Medication Cart unattended and unsecured while looking for an outlet for the computer. During an interview on 8/1/2024 at 4:00 PM, the Director of Nursing (DON) confirmed that medications should be in sight of the nurse at all times.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when there were unlabeled, undated, and expired items in 2 of 2 resident nourishment refrigerators. The findings include: 1. The facility's undated policy titled, Use or storage of food brought in by family or visitors, revealed .All food items .by the family or visitor brought in must be labeled . and dated .The facility may refrigerate labeled and dated .items in the nourishment refrigerator .If not consumed within 3 days, food will be thrown away by the facility staff . 2. Observation in the ,d+[DATE] Hall Nutrition Room on [DATE] at 3:46 PM, with Licensed Practical Nurse (LPN) G revealed the following in the residents' nourishment refrigerator: A cup of (named brand) ice cream unlabeled and undated. Three (3) tubs of (named brand) ice cream unlabeled and undated. A gallon of orange juice unlabeled and undated. 3. Observation in the ,d+[DATE] Nutrition Room on [DATE] at 3:59 PM, with LPN H, revealed the following in the residents' nourishment refrigerator: A box of breakfast croissants undated. A carton of ice cream unlabeled and undated, A frozen dinner unlabeled and undated. A gallon of milk undated. A pack of bologna undated. A bag of pre-sliced salami undated and expired. Two (2) containers of vanilla protein drinks undated. A pitcher of milk undated. A container of unsweetened applesauce undated. A bag of grapes unlabeled and undated. 2 boxes of tortilla pockets unlabeled and undated. A gallon of milk unlabeled and undated. A bag of lunch meat unlabeled and undated. A bottle of creamer unlabeled and undated. A six pack of (named brand) alcoholic beverage with only one bottle left for Resident #7. Resident #7 did not have an order and was not care planned for alcohol. During an interview on [DATE] at 3:48 PM, LPN G was asked if all items in the residents' nourishment refrigerator should be labeled and dated. LPN G stated, Yes. During an interview on [DATE] at 4:02 PM, LPN H was asked should alcoholic beverages be in the resident's nourishment refrigerator. LPN H stated, Absolutely not. LPN H was asked if unlabeled, undated, or expired items should be in the resident nourishment refrigerator. LPN H stated, No. During an interview on [DATE] at 4:08 PM, The Director of Nursing (DON) was asked should alcohol for residents be care planned and ordered. The DON stated, Yes. The DON was asked if alcohol should be stored in the resident's nourishment refrigerator. The DON stated, No, it should be stored like narcotics and signed out. During an interview on [DATE] at 8:32 AM, the Certified Dietary Manager confirmed that there should not be alcohol in the resident's nourishment refrigerator, all foods should be dated with an open date, not be expired, and be labeled with the resident's name. During an interview on [DATE] at 8:38 AM, The DON confirmed that the facility did not have an alcohol storage policy for residents.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident environment that was safe, clean and sanitary to prevent the spread of disease-causing organisms and infections when Resident #5 who had wounds infected with maggots, was observed handling linens and propelling throughout the facility with the drainage/maggots leaking onto the floor from his wheelchair and when 3 of 70 sample residents (Resident #12, #13 and #14) reviewed for infection control. The facility had a census of 70. A partial extended survey was conducted 11/1/2023 through 11/2/2023. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to Resident #5, whose wounds were infected with maggots and had drainage, was observed propelling in his wheel chair and draining fluids and maggots onto the facility floor, when Resident #5 was observed to be scratching and touching his wounds with his hands, and then touching towels/linens on the clean linen cart, and when 3 of 70 sampled residents (Resident #12, #13 and #14) complained of rolling there wheelchair in the drainage and getting it on their hands. The facility's failures resulted in Immediate Jeopardy. All residents had the potential to be affected by the deficient practice. The Administrator, Regional Nurse Consultant (RNC) and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-584 on 11/1/2023 at 9:15 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-584 at a scope/severity of J which is substandard quality of care. The Immediate Jeopardy began on 10/25/2023 through 11/1/2023 with the last day of IJ being 11/1/2023. The facility submitted an acceptable IJ Removal Plan on 11/3/2023 at 2:01 PM. The corrective actions of the Removal Plan was validated by the surveyor on 11/6/2023 through review of medical record review, observations, and interviews. Noncompliance of F-584 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility's undated policy titled, Isolation Precautions, revealed .Contact precautions .intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment .Facility staff will apply Standard Precautions to all residents under the assumption that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services . Review of the facility's policy titled, RESIDENT RIGHTS, dated 10/18/2022, revealed .All residents will be treated equally .Safe environment. The resident has the right to a safe, clean, comfortable, and homelike environment . 2. Review of medical record revealed Resident #5 was admitted to the facility on [DATE], with a readmission on 7/12/2023, with a diagnosis of Paraplegia, Obstructive and Reflux Uropathy, Antisocial Personality, Pressure Ulcer to the Buttock Stage 3, right heel, and Sacral, Opioid Dependence, and Enterostomy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact, rejected care 4 to 6 days a week, and was totally dependent on the staff for Activities of Daily Living (ADLs). Review of the Behavior Note, dated 9/11/2023, revealed .Res [resident] declined personal hygiene and wound care during hospice visit today .Res continues with very foul odor with fluids dripping from wheelchair. Linens in wheelchair are visibly soiled . Review of the Social Service Notes, dated 10/23/2023, revealed .refused condom catheter placement .Pt aware he was leaving bodily fluids all over the hallway floor and in his room . Review of medical record revealed Resident #12 was admitted to the facility on [DATE] with a diagnoses of Heart Failure, Diabetes, Chronic Respiratory Failure, and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 15, which indicated he was cognitively intact. Review of medical record revealed Resident #13 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia, Epilepsy, and Chronic Obstructive Pulmonary Disease Review of the quarterly MDS dated [DATE] revealed Resident #13 had a BIMS score of 15, which indicated he was cognitively intact. Review of medical record revealed Resident #14 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Muscular Dystrophy. Review of the quarterly MDS dated [DATE] revealed Resident #14 had a BIMS score of 15, which indicated she was cognitively intact. 3. Observation and interview on 10/25/2023 at 6:54 AM, Licensed Practical Nurse (LPN) #3 was asked what the large brown dried puddle was on the floor near the 500-hall nursing station. LPN #3 stated . [Named Resident #5] .he let his wounds drip all over the facility and maggots are falling from the back of his wheelchair . Observation on the 300 Hall on 10/30/2023 at 10:11 AM, revealed Resident #5 was at the clean linen cart pulling linen off the cart and pilling it onto his wheelchair. Resident #5 was observed to reach down the right side of his back with multiple up and downward scratching motion, and continued to pull the clean linen off the linen cart placing the linen onto his wheelchair. Resident #5 moved away from the linen cart to the other side of the hallway and a half dollar size puddle of clear drainage was observed next to the linen cart. Observation on the 300-Hall on 10/30/2023 at 11:10 AM, with LPN #5 revealed a puddle of clear liquid on the floor across from the linen cart where Resident #5 was sitting in his wheelchair. Observation on the 600-Hall on 10/31/20023 at 10:34 AM, revealed two small puddles of fluid on the floor in the hallway near the double fire doors on the left side of the hall. 4. During an interview on 10/30/2023 at 8:57 AM, Licensed Practical Nurse (LPN) #1 was asked if she was aware Resident #5 was leaking drainage from his wheelchair. LPN #1 stated, .Yes .we have reported he [Resident #5] has drainage coming from his wounds .told [Named Assistant Director of Nursing [ADON] he is leaking again .we were told he has a right to refuse care . LPN #1 was asked if she knew if any of the residents complained about the drainage and maggots. LPN #1 stated, .Yes .they are getting this [drainage/maggots] on their wheelchairs .getting it on their hands when they roll over it in their wheelchairs . During an interview on 10/30/2023 at 1:09 PM, Certified Nursing Assistant (CNA) #2 was asked if she had seen any drainage or maggots coming from Resident #5's wheelchair. CNA #2 stated, .I have .just in his room .a hand full [maggots] in the floor .never seen in the hallway .they crawl to the edge of the door .just maggots .he does have liquid that drips down the hallway .he come out from his hall and go to the door to smoke break and down the 600 hall to the dining room .it like drops .sometime it's big drops .sometimes it's grape size drops .if he is sitting in one spot it will wind up being a puddle . CNA #2 was asked if any of the residents complained of the drainage and maggots. CNA #2 stated, .Yes . [Named Resident #12, #13, and #14] .when he sat [sit] and smoke it's a puddle under him .smells and he is leaking . CNA # 2 was asked if he was allowed to pull linen off the linen cart. CNA #2 stated, .I don't think so .he will help himself . During an interview on 10/30/2023 at 1:10 PM, the Hospice RN was asked if she seen the maggots drop off his wheelchair. The Hospice RN stated, .Yes ma'am .they will be in the hallway .on the 300 Hall .where he wanders there will be droplets everywhere he goes .it's a possibility there are some residents who wander down the hall bare footed and could step in it [maggots or drainage] . The Hospice RN was asked what all the drainage from Resident #5 is. The Hospice RN stated, .the catheter could not get it [place] .I could not advance the condom catheter .the [condom catheter] would not stay on .he is constantly dribbling with urine and saturated in urine all day .the drainage is all the above .ostomy .urine .his wounds also drain . During an interview on 10/30/2023 at 2:09 PM, the Wound Care Nurse was asked if she felt it was a health hazard for the other residents when Resident #5 is observed leaking drainage and maggots throughout the facility. The Wound Care Nurse stated, .I would not like it .I would not be happy if I rolled through [wheelchair] and got it on my hands . During an interview on 10/30/2023 at 3:45 PM, the Director of Nursing (DON) was asked what you have done to protect the other residents in the facility about the drainage. The DON stated, .We can't make him stay in his room .we have attempted to get guidance[cooperate] .have not gotten it .guidance on how to handle the situation .no ma'am . The DON was asked if she was made aware when Resident #5 was outside smoking over the summer and maggots fell out from under his wheelchair and the staff had to wash down the smoking area. The DON stated, .No, not aware of that . During an interview on 10/31/2023 at 11:19 AM, the Social Worker was asked if it is safe for the other residents in the facility when Resident #5 is dripping drainage and maggots in the facility. The Social Worker stated, .I don't know what the fluid is .I don't think I would want a resident walking or wheeling through it [drainage] . During an interview on 11/2/2023 at 7:19 AM, the Floor Technician was asked if he remembered going outside on the smoking area and hosing down maggots Resident #5 had dropped on the concrete. The Floor Technician stated, .Yes .I was called outside they [staff] came and got me to go to the smoking area near the 500-nursing station .in the smoking area .it was over the summer .I did have to hose off the concrete cement .there was maggots .I had to hose it off for safety . During a telephone interview on 11/2/2023 at 8:15 AM, the Hospice Medical Director was asked if he was aware Resident #5 had maggots in his wound. The Hospice Medical Director stated, .Yes .I have been made aware of that .we have tried to stress doing the wound care on a regular basis .he is not interested in the treatments on regular basis . The Hospice Medical Director was asked what is Resident #5's prognosis. The Hospice Medical Director stated, .he is on hospice care .it's a pretty poor life expectancy less than 6 month .he has osteomyelitis, wound problems, and he has an infection in his wounds . The Hospice Medical Director was asked if he was aware Resident #5 was leaking fluids and maggots throughout the facility. The Hospice Medical Director stated, .I believe they have told me his wounds were oozing from the chronic inflammation and from his infection .we have addressed the need for wound care and ostomy care . The Hospice Medical Director was asked should Resident #5 be in contact isolation with the chronic infection in his wound drainage. The Hospice Medical Director stated, .that I'm not sure of .he was getting treated for chronic osteomyelitis at the hospital, and his infection that is bone deep you can see the bones and hardware . The Hospice Medical Director was asked if a resident has chronic osteomyelitis is that a type of wound infection. The Hospice Medical Director stated, .Yes .that's correct . The Hospice Medical Director was asked if it was safe environment for the other residents in the facility when Resident #5 is going throughout the facility leaking drainage and maggots on the floors. The Hospice Medical Director stated, .No .it doesn't sound like it is .if you don't know what in the fluids are .it would be a risk for the other residents .he would need to be keep in some type of isolation .he would need to be in contact isolation .that would be appropriate . The Hospice Medical Director was asked, what was the reason for Resident #5's admission to hospice care. The Hospice Medical Director stated, .part of his diagnosis is for pain management .he stops all treatment in the facility .they contacted us .he was placed on hospice care . During an interview on 11/2/2023 at 11:30 AM, the Infection Preventionist was asked what type of resident would be placed in contact isolation. The Infection Preventionist stated, .a resident with .any kind of infection .the resident may or may not have .infected wounds . The Infection Preventionist was asked should the resident have signage on their door to identify the isolation. The Infection Preventionist stated, .Yes . The Infection Preventionist was asked if have a resident who is dripping drainage from their wounds should they be isolated. The Infection Preventionist stated, .I always been taught if it is cover .they can leave the room .if it is dripping and the dressings are saturated the nurse should be notified to change it dressing .they [the resident] would not be allowed to come out of the room if the wound is dripping in the floor .it [dressing] should be changed . During an interview on 11/2/2023 at 2:35 PM, the Nurse Practitioner (NP) was asked looking at the drainage and maggot dripping on the floor do you believe the resident have the right to a is safe and clean environment. The NP stated, .Yes .sure . During an interview on 10/25/2023 at 3:00 PM, Resident #12 was asked if he had any concerns with Resident #5 leaking drainage and maggots in the facility. Resident #12 stated, .Oh .yea .definitely we were outside smoking during break and there was a big puddle of them [maggots] out there .they had to get someone to come and wash them [maggots] down . Resident #12 was asked when was the last time he saw the drainage and maggots in the facility. Resident #12 stated, .it was last week .we have to roll over it in our wheelchair . During an interview on 10/30/2023 at 5:48 PM, Resident #13 was asked if he had any concerns about Resident #5 drainage and dropping maggots in the facility. Resident #13 stated, .if we don't see it, we roll right through it .it gets on our hands sometime .we see piles of maggots on the floor fall out the back of his wheelchair . Resident #13 was asked how often you see the drainage and maggots. Resident #13 stated, .if he is out of his room, its everyday .you can look under his chair it looks like brown water .his blanket is soiled with brown stains .he has this strong odor about him like a dead animal . Resident #13 was asked if he felt it was a health hazard for the drainage and maggot on the floor in the facility. Resident #13 stated, .Yes .to us it is .he has known he has maggots .when he sat [sits] in one spot .you can see a little puddle under him .the other night he was sitting by the tv [television] eating .he had 10 inch puddle under the chair .he drops little drips down the hall when he roll down the hallway .I saw the maggots .outside and in front of [Named Social Workers] office one day .we have to roll our wheelchair with our hand and eat dinner with the same hands . During an interview on 10/30/2023 at 8:02 AM, Resident #14 was asked if she had any concerns or had she seen any drainage or maggots on the floor from Resident #5. Resident #14 stated, .Yes .liquid all over the floor .every day .it's not safe for everyone in this building .us that know try to roll around it [drainage] .we have some that don't know .it gets on the wheelchair .on their [residents who wander] feet's walking through it .it's not safe .maggots on the floor .yes ma'am . Resident #14 was asked when the last time was she seen the maggots on the floor. Resident #14 stated, .a month ago .I was coming down the hall .it was in a brown pile .still alive and the pile was kind of moving .he [Named Resident #5] spreading it around the rest of the building .I seen it outside too .the maggots in a puddle underneath his wheelchair .they [staff member] got one of the housekeeping with a water hose and sprayed it down .we don't understand why he [Resident #5] don't realize this .[dropping drainage and maggots] . Resident #14 was asked if she felt it was a health hazard with the drainage and maggots being dropped in the facility. Resident #14 stated, .Yes .when it brown and stinky and looks like [feces] .yes, it is a health hazard . The surveyors verified the Removal Plan by: 1. On 8/1/2023 FNP spoke with the resident regarding his refusal of most all care to include wound care, incontinence care and hygiene and importance in complying with care. On 10/31/2023 Resident #5 was seen by FNP (Family Nurse Practitioner) regarding reports of resident ongoing refusals for wounds to be seen or dressing changes, incontinence care and resident awareness of wound status. FNP notes per wound notes from 10/27/2023 Resident has declined for facility staff to or complete wound care. All measurement and assessment finding are through hospice findings due to resident refusing for facility staff to complete wound care. There is less odor and less drainage from wounds this week. The surveyor verified by medical record review, observation, and staff interviews. 2. On 10/31/2023 a waterproof drainage barrier was placed. The barrier attaches to the underside, external portion of the wheelchair extending the length of the wheelchair to the front underside of the chair to ensure no direct contact made with resident. as the barrier is not touching the patient or impeding movement, the resident was acceptable of the barrier placement. DON (Director of Nursing) discussed with patient and patient verbalized agreement. Nursing staff education begun 10/31/2023 to change drainage barrier daily and as needed for soilage & laundering. In order to monitor, the licensed nurses have been assigned a task on the EMAR (Electronic Medication Administrating Record) to change the barrier daily and as needed through their designated shift. Nurses will visualize the barrier is in place and functioning properly underneath the external portion of resident's wheelchair throughout their shift. The surveyor verified by medical record review, observation, and staff interviews. 3. On 11/1/2023 DON visualized Resident #5 in wheelchair with no drainage noted to floor in room or common area outside of room, floor clean with waterproof drainage barrier in place functioning properly. The surveyor verified by observation and staff interviews. 4. Education began on 11/1/2023 with Housekeeping/Environmental services staff on proper cleaning techniques which included a deep clean procedure form & the 5-step cleaning method. The 5-step cleaning method includes: 1. Pulling trash out of all assigned rooms (per housekeeper); 2. Sweep; 3. Mop; 4. Bathroom; and 5. Dusting. Education also included a monthly deep cleaning schedule. The surveyor verified by medical record review, observation, and staff interviews. 5. On 11/1/2023 the Linen cart on 300-hall removed from the Hallway, cleaned, and linen laundered & replaced. All linen from hallway was placed in a locked storage area. The surveyor verified by observation and staff interviews. 6. Education began on 11/1/2023 with laundry personnel and nursing staff regarding linen cart removal & placed behind locked doors. The surveyor verified by medical record review, observation, and staff interviews. 7. Resident #5 personal linen placed in room. Nursing home administrator spoke with resident on 11/1/2023 regarding personal linen placement in room. Visual reminder placed on personal linen cart in Resident #5's room for resident & staff. Resident agreeable currently. The surveyor verified by observation and staff interviews. 8. Education provided to Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) to clean floor with disinfectant after housekeeping off duty or when unavailable. They will clean the floors with disinfectant when any substance is visualized on the floor. The surveyor verified by observation and staff interviews. 9. Education began 11/1/2023 to all staff members by Director of Nursing regarding F584 Resident Rights: Safe/Clean/Comfortable/Homelike Environment. The surveyor verified by observation and staff interviews. 10. Education will continue each shift until 100% (percent) of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The surveyor verified by observation and staff interviews. 11. Newly hired nursing & (and) housekeeping employees will receive education of above prior to working the floor. The surveyor verified by observation and staff interviews. 12. The Housekeeping staff will monitor resident #5 room cleanliness per the cleaning assignment protocol which included a deep clean procedure form and deep cleaning schedule. Resident #5's room will receive a weekly deep clean, which is enhanced from the standard deep cleaning schedule which is monthly. Housekeeping Supervisor will monitor by utilizing the deep clean list form (audit tool) for the enhanced cleaning schedule assignment and completion. This process will include the Housekeeping Supervisor taking the deep clean list form that has been checked off by the housekeeper and visualizing the room for herself. She will check the room by completing the deep clean list form. This action will be completed weekly. The surveyor verified by observation, and staff interviews. 13. The Environmental Supervisor will report any deficiencies noted from the deep cleaning list form to the Administrator. The surveyor verified by observation and staff interviews. 14. The Administrator will report any trends identified in the monthly QAPI (Quality Assurance and Performance Improvement) Committee meeting. The surveyor verified by staff interviews. 15. Removal plan discussed and approved by Medical Director (MD) on 11/1/2023, 11/2/2023, and 11/3/2023. The surveyor verified by staff interviews. 16. Reviewed and approved removal plan by QAPI Committee on 11/1/2023, 11/2/2023, and 11/3/2023. The surveyor verified by observation and staff interviews. The facility is required to submit a Plan of Correction.

Based on policy review, timeanddate.com, medical record review, fall investigation review, observation and interview, the facility failed to provide adequate supervision for a cognitively impaired resident at risk of elopement, and ensure a safe environment for 2 of 7 (Resident #16 and #11) sampled residents reviewed for accidents, and supervision. On 10/31/2023 Resident # 16 exited the facility through the front exit door, by a visitor who entered the door code, opened the door, and let Resident #16 outside into the courtyard, an unsafe environment. Resident #16 was observed knocking on the 300/400 Hall exit door approximately 174.1 feet from the front door. The temperature outside was 46 degrees. The facility failed to conduct appropriate elopement assessments and elopement drills on all shifts with the elopement on 10/31/2023. The facility's failure to prevent a resident with known exit seeking behaviors from eloping to an unsafe environment resulted in Immediate Jeopardy for Resident #16. The facility failure to prevent and monitor falls resulted in actual harm when Resident #11 who was severely cognitively impaired and was at high risk for falls sustained a left hip fracture that required surgery to repair. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Regional Nurse Consultant (RNC) #2 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 on 11/29/2023 at 10:35 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-689 at a scope/severity of J which is Substandard Quality of Care. The Immediate Jeopardy for F689 began on 10/31/2023 through 11/30/2023 with the last day of IJ being 11/30/2023. An acceptable IJ Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on 12/1/2023 at 1:02 PM. The corrective actions of the Removal Plan was validated by the surveyor on 12/4/2023 through review of medical record review, education review, observations, and interviews. Noncompliance of F-689 continues at a scope and severity of G related to Resident #11's falls and injury. The facility is required to submit a plan of correction. The findings include: 1. Review of the undated policy titled Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves .a safe area without authorization .and /or any necessary supervision to do so .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, Implement interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .Resident will be assessed for risk of elopement upon admission/readmission and quarterly throughout their stay by interdisciplinary care plan team (IDT) using the Elopement Risk .Supervision will be provided to help prevent accidents or elopements .Active exit seeking residents will be placed under staff supervision .Reporting requirement to the State agency shall be conducted .Procedure Post-Elopement .A nurse will perform a physical assessment, document, and report finding to physician .A social service designee will re-assess the resident and make any referrals . Review of the Facility's undated policy titled Incident and Accidents, revealed .It is the policy of this facility for staff to utilize Risk management, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident .Incident is defined as occurrence or situation that is not consistent with the routine care of a resident .The purpose of incident reporting can include .Assuring that appropriate and immediate interventions are implemented and corrective action are taken to prevent recurrences and improve the management of resident care .Licensed staff will utilize Risk Management to report incidents/accidents and assist with completion of any investigation information to identify root cause .The following incidents/accidents require an incident/accident report but are not limited to .Elopement .Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions . Review of the Facility's undated policy titled Accidents and Supervision, revealed .The resident environment remains as free of accident hazards as it possible, and each resident receives supervision .to prevent accidents .Risk refers to any external factor, facility characteristic or characteristic of an individual resident that influences the likelihood of and accident .Supervision refers to intervention and means of mitigating risk of an accident . Review of the Facility's undated Policy titled, Fall Risk Assessment, revealed .It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents . 2. Review of medical record revealed Resident #16 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, Atrial Fibrillation, Chronic Kidney Disease, and Dementia. Review of the Care Plan dated 6/20/2021, revealed .Potential for wandering/elopement r/t dx of dementia, confusion and disoriented to place .12/20/2022 noted wandering .8/1/2023 with confusion noted and looking for her red car .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . initiated .3/26/2023 .Identify pattern for wandering .initiated 3/26/2023 .Observe for triggers for wandering/eloping, Document .initiated 8/7/2023 . Review of the SLUMS Examination dated 12/5/2022, revealed Resident #16 had a score of 8/30 which indicated Dementia (group of symptoms affecting memory, thinking and social abilities). The SLUMS score interpretation provides different thresholds based on the education level of the patient. Scores of 27 to 30 are considered normal in a person with a high school education, scores between 21 and 26 suggest a mild neurocognitive disorder, and scores between 0 and 20 indicate dementia. Review of Care Plan dated 4/18/2023, revealed .Resident educated on asking for staff assistance with outdoor activity . Review of the Physician's Progress Note dated 6/2/2023, revealed .Don [Director of Nursing] requests resident be seen, reports she is currently on 1:1 observation r/t [related to] wandering and exit seeking .Severe late onset Alzheimer's dementia with agitation . Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 6/2/2023, revealed .Situation: Resident noted with increased anxiety and restless behaviors. Background: Resident has Dx [diagnosis] of Alzheimer's .Assessment (RN) [Registered Nurse]/Appearance (LPN) [Licensed Practical Nurse] .Resident is walking up to exit doors looking for her red car in the parking lot. Resident states that she is going outside the door. Staff are unable to reorient or redirect resident. Attempts to provide activity are unsuccessful. Her anxiety has progressed this afternoon. Behaviors appear to occur more often and more severely in the afternoon hours . Review of the Elopement Risk dated 6/2/2023, revealed Resident #16 had a score of 16 indicating she was at high risk for elopement. Review of the Behavior Note dated 6/4/2023, revealed .Res [resident] noted packing up belongings in her room. Res asking where her husband is and how long will it be before he comes back. Redirection provided by staff with no success . Review of the Care Plan dated 6/7/2023, revealed .The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] dx Dementia . Review of the Mental Health and Wellness note dated 6/7/2023, revealed .History of Present Illness .Review of facility documentation does not reveal any new behavioral issues with exception of increased exit seeking behaviors . Review of the Behavior Note dated 6/8/2023, revealed .Resident noted with exit seeking behavior .pulling on exit door . Review of the General Nursing Note dated 6/8/2023, .This nurse observed resident pulling on door attempting to go to parking lot stating, 'I'm looking for my car so I can go home. I don't live here .' Increased agitation noted .Attempted to redirect and reassure resident w/o [without] success . Review of the Physician's Progress Note dated 6/9/2023, revealed .Severe late onset Alzheimer's dementia with agitation . Review of the IDT [Interdisciplinary Team] General Note dated 6/12/2023, revealed .Resident was placed on 1:1 observation 6/8/23-6/9/23 r/t [related to] exit seeking behaviors . Review of the Social Progress Note dated 6/18/2023, revealed .Pt [patient] has dx of dementia .Pt is confused and forgetful .Pt has trouble concentrating at times .Pt recently had exit seeking behaviors . Review of the Care Plan dated 6/20/2023, revealed .Resident requires assist with ADLS [activity of daily living] R/T dx of dementia, deconditioning, unsteady gait .Resident needs supervision with 1 person assist for locomotion on unit . Review of the annual MDS assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 10, indicating she was moderately impaired, trouble concentrating on thing, such as reading the newspaper or watching television, required supervision and physical help for her activities of daily living (ADLs) and coded for cognitive loss/dementia. Resident #16's assessment was coded not exhibited for wandering behaviors. Review of the Social Progress Note dated 7/16/2023, revealed .Pt [patient] annual assessment is completed. Pt has dx [diagnosis] of dementia .Pt has Alzheimer's [a degenerative brain disease that causes memory loss, impaired thinking, disorientation, and changes in personality and mood] .Pt is confused and forgetful . Review of the General Nurse Note dated 7/23/2023, revealed . [Named Family Member #2] states that she has noted resident to be confused this afternoon. Resident has been calm and cooperative past few days, Confusion is baseline for resident, yet [Family Member #2] thinks it is worse today. [Family Member #2] states that resident was having trouble remembering who her [Family Member #2] was . Review of the Interdisciplinary Team General Note dated 8/2/2023, revealed .Pt noted on 8-1-23 [8/1/2023] with confusion looking for her red car and her daughter . Review of SBAR dated 8/3/2023, revealed .Resident noted recently with confusion, looking for cars in parking lots, smearing feces in bathroom and placing blame elsewhere . Review of the Physician's Orders date 8/5/2021, revealed monitor exit seeking behaviors this shift, and every day and night shift. Review of the Morse Fall Scale dated 8/27/2023, revealed Resident #16 scored a 55.0 indicating she was High Risk for falls. The Fall scale range revealed a 15-50 is high risk for falls. Review of the Medicare Meet IDT Note dated 9/1/2023, revealed .Pt referred to PT [Physical Therapy] due to noted unsteadiness during standing and ambulation and balance difficulties during ADLs [Activity of Daily Living] . Review of the Elopement Risk dated 9/1/2023, revealed Resident #16 scored a 6 indicating she was at low risk for elopement. There was no documentation on the Medication Administration Records (MAR) dated September and October 2023, for monitoring Resident #16's exit seeking behaviors. Review of the quarterly MDS assessment dated [DATE], revealed Resident #16 had a BIMS score of 13, indicating she was cognitively intact, trouble concentrating on things, such as reading the newspaper or watching television, and required supervision and physical help for her activities of daily living (ADLs) . Resident #16 was not coded for wandering behaviors. Review of the General Nurse Note dated 9/24/2023, revealed .Resident noted with confusion .Resident states 'We all came to this church together, if I would've known it would be like this, I would've never came. I'm very unhappy with the ones who came here with me & just left me here like this by myself. Something has got to be done about all of this' . Review of the General Nurse Note dated 9/24/2023, revealed .Resident noted with confusion this afternoon. Resident noted pacing looking for car . Review of the Care Plan dated 9/27/2023, revealed .Resident at risk for pain r/t [related to] dx [diagnosis] of depression .dementia may not be able to articulate needs . Review of the Medicare Meet IDT Note dated 10/6/2023, revealed .Pt referred to PT [Physical Therapy] due to noted unsteadiness during standing and ambulation and balance difficulties during ADLs [Activity of Daily Living] . Review of the Care Plan dated 10/15/2021, revealed .Resident needs supervision with 1 person assist for transfers .Resident needs supervision with set-up assist for locomotion off of unit .Resident needs supervision with set-up for ambulation in corridor . Review of the Physician's Progress Note dated 10/27/2023, revealed . Severe late onset Alzheimer's dementia with agitation [In the late stage of the disease Alzheimer's, called severe dementia due to Alzheimer's disease, mental function continues to decline. The disease also has a growing impact on movement and physical capabilities] . Review of TimeandDate.com dated 10/31/2023, revealed the weather at 5:55 PM was 46 degrees with a low of 34 degrees. Review of the COMMUNICATION-with Family, 10/31/2023 at 10:34 PM, revealed .Alerted RP to incident involving resident going outdoors to pick a rose, spoke to RP regarding stable vital signs, no injuries present, 1:1 initiated per agency protocol, continuing to monitor resident, no concerns voiced regarding incident. Review of the Investigation Summary dated 10/31/2023, revealed .Interviews held with per IDT with staff present noted that visitor had opened door coming in to visit family member and resident was standing at the door, visitor allowed resident to go through the door & he walked to his family member's room. Visitor stated there had only been no more than approximately 3-5 minutes since time he entered facility & time staff member came & asked him if he had seen a resident go out the front door . Review of the medical record revealed the facility failed to reassess Resident #16 for elopement risk when she exited the facility on 10/31/2023. Review of the Physician's Progress Note dated 11/3/2023, revealed .Routine follow up nursing home visit. No change in diagnosis or medicines since last visit. There was no documentation the Medical Director assessed the Resident #16 related to the elopement. Review of the Elopement Risk dated 11/9/2023, revealed Resident #16 scored a 16 indicating she was at high risk for elopement. Review of the ELOPEMENT DRILL DOCUMENTATION FORM dated and performed on 11/10/2023, revealed an elopement drill that was only completed for the first shift. There were no drills performed for the other 2 shifts related to the 10/31/2023 elopement. The facility failed to conduct an appropriate elopement assessments and elopement drills on all shifts with the elopement on 10/31/2023. Observation on 11/21/2023 at 10:54 AM, with the Maintenance Director and Assistant revealed the Maintenance Director used a measuring wheel with digital display to measure the distance from the front door to the pathway Resident #16 traveled to the 300/400 Hall exit door was 174.1 feet. The measurement from the resident room to the front door was 198.1 feet. Observation of the courtyard on 11/21/2023 at 10:57 AM, revealed the following: a. To the left of the front door was a huge rock in the flower bed on the side of the metal railing and a concrete child statue, a large black metal Shepards hook, concrete pathway with open groves leading to the 300/400 Hall exit door, a concrete area with a concrete table with 2 concrete benches, a tree with 3 large trunks with one of the trunks cut and exposing the sharp wooden edges, at the base of the tree was exposed large tree roots, on the far back wall of the facility was a black hose pipe curled up on the wall hooked up to a faucet, a metal gate with a latch that was easily opened that opened to the facility parking lot and street, behind the rose bushes was a large black box, a black long water hose attached to a water faucet lying on the ground, a gravel path leading to the large black box, several stepping stones in the flower bed and around the black box, 2 black plastic pipes with ridges [single wall perforated drain pipe] coming from under the ground on each side of the rose bushes and a metal bench on the pathway across from the rose bushes. b. Exiting the front door was a paved concrete walkway with black metal railing on each side leading to the black metal front gate with a latch that easily opens. A gate latch is a locking mechanism that is used to secure gates on fences using a metal bar and lever that is raised to open the latch and lowered to close it. c. To the right of the front door in the courtyard was a large 3 tier concrete water fountain with dirt in each tier, a flagpole with a concrete base with uneven ground, 2 large ant hills, a large covered patio with a gallon of hand sanitizer sitting on the wooden rail, a fire extinguisher in a glass case, a fire blanket, a large gray trash can, a small red metal container for cigarette butts, several metal tables and chairs, to the right outer side of the covered patio was a concrete flower bed filled with dirt, a black device with a water faucet on top with a black hose attached, and black mesh netting. d. The right side of the covered patio contained 2 small ponds with multiple sized medium to large rocks, the ponds were filled with gravel, a large blue handled shovel and a small wooden bridge was between the 2 ponds, and a single wall perforated black plastic drain pipe emerged from the ground over one of the ponds, which contained a large steppingstone. During an interview on 11/21/2023 at 9:11 AM, the Infection Preventionist was asked about the day Resident #16 exited from the facility on 10/31/2023. The Infection Preventionist stated, .I was working as an aide that day on the 300/400 Hall .I have a text when it occurred .I was leaving the floor going to my office to get something .I was behind the desk charting .I was coming from the nursing station in route to my office .as I was passing the east wing doors [300/400 Hall] .she [Resident #16] was approaching the door trying to get in . The Infection Preventionist was asked if she knew how long Resident #16 was outside. The Infection Preventionist stated, .No I don't . it was 5:56 PM when I saw her .she was reaching for the door .I saw her through the glass door . The Infection Preventionist was asked if she witnessed Resident #16 exit the facility. The Infection Preventionist stated, .No . During an interview on 11/21/2023 at 10:43 AM, the Regional Nurse Consultant #1 was asked if the elopement incident on 10/31/2023 was reported to the state. The Regional Nurse Consultant #1 stated, .No . she [Resident #16] did not meet the definition of elopement .nothing to report . The Regional Nurse Consultant #1 was asked if any staff members saw Resident #16 exit the facility. The Regional Nurse Consultant #1 stated, .No . a visitor saw her go out the door . The Regional Nurse Consultant #1 was asked if the visitor screened in the facility to verify the time the resident exited the facility. The Regional Nurse Consultant #1 stated, .No . I do not have a punched time . The Regional Nurse Consultant #1 was asked if the Ombudsman was notified. The Regional Nurse Consultant #1 stated, We did not . The Regional Nurse Consultant #1 was asked who is responsible to ensure the resident safety in the facility. The Regional Nurse Consultant #1 stated, .Anyone . The Regional Nurse Consultant #1 was asked if the facility completed an elopement assessment post elopement. The Regional Nurse Consultant #1 stated, .No . we did not complete another one .we did not deem she tried to elope .on 9/1/2023 she was a low risk . The Regional Nurse Consultant #1 was asked if the care plan was revised to reflect the resident exiting the facility. The Regional Nurse Consultant #1 stated, .If they are exit seeking and can't redirect .yes .that is not anything necessary to care plan [when resident gets out the building] . The Regional Nurse Consultant #1 was asked what she considered and elopement. The Regional Nurse Consultant #1 stated, .In our policy we have the definition of elopement when a resident leaves the premise or a safe area . Observation and interview on 11/21/2023 at 11:28 AM, out on the courtyard, the Administrator was asked if he felt it was safe for the Resident#16 to be outside, alone, and unsupervised in the courtyard. The Administrator stated, .After investigation we felt it was safe .after what she [Resident #16] told us she was safe .she walked down the sidewalk from the front door to pick the [NAME] .it had gotten cooler 2 nights before .there had been [NAME] on the bushes .there was no blooms when she was outside .there was just buds . The Administrator was asked if he felt a resident who was outside alone, without staff knowledge, and unsupervised was safe. The Administrator stated, .Yes . The Administrator was asked if it was dark outside. The Administrator stated, .It was darker .yes . The Administrator was asked who's responsible for the resident's safety in the facility. The Administrator stated, .The Administrator . The Administrator was asked if he was familiar with the federal regulation related to elopement. The Administrator stated, .Yes .the residents have to be in a safe environment at all times . The outside courtyard was noted with several rose bushes with long sharp [NAME], uneven ground and groves and cracks in the concrete pavement. During an interview on 11/21/2023 at 3:35 PM, LPN #7 was asked about the nurse's note written on 10/31/2023 at 7:03 PM, that documented Resident #16 had an incident involving elopement. LPN #7 stated, .after the investigation it was determined it was not an elopement .I was told that it was incorrect documentation and not a true elopement .by [Named Regional Nurse Consultant #1] . During a telephone interview on 11/21/2023 at 12:47 PM, the Registered Nurse (RN) Supervisor #1 was asked about the incident when Resident #16 got out the facility on 10/31/2023. The RN Supervisor #1 stated, .what I know about that [Resident #16 elopement] .we were at 300/400 nursing desk .[Named Infection Preventionist and Licensed Practical Nurse [LPN #5] and me .[Named Infection Preventionist] said [Named Resident #16] is outside .by this time she was knocking on the door [300/400 Hall door] wanting to come in .we had seen her walk by the window .there is a big window there at the nursing station .[Named Infection Preventionist] went around and open the door [300/400 Hall door] and she came in . The RN Supervisor was asked if she know how Resident #16 got outside. The RN Supervisor stated, .No . not at that time . [Named LPN #1] she is the one who figured out how she got out .it was by a family member . [Named LPN #1] asked [Named Family Member #1] if he had seen anybody go out .he said yes .there was a lady there [at the front door] he thought she was a visitor .when he opened the door to come in, he allowed her out . The RN supervisor was asked how the family member got into the building and if he had the code to the door. The RN Supervisor stated, .at the time he did have the code .yes . The RN Supervisor was asked if it was dark and cold outside. The RN Supervisor stated, .It was .it had start to get dark .it was cool . The RN Supervisor was asked how Resident #16 was dressed and if she appeared to be cold. The RN Supervisor stated, .she was fully dressed in a shirt, pants, and shoes .I asked her what she was doing outside .I told her it's cool out there .she said just a little . The RN Supervisor was asked if any of the staff members witnessed Resident #16 exit the facility. The RN Supervisor stated, .No . not that I'm aware of .as far as I know no one saw her leave the facility .we saw her at the window .she was knocking on the door to come back in . The RN Supervisor was asked if she had any [NAME] in her hand when she was knocking on the 300/400 Hall door. The RN Supervisor stated, .No .she did not have anything in her hands .not that I recall . During a telephone interview on 11/21/2023 at 1:06 PM, Licensed Practical Nurse (LPN) #1 was asked to tell me about the incident when Resident #16 exited the facility. LPN #1 stated, .I know that I was sitting on 600- Hall completing my alert charting for the evening .I noticed a few of the staff members coming from the 300/400 Hall with [Named Resident #16] they looked panic in the face .I asked, what's wrong .[Named RN Supervisor #1] said she [Resident #16] was outside .me and [Named LPN #5] said someone had to let her out .let's go outside to see if there are any family members we can ask .I went outside and searched the area .there was no family in sight .I had seen 2 family members who just came in [Named family member #2] he has seen a resident up there [front] roaming on the 100/200 Hall at nursing station .I left him and went to next family member [Named family member #1] .asked if he let anyone out .he said yes, he let a lady out she [Resident #16] had on shoes and everything .I told him you just let one of our residents out the building .from there [Named RN Supervisor #1] called [Named DON [Director of Nursing] . LPN #1 was asked if the family member told her a time frame when he let Resident #16 out the facility. LPN #1 stated, .No . I don't know the time .I can't say for sure .I thought he was in the building for 3-5 minutes .but he did not screen in the building like he was supposed to .I can't give a time frame .no ma'am . LPN #1 was asked if the family member had the code to the door. LPN #1 stated, .Yes . During a telephone interview on 11/21/2023 at 1:18 PM Certified Nursing Assistant (CNA) #10 was asked when Resident #16 exited the facility on 10/31/2023. CNA #10 stated, .I was walking towards the front and me and [Named Infection Preventionist] seen her at the side door at the 300/400 Hall exit door .she [Resident #16] needed to be let in . I knew she was not to be out there [in the courtyard] in the first place .she was standing close to the door .she was on the concrete in front of the door . CNA #10 was asked if she saw Resident #16 knocking on the 300/400 Hall exit door. CNA #10 stated .No I don't believe so .we [Named Infection Preventionist] open the door and let her in . CNA #10 was asked if Resident #16 said anything about how she got outside. CNA #10 stated .No . she said it was cold outside and glad to be back in . CNA #10 was asked how Resident #16 was dressed. CNA #10 stated, .She had on long sleeves, jeans, shoes . CNA #10 was asked if Resident #16 had any [NAME] or anything in her hands. CNA #10 stated .No . not that I remember . CNA #10 was asked if Resident #16 stated she was outside picking [NAME]. CNA #10 stated .No ma'am . CNA #10 was asked if she saw Resident #16 exit the facility. CNA #10 stated, .No . During an interview on 11/21/2023 at 3:35 PM, LPN #7 was asked about the night of 10/31/2023 Resident #16 exited the facility. LPN #7 stated, .I got involved when the RN Supervisor [was] walking [Named Resident #16] down the hallway .I [was] at the end of the hallway doing a medication pass .I took her [Resident #16] to her room for vital signs and head to toe assessment .I asked her what happen .she said she wanted to go outside to pick flowers .notified [Named DON] of the situation .got investigation statements .complete incident report .she had no injuries .no reported pain .I started neuro [Neurological] checks and put her on 1:1 till the end of the investigation . LPN #7 was asked what Resident #16 was wearing. LPN #7 stated, .No jacket .she had on house shoes, 3/4 length sleeved shirt and pants .LPN #7 asked if she saw Resident #16 exit the facility. LPN #7 stated, .I did not see her exit the building . LPN #7 was asked when the last time she saw Resident #16 on 10/31/2023. LPN #7 stated, .It was around 5:35 PM [The Infection Preventionist revealed it was 5:56 PM when she let Resident #16 back in the facility] . During an interview on 11/27/2023 at 9:04 AM, the Occupational Therapist was asked if it was a safe area outside in the courtyard walking alone unattended. The Occupational Therapist stated, .she doesn't need to be by herself .different area such as in the flower beds she not safety or uneven ground it would not be safe it could cause some loss of balance . The Occupational Therapist was asked if it was a safe idea situation for Resident #16 to be outside alone with her history of high risk for fall. The Occupational Therapist stated, .No . During an interview on 11/27/2023 at 10:06 AM, the Speech Therapist was asked if he assessed Resident #16 cognition. The Speech Therapist stated, .Yes .I completed a standardize cognitive assessment to get an idea of how safe and oriented the resident was .she was well into the dementia with a score of 8/30 .1-19 less than high school graduate and fall into the dementia range and she scored an 8/30 .I talk to her daily .her cognition if I tested her again it would be the same or worse .she has severe memory issues, short term and long term .that how it's been since the day I met her .she is not cognitively intact . The Speech Therapist was asked if he thought it was safe for Resident #16 to be in the courtyard alone. The Speech Therapist stated, .I would not think so . Speech Therapist was asked if he thought Resident #16 could make a reasonable decision on her own. The Speech Therapist stated, .no ma'am . During an interview on 11/27/2023 at 3:34 PM, the Medical Director was asked if he was notified when Resident #16 exited the facility. The Medical Director stated Yes . The Medial Director was asked what he would consider and elopement. The Medical Director stated, .if they [a resident] get outside the building unsupervised and unwitnessed . The Medical Director was asked what he considered a safe area. The Medical Director stated, .Inside the building . The Medical Director was asked what he considered an unsafe area. The Medical Director stated, .the streets .off the property .area in the parking lot .mechanical room .laundry room . The Medical Director was asked what about the courtyard. The Medical Director stated, .no patient should go out there [courtyard] without family members . The Medical Director was asked should a resident with high risk of fall be in the courtyard alone. The Medical Director stated, .[TRUNCATED]

Based on policy review, Job Description, record review, observation, and interview, the facility failed to maintain an infection prevention program to prevent the development and transmission of infection when Resident #5, whose wounds were infected, with maggots, and draining, was observed propelling in his wheel chair and draining onto the facility floor and when Resident #5 was observed to be scratching and touching his wounds with his hands, and then touching towels/linens on the clean linen cart. The facility failed to ensure staff used appropriate infection control practice for 3 of 3 (Certified Nursing Assistant (CNA) #1, #2 and #3) CNAs observed to perform personal hygiene care. The facility had a census of 70. The facility's failure to prevent the development and transmission of potential infection when Resident #5, who had wounds infected with maggots, was observed propelling himself throughout the facility, and large amount of drainage/maggots was noted to leak on the floor placed residents at risk, which resulted in Immediate Jeopardy. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Regional Nurse Consultant (RNC) and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-880 on 11/1/2023 at 9:15 AM, in the Interview Room. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of J. The Immediate Jeopardy began on 10/25/2023 through 11/1/2023 with the last day of IJ being 11/1/2023. An acceptable IJ Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on 11/3/2023 at 2:01 PM. The corrective actions of the Removal Plan was validated by the surveyor on 11/6/2023 through review of medical record review, education review, observations, and interviews. Noncompliance of F-880 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility's undated policy titled, Isolation Precautions, revealed .Contact precautions .are measure that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment .Facility staff will apply Standard Precautions to all residents under the assumption that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services . Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .Before applying and after removing personal protective equipment (PPE), including gloves . Review of the facility's undated policy titled, Catheter Care, revealed .It is the policy of this facility to ensure that residents with indwelling catheter received appropriate catheter [helps drain urine from your body] care .Using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner soap) .with a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis .with a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter .Dry area with towel . Review of the facility's undated policy titled, Perineal Care, revealed .Perineal care .refers to the care of the external genitalia and the anal area .Basin .filled .with warm water .Washcloths, towels, toilet paper .Perineal Cleanser .If perineum is grossly soiled, turn resident onside, remove any fecal material with toilet paper, the remove and discard .Cleanse buttocks and anus, front to back .Thoroughly dry . Review of the Infection Preventionist Job Description signed 10/11/2021, revealed .Develop and implements and ongoing infection prevention and control program to prevent recognize and control the onset and spread of infection in order to provide a safe, sanitary, and comfortable environment .Oversee resident care activities that increase risk of infection ( .use and care of urinary catheters, wound care, incontinence care .Treats all residents with dignity and respect. Promotes and protects all resident's rights .) 2. Review of medical record, revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Paraplegia, Contracture Right and Left Knee, Peripheral Vascular Disease, Major Depression, Obstructive and Reflux Uropathy, Pain, Antisocial Personality, Pressure Ulcer to the Buttock Stage 3, right heel, and Sacral, Opioid Dependence, Enterostomy, and Anxiety. Medical record review revealed Resident #5 was admitted to the hospital from 2/15/2023 - 2/27/2023 and was admitted for Hospice Services on 2/28/2023. Review of the Hospital Records dated 2/15/2023, revealed, .2/16/2023 . Consultation .IMPRESSION AND PLAN .status post ileostomy [a stoma that is surgically constructed to create an opening for intestinal waste to exit the body], chronic Foley [catheter is inserted into the urethra, the tube that carries urine out of the body], chronic nonhealing wound, decubitus [injuries to skin and underlying tissue resulting from prolonged pressure on the skin] sacrum, bilateral hip, buttock and thigh, also lower extremity left leg, chronic osteomyelitis [an infection in the bone caused by bacteria or fungi] with exposed joint cavity and severe contracture .He has plethora [large or excessive amount] of pathogens growing from his wounds, MRSA [Methicillin-resistant Staphylococcus aureus (MRSA) is an infection of Staphylococcus (staph) bacteria staph bacteria that's become resistant to many of the antibiotics], Enterococcus faecalis [Enterococcus faecalis is a species of bacteria that is naturally found in the intestines which cause difficult to treat infection in the nosocomial setting. The are a common cause of urinary tract infection, bacteremia], ESBL Providencia [Extended spectrum beta-lactamases (or ESBLs for short) are a type of enzyme or chemical produced by some bacteria that are responsible for a wide range of human infections] .History and Physical Exam .Assessment/Plan .Infected wounds .Chronic wounds .Sepsis [a serious condition in which the body responds improperly to an infection] .Anemia [is defined as a low number of red blood cells] . Review of the Mental Health and Wellness Notes, dated 3/15/2023, revealed .No reported concerns of increased or worsening behavior . The Mental Health Note failed to address Resident #5's continued noncompliance and refusal of care in the facility. Review of the Behavior Progress Note dated 5/22/2023 at 11:03 AM, revealed .Resident [Resident #5] noted with foul odor and fluids leaking from wheelchair .at 20:42 [8:42 PM] .Pt [patient]noted with extremely foul smelling and dripping brownish liquid from underneath him . Review of the Interdisciplinary Team (IDT) note dated 5/22/2023 Note at 20:42 [8:42 PM] .Pt [patient] noted with extremely foul smelling and dripping brownish liquid from underneath him . Review of the Mental Health and Wellness Notes, dated 6/7/2023, revealed .No reported concerns of increased or worsening behavior . Record review revealed Resident #5 was admitted to the hospital on 6/29/2023 - 7/12/2023. Review of Named Hospital Records dated 6/29/2023, revealed .Chronic extensive lower extremity wounds .Evidently upon arrival to the ER [emergency room ] these wounds were covered and maggots .Bacteremia [bloodstream infection] due to Salmonella [common bacterial disease .fecal matter is one of the most common transport mechanisms for this infection] species .Recurrent pressure wounds infections .Chronic bilateral lower extremity osteomyelitis [infection in a bone] .admitted with recurrent infection of pressure wounds .he has maggots [the larva of a fly] coming out of his sacral wound. His ostomy [opening in the abdomen for waste .to exit the body] is not attached and he has feces pouring onto his abdomen .He has bad decubitus [Ulcers which occur on the skin surface due to prolonged pressure] wound with drainage chronic osteomyelitis .polymicrobial [diseases, caused by combinations of viruses, bacteria, fungi, and parasites, are being recognized with increasing frequency] MRSA and ESBL .His wounds are deep down to joint cavity with exposed joint tissue . Review of the Hospice Visit Noted Report, dated 7/14/2023, revealed .PT [Patient- Resident #5] HAD TO GO TO THE HOSPITAL AND HE HAD SOME INFECIONS FROM HIS WOUNDS . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Metal Status (BIMS) score of 14, which indicated he was cognitively intact, rejected care 4 to 6 days a week, and was totally dependent on the staff for Activities of Daily Living (ADLs). Review of the Hospice Visit Note Report, dated 7/18/2023, revealed .PT [Resident #5] IS LAYING IN WC [wheelchair] IN ROOM RN [Registered Nurse] ASSESSMENT COMPLETED .RN NOTES MAGGOTS IN FLOOR UNDERNEATH PT . Review of the Hospice Visit Note Report dated 7/31/2023, revealed .PT IS LAYING IN WC IN ROOM .PT HAS COLOSTOMY, WHICH IS CURRENTLY UNCOVERED WITH STOOL NOTED IN FLOOR UNDER WHEELCHAIR .MAGGOTS ALSO NOTED IN FLOOR SCATTERED AROUND ROOM . Review of the Hospice Visit Note Report dated 8/2/2023, revealed .PT IS LAYIG IN WC IN ROOM, SWATTING FLIES .ASSISTANCE WITH TRANSFERRING TO BED .WHEN STAFF CAME IN TO CLEAN WHEELCHAIR HIS CHAIR WAS COVERED WITH CRAWLING MAGGKTS [maggots] FROM HIS WOUNDS . Review of the Hospice Visit Note Report dated 8/31/2023, revealed .PT RESTING IN WC UPON ARRIVAL PT HAS STRONG ODOR FOUL ON ROOM FROM WOUNDS .MAGGOTS IN WOUNDS . Review of the Behavior Note dated 9/11/2023, revealed .Res [resident] declined personal hygiene and wound care during hospice visit today .Res continues with very foul odor with fluids dripping from wheelchair. Linens in wheelchair are visibly soiled . Review of the Hospice Visit Note Report dated 9/11/2023, revealed .LARGE PRESENTS OF FLYS IN ROOM AND PT [patient] PILES LINENS ON TOP OF HIM IN EFFORT TO MASK THE ODOR, PT TRAILS DRAINAGE THROUGHOUT FACILITY FROM WOUNDS AS HE ROLLS DOWN THE HALL IN WC [wheelchair] .PT VERBALIZED UNDERSTANDING OF NOT DOING WOUND CARE AND THAT MAGGOTS ARE IN HIS WOUNDS . Review of the Hospice Visit Note Report dated 9/14/2023, revealed .PT RESTING IN W/C AT NURSING STATION .PT STACKS LINENS OVER SELF TO MASK ODOR STRING [strong] ODOR THROUOUT [throughout] HALLWAY, PT LEAKS DRAINAGE THROUGHOUT HALLWAY AS HE ROLLS ALONG WITH MAGGOT .REMOVED OLD DRESSING GREEN BLACK WET AND COATED WITH ROTTING FLESH, PT HAS MAGGOTS ALL THROUGHTOUT WOUNDS, ALL OVER SCROTUM, PENIS AND IN AND OUT OF ANUS [opening at the end of the intestines where waste leaves the body] . Review of the Mental Health and Wellness Notes dated 9/14/2023, revealed .No reported concerns of increased or worsening behavior . Review of the Hospice Visit Note Report dated 9/20/2023, revealed .FOUL ODOR AND LEAKING WOUND DRESSINGS, MAGGOTS CRAWLING DOWN WHEEL CHAIR [wheelchair] AND ON FLOOR IN PT ROOM . Review of the Hospice Visit Note Report dated 9/21/2023, revealed .Social Worker Hospice Notes .MULTIPLE FLIES NOTED FLYING AROUND PT WHEELCHAIR. PT WOUNDS APPEAR TO BE LEAKING ONTO FLOOR IN A TRAIL BEHIND HIM . Review of the Interdisciplinary Team (IDT) General Note dated 9/22/2023, revealed, .This nurse asked resident if he could please change colostomy bag as he is leaving behind a mess on the floor . Review of the Hospice Visit Note Report dated 10/2/2023, revealed .REPORTS PURULANT DRAINAGE IN THE FLOOR AROUND PT . Review of the Hospice Visit Note Report dated 10/16/2023, revealed .URINE AND WIUND [wound] DRAINAGE DRIPPINGBIN [dripping in] FLOOR AROUND PT . EDUCATION TO PT ON HAND HYGEINE FROM DIGGING IN WOUNDS PICKING OFF MAGGOTS AND NOT WASHING HANDS . Review of the Social Service Notes dated 10/23/2023, revealed .condom catheter noted in place and leaking urine on the floor . Review of the Social Service Notes dated 10/23/2023, revealed .refused condom catheter placement .Pt [patient] aware he was leaving bodily fluids all over the hallway floor and in his room . During observation and interview on 10/24/2023 at 12:15 PM, Resident #5 was asked if he had maggots in his wound. Resident #5 stated, .No . Resident #5 was asked how often his dressing is changed. Resident #5 stated, .every other day .on the day shift .by .hospice .and aide come in the same day, and they do my wounds .bed bath at the same time .on Monday and Thursday . During the interview there was a fly that landed on the resident right arm and gown, the linen under him was saturated with a brownish red stain, and there was a strong foul odor. Resident #5 was asked if the facility had a problem with flies. Resident #5 stated, .Yes, it is .it's all around the building .not as bad as it used to be . Observation in the resident's room on 10/24/2023 at 1:57 PM, revealed a fly that landed on his blanket. Observation and interview on 10/25/2023 at 6:54 AM, Licensed Practical Nurse (LPN) #3 was asked what the large brown dried puddle was on the floor near the 500-hall nursing station. LPN #3 stated . [Named Resident #5] .he let his wounds drip all over the facility and maggots are falling from the back of his wheelchair .when I see them [maggots] .I sweep them up and took them outside . LPN #3 was asked what the facility doing about Resident #5's drainage. LPN #4 stated, .I don't know .that is one of his puddles on the floor by the nursing station on the 500/600 hall .we try talking to him .he will say oh that is not mine .he will deny it .say it not his .he knows it his .we have told him . Observation on 10/25/2023 at 1:56 PM, revealed Resident #5 sitting at the 300-hall nursing station in his wheelchair watching a show on his tablet. Resident #5 had a strong foul odor and the linen under him was visibly soiled with a large amount of reddish-brown stain. Review of the Physician's Orders dated 10/30/2023, revealed .Cleanse wound to right hip .Apply Dakin's [used to prevent and treat skin and tissue infections that could result from pressure sores] soaked gauze and cover with dry dressing three times weekly and prn [as needed] .Cleanse wound to right great toe .Apply Dakins [Dakin's] soaked gauze and cover with dry dressing .Cleanse wound to right knee with wound cleanser, pat dry .Apply dakins [Dakin's] soaked gauze and cover with dry dressing three times weekly and prn . Resident #5 wounds were soaked with the Dakin's solution which is used to treat tissue infection and maggots in the wounds. Observation and interview on 10/30/2023 at 5:24 AM, LPN #4 was asked what's the pinkish brown dried puddle in the hallway is. LPN #4 stated, .its dried drainage [Named Resident #5] .at times you have to mop the 300 hall and the 200 .in front of the nursing station on the 500/600 hall around where it goes in towards the smoking area .it's not fair for the other residents to have to roll through that [drainage] . LPN #4 was asked if they had housekeeping on the night shift. LPN #4 stated, .No . LPN #4 was asked how often this occurs with Resident #5 leaving drainage on the floor. LPN #4 stated, .Daily . LPN #4 was asked what the facility is doing about the daily drainage. LPN #4 stated, .Nothing during the night .nothing is said . During an interview on 10/30/2023 at 5:51 AM, CNA #5 was asked if she has noticed any drainage coming from Resident #5's wheelchair. CNA #5 stated, .Yes ma'am .he did have a catheter he refused that .I'm not sure where its coming from .not sure he has wounds and urine .it drops from his chair .see drops here and a drop there . CNA #5 was asked if she was aware of any residents who have complained about Resident #5's drainage. CNA #5 stated, .Yes . [Named Resident #12 and #13] . CNA #5 was asked if she had seen any maggots coming from Resident #5's wheelchair. CNA #5 stated, .Yes ma'am .where ever he sit when he has them, they will fall right there .there has been people telling him he act like he doesn't care .I saw them myself it was sometime in late September early October .when I saw it in the common area on the 300 and 400 hall .it was like one here and one there .they was just crawling .just the maggots no liquid . During an interview on 10/30/2023 at 6:32 AM, CNA #6 was asked if she has ever seen maggots or drainage coming from Resident #5's wheelchair. CNA #6 stated .One day he was sitting on the 300/400 hall, one other aide brought to my attention .maggots was moving under his chair .we were killing them to keep from going in the other residents rooms .there was a puddle of fluid in the hallway I almost stepped in it .one day it was trails where ever he went .we got the mop and got it up .he was sitting up front at the desk .he rolled back to his room .there was trails going back to his room .about the size of a large grape . CNA #6 was ask if she had seen any flies in the facility. CNA #6 stated, .Yes ma'am .quite a bit, in the last 2 months . CNA # 6 was asked if she had any residents complain of the leaking of drainage in the hallways. CNA #6 stated, .Yes ma'am . [Named Resident #14] complained about Resident #5's drainage. Observation on the 300-hall nursing station on 10/30/2023 at 8:26 AM, revealed Resident #5 sitting at the nursing station in his wheelchair, a strong foul odor was noted. Observation on the 300-hall on 10/30/2023 at 10:11 AM, revealed Resident #5 was at the linen cart pulling linen off the cart and pilling it onto his wheelchair. Resident #5 was observed to reach down the right side of his back with multiple up and downward scratching motion, and continued to pull the clean linen off the linen cart placing the linen onto his wheelchair. Resident #5 moved away from the linen cart to the other side of the hallway and a half dollar size puddle of clear drainage was noted next to the linen cart. Observation in Resident #5's room on 10/30/2023 at 10:56 AM, revealed multiple flies landed on the over bed table, flies crawling on the walls and 4 flies lying on the resident's bed. Observation and interview on the 300-hall on 10/30/2023 at 11:10 AM, revealed a puddle of clear liquid on the floor across from the linen cart where Resident #5 was sitting in his wheelchair. LPN #5 went to the desk to get a bleach wipe to clean the puddle up and stated, it looked like urine .it [drainage] has a yellow tint to it. During an interview on 10/30/2023 at 1:10 PM, with the Hospice Registered Nurse (RN) and the Hospice Certified Nursing Assistant (CNA). The Hospice RN was asked when she provides wound care for Resident #5 how often is he getting a bath. The Hospice RN stated, .he gets his wound care on Mondays and Thursdays at 1:00 PM .the CNA comes with me and she gives him his bath . The Hospice RN was asked how long he has had the maggots in his wound. The Hospice RN stated, .he had the maggots since I started his care .it been for the past 3 to 4 months .he removes his dressing .I text [Named Wound Care Nurse] she tells him to get ready .he removes his dressing because of the maggots .all the wounds have maggots .buttock .down his left leg to the heel .right leg not as bad .he has 3 wounds on that leg .he take his hand and scrapes the maggots off with his hand . The Hospice RN was asked if she had seen the maggots drop from his wheelchair. The Hospice RN stated, .Yes ma'am .they will be in the hallway .on the 300-hall .where he wanders, there will be droplets everywhere he goes .a possibility that .some residents wander down the hall bare footed and could step in it [maggots or drainage] . The Hospice RN was asked if she had seen a lot of flies in the facility. The Hospice RN stated, .Yes, it like something out of a movie . The Hospice RN was asked where all the drainage is from. The Hospice RN stated, .the catheter could not get it [place] .I could not advance the condom catheter .the [condom catheter] want stay on .he is constantly dribbling with urine and saturated in urine all day .the drainage is all the above .ostomy .urine .his wounds also drain . The Hospice RN was asked what type of treatment in place for Resident #5's wounds. The Hospice RN stated, .clean with wound cleanser and Dakin's solution with a wet to dry dressing .the wound care nurse helps with wound care .[Named Wound Care Nurse] come in . During an interview on 10/30/2023 at 2:09 PM, the Wound Care Nurse was asked if she had seen maggots in Resident #5's wound. The Wound Care Nurse Stated, .Yes .all through the summer .in the summer there were a significant amount .we have a fly problem .he is not clean .they have a good food source . The Wound Care Nurse was asked if she had seen a lot of drainage coming from Resident #5. The Wound Care Nurse stated, .the sheets are soaked in drainage .it's either urine or from his ostomy .he roll around without his ostomy bag .sometime the drainage is worse than other times .right now it more urine .in the past it has been bad .sometimes it's dark and slimy .amber red . black, brown .don't know what it's going to be [the drainage] . use chuck pads .more absorbent .tried condom catheter .no go .ostomy bag .he wasn't keeping it [catheter or ostomy bag] on . Observation of the 600-hall on 10/31/20023 at 10:34 AM, near the double fire door on the left side of the hall near room [ROOM NUMBER] revealed two small puddles of fluid on the floor in the hallway. During an interview on 10/31/2023 at 12:15 PM, with the Regional Services Advisor and the Administrator, the Regional Services Advisor was asked if he was aware Resident #5 still had maggots in his wound. The Regional Services Advisor stated, .Yes off and on .it's been 2 weeks ago .they would clear up and come back . The Regional Services Advisor was asked who is ultimately responsible for the safety and welfare of the residents in this building. The Regional Services Advisor stated, .that is us, the Administrator . The Regional Services Advisor was asked with Resident #5's drainage and maggots from his wheelchair onto the floor, is it a safe and clean environment for the other residents. The Regional Services Advisor stated, .there are times when he is dripping .it's not the most sanitary thing .from that standpoint .it is not the most sanitary thing for them (the other residents) to wheel through the drainage and get it on their hands .no its not . During an interview on 10/31/2023 at 12:38 PM, the Director of Nursing (DON) was asked if the facility had addressed or completed a (PIP) Performance Improvement Project to address Resident #5's noncompliance and dripping the drainage and maggots through the facility. The DON stated, I don't have a PIP on [Named Resident #5] on his noncompliance .or have a plan in place .no I don't .we have a risk meeting weekly .clinical meeting daily .he has been discussed in QA [Quality Assurance] .I don't have any documentation of that with his name on it . During an interview on 11/1/2023 at 7:19 AM, the Infection Preventionist was asked if the Resident #5's wounds and maggots would considered an infection and is that something to track. The Infection Preventionist stated, .Yes .I would say yes . The Infection Preventionist was asked who is responsible for infection control in the facility. The Infection Preventionist stated, .It is everyone responsibility in the facility for infection control . The Infection Preventionist was asked should Resident #5 be allowed to handle and pull linen off the linen cart. The Infection Preventionist .No he should not be doing that . During a telephone interview on 11/1/2023 at 8:43 AM, the Psychiatric Family Nurse Practitioner (FNP) was asked if she had addressed Resident #5's behaviors. The FNP stated, .the last time I saw him was on 9/14/2023 .I have been seeing him for a while .I started in January 2022 .note say routine follow-up with him .he is sleeping fine nothing bothering him . his behaviors are chronic and ongoing .I been there for 6 month and there is nothing new . The FNP was asked if she has looked at the root cause of his refusal and behaviors. The FNP stated, When I talk to him, he doesn't want to engage in a conversation with me .he is busy watching videos .when I ask any question, he say .'I'm fine .I'm good' .not able to get meaningful conversation out of him .no he never shared with me the reasoning behind his refusal of care and treatments . The FNP was asked if she had addressed the maggots in his wound and the drainage. The FNP stated, .I have not been told that [about the maggots/drainage] but I do read their notes the facility documentation .I know his wound care has been an issue for a very long time .the fluids /drainage in the facility I have not address those issues with him specifically .my opinion of the situation and him as a person .he is a young guy who had this happen in his life and substance use disorder arrested development in his brain has developed .the way he thinks as a young guy living in a nursing home .he is ticked off about it .refusing care .he don't understand .he don't care .he want to control his life the best way he can .there is no medication to change the fact of how he feels .all that has happen to him .that don't change the fact the choice he is making is affecting everyone around him .he is affecting other resident in the facility .absolutely . During an interview on 11/1/2023 at 1:15 PM, the Wound Care Doctor was asked if Resident #5 had any type of infection. The Wound Care Doctor stated, .he has a strong body odor .he will not shower .yes .a 100 % [percent] infection .his wounds have colonized .it has created bacteria that has become a part of him . During an interview on 11/2/2023 at 7:19 AM, the Floor Technician was asked if he had seen any maggots coming from Resident #5. The Floor Technician stated, .Yes .occasional in the hallway .mainly on the 300-hall .maggots around his doorway . The Floor Technician was asked if he remembered going outside on the smoking area and hosing down maggots Resident #5 had dropped on the concrete. The Floor Technician stated, .Yes .I was called outside they [staff] came and got me to go to the smoking area near the 500-nursing station .in the smoking area .it was over the summer .I did have to hose of the concrete cement .there was maggots .I had to hose it off for safety . During a telephone interview on 11/2/2023 at 8:15 AM, the Hospice Medical Director was asked if he was aware Resident #5 had maggots in his wound. The Hospice Medical Director stated, .Yes .I have been made aware of that .we have tried to stress doing the wound care on a regular basis .he is not interested in the treatments on regular basis . The Hospice Medical Director was asked what is Resident #5's prognosis. The Hospice Medical Director stated, .he is on hospice care .it's a pretty poor life expectancy less than 6 month .he has osteomyelitis, wound problems, and he has an infection in his wounds . The Hospice Medical Director was asked if he was aware Resident #5 was leaking fluids and maggots throughout the facility. The Hospice Medical Director stated, .I believe they have told me his wounds were oozing from the chronic inflammation and from his infection .we have addressed the need for wound care and ostomy care . The Hospice Medical Director was asked should Resident #5 be in contact isolation with the chronic infection in his wound drainage. The Hospice Medical Director stated, .that I'm not sure of .he was getting treated for chronic osteomyelitis at the hospital, and his infection that is bone deep you can see the bones and hardware . The Hospice Medical Director was asked if a resident has chronic osteomyelitis is that a type of wound infection. The Hospice Medical Director stated, .Yes .that's correct . The Hospice Medical Director was asked if it was safe environment for the other residents in the facility when Resident #5 is going throughout the facility leaking drainage and maggots on the floors. The Hospice Medical Director stated, .No .it doesn't sound like it is .if you don't know what in the fluids are .it would be a risk for the other residents .he would need to be keep in some type of isolation .he would need to be in contact isolation .that would be appropriate . The Hospice Medical Director was asked, what was the reason for Resident #5's admission to hospice care. The Hospice Medical Director stated, .part of his diagnosis is for pain management .he stops all treatment in the facility .they contacted us .he was placed on hospice care . During a telephone interview on 11/2/2023 at 10:16 AM, the Director of Hospice Care was asked if she was aware Resident #5 had maggots in his wounds. The Director of Hospice Care stated, .I came out about a month ago .just to check in with [Name Resident #5] .he refuse wound care from my nurse .when I came that day he would not let me get close .I did not see any maggots .he would not keep the colostomy bag on .when my staff get there he will say I'm hurting .we have him on Methadone [is a long-acting opioid medication that is used to reduce withdrawal symptoms] .we told him we are here to help you .no nursing home in Memphis will accept him .tried a condom catheter he would not keep it on .sent to the hospital for a suprapubic catheter [is a medical device that helps drain urine from your bladder .enters your body through a small incision in your abdomen] he would not get the surgery .he is schedule on Mondays and Thursday at 1:00 PM for his wound care .it not for us to do all the wound care .the other times the facility is responsible for his wound care . The Director of Hospice Care was asked if she was aware of Resident #5 leaking drainage and maggots throughout the facility. The Director of Hospice Care stated, .Yes .sometimes he can be saturated with urine or be soiled . The Hospice Director was asked, what was the reason for Resident #5's admission to hospice. The Director of Hospice Care stated, .because of osteomyelitis .he is rotten from the inside out .the wounds are never going to heal .he is admitted for signs and symptom management which is his primary .pain management is a part of every service .his diagnosis of osteomyelitis and the wounds are secondary . The Director of Hospice Care was asked, what is the Dakin's solution is used for. The Director of Hospice Care stated, .Dakin's is an aggressive wound cleanser .for odors .to help keep the wounds clean .with the amount of drainage coming from the wound, colostomy bag and the catheter .all the body fluid .are going to get on the wounds .without the Dakin's it will be, we are doing the best we can to provide comfort . 3. Observation in Resident #6's room on 10/25/2023 at 10:30 AM, revealed CNA #1 gathered her supplies to provide indwelling urinary catheter care, entered Resident #6's room, placed the supplies on a barrier on the over bed table, provided privacy, filled the basin with warm water, donned her gloves, and placed the wash cloths in basin. CNA #1 removed the washcloth from the basin, applied soap, and cleaned down catheter tubing with 4 strokes. CNA #1 [TRUNCATED]

Based on facility document review, medical record review, observation, and interview, the facility failed to maintain an effective pest control program in 6 of 70 (Resident #2, #3, #5, #6, #9, and #15) resident reviewed for flies in their rooms, the failure to prevent parasites or possible maggots for 1 of 70 (Resident #5) resident reviewed for maggots in the wound, and 3 of 4 (300-Hall, 400-Hall and 500-Hall) halls on 4 of 8 ( 10/24/2023, 10/25/2023, 10/30,2923 and 11/1/2023) days of onsite observations. The findings include: 1. Review of the Named Pest Control Contract dated 1/1/2023, revealed . [Name Pest Control Company] proposes to provide structural pest management services for the control of cockroaches, ants, rodents, silverfish and other structural pest infestations (with the exception of flies, fleas, bed bugs, mosquitoes and wood destroying organisms) by periodic treatment using products according to approved label procedures . 2. Review of medical record, revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of Dementia, Heart Failure, Mood Disorder, Pain, and Gastroesophageal Reflux Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Observation in the resident's room on 10/30/2023 at 9:32 AM, revealed a fly was observed flying around Resident #2's room. 3. Review of medical record, revealed Resident #3 was admitted to the facility on [DATE] with a readmission on 10/3/2023 with a diagnosis of Metabolic Encephalopathy, Neuromuscular Bladder, Diabetes, Major Depression, Benign Prostatic Hyperplasia, Anxiety Disorder, Pain, and Retention of Urine Review of the quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. Resident #3 had a wound and a urinary catheter. Observation in the resident's room on 10/25/2023 at 11:33 AM, revealed a fly was observed flying around in Resident #3's room. 4. Review of medical record, revealed Resident #5 was admitted to the facility on [DATE] with a diagnosis of Paraplegia, Peripheral Vascular Disease, Major Depression, Obstructive and Reflux Uropathy, Pain, Antisocial Personality, Pressure Ulcer to the Buttock Stage 3, Right Heel, and Sacral, Opioid Dependence, Enterostomy, and Anxiety. Review of the quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 14, which indicated he was cognitively intact. Review of the Hospice Visit Note Report, dated 8/31/2023, revealed . HAS STRONG ODOR FOUL IN ROOM FROM WOUNDS .MAGGOTS IN WOUNDS . Review of the Hospice Visit Note Report, dated 9/11/2023, revealed .PT [patient- Resident #5] TRAILS DRAINAGE THROUGHOUT FACILITY FROM WOUNDS AS HE ROLLS DOWN THE HALL IN WC [wheelchair] .MAGGOTS ARE IN HIS WOUNDS . During an interview and observation on 10/24/2023 at 12:05 PM, revealed Resident #5 sitting at the 300/400 Hall Nursing station and Resident #5 was asked if he noticed a problem with the flies in the facility. Resident #5 stated, .Yes .its [flies] all around the building . Resident #5 had 2 flies around him one landed on his arm, and another landed on his gown. During an interview on 11/2/2023 at 7:19 AM, the Floor Technician was asked if he remembered going outside on the smoking area and hosing down maggots that had dropped from Resident #5's wheelchair onto the concrete. The Floor Technician stated, .Yes .I was called outside they [staff] came and got me to go to the smoking area near the 500-nursing station .in the smoking area .it was over the summer .I did have to hose of the concrete cement .there was maggots .I had to hose it off for safety . 5. Review of medical record, revealed Resident #6 was admitted to the facility on [DATE] with a readmission on 6/12/2023 with a diagnosis of Dysphagia, Alzheimer's, Heart Failure, Defibrillator, Neuromuscular Dysfunction of Bladder and Gastrostomy. Review of the quarterly MDS dated [DATE] revealed Resident #6 had a BIMS score of 7, which indicated he had was cognitively intact. During an observation and interview on 10/24/2023 at 1:57 PM, revealed a fly that landed on Resident #6's blanket. Family Member #3 was asked if she noticed a problem with the flies in the facility. Family Member #3 stated, .Yes . 6. Review of medical record, showed Resident #9 was admitted to the facility on [DATE] with a readmission on 8/15/2023 with a diagnosis of Parkinson Disease, Peripheral Vascular Disease, Diabetes, Functional Urinary Incontinence, Pressure Ulcer Sacral Stage 3. Review of the quarterly MDS dated [DATE] revealed Resident #9 had a BIMS score of 10, which indicated he was moderately impaired. During an observation and interview in the resident's room on 11/1/2023 at 1:15 PM, with the Wound Care Nurse, Licensed Practical Nurse (LPN) #5 and the Wound Care Doctor revealed, during the dressing change a fly was observed flying around the room and landing on Resident #9 forehead. Resident #9 stated, .I wish you get that fly out of here . 7. Review of medical record, showed Resident #15 was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Diabetes, Dysphagia, and Hypertension. Review of the admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 15, which indicated he was cognitively intact. Observation in the resident's room on 10/30/2023 at 10:56 AM, revealed several flies crawling on the wall, on the over bed table, and 4 flies on Resident #15's blanket on the bed. Review of the Named Pest Control Services revealed invoices dated from January 2023 through October 2023 for pest elimination services. 7. During an interview on 10/30/2023 at 6:32 AM, Certified Nursing Assistant (CNA) #6 was asked if she had noticed the flies in the facility. CNA #6 stated, .Yes ma'am .I have seen quite a bit in the last 2 months . During an interview on 10/30/2023 at 1:10 PM, the Hospice Nurse was asked if she noticed flies in the facility. The Hospice Nurse stated, .Yes . During an interview on 10/31/2023 at 12:15 PM, the Regional Services Advisor was asked what the facility has done to control the flies in the facility. The Regional Services Advisor stated, .The exterminators have been coming in the facility .we clean his [Resident #5] room as often as he let us .I have spoken to him [Resident #5] about the maggots and flies .he said that it is not his problem .we offering to get him cleaned up if follow MD [Medical Directors] orders this will get cleaned up, he was c/o [complaining] about the flies . During an interview on 11/1/2023 at 9:27 AM, the Maintenance Director was asked what the facility had done about the multiple flies in the facility. The Maintenance Director stated, .when got a complaint about the flies we call the bug people .I talked with the bug man and asked what we can do about the flies in the facility .he recommended the fly lights . The Maintenance Director was asked when he installed the fly light traps (Ultraviolet Fly Light Trap is an insect trap that uses powerful ultraviolet rays to attract flies and other flying insect pests without the use of chemicals). The Maintenance Director stated.The lights came in on 10/1/2023 . During an interview on 11/1/2023 at 11:02 AM, LPN #6 was asked if she seen a lot of flies in the facility. LPN #5 stated, .Yes .I had a resident next to him complain .they had flies in their room .it was from him [Resident #5] .there is a strong odor most of the times coming from him and his room .the residents family member in [2 named rooms] would comment about the flies . During an interview on 11/1/2023 at 1:53 PM, the daughter of random resident in a named room was asked if she noticed a lot of flies in the in the room. The daughter stated, .I just noticed one flying around here .some days it's really bad .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure that an indwelling urinary catheter was secured for 1 of 3 sampled residents (Resident #6) reviewed for indwelling urinary catheter. The findings include: 1. Review of the facility's undated policy titled, Indwelling Catheter Use and Removal, revealed .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter . 2. Review of medical record, revealed Resident #6 was admitted on [DATE] with a readmission on 6/12/2023 with diagnoses of Dysphagia, Alzheimer's, Heart Failure, Defibrillator, Neuromuscular Dysfunction of Bladder and Gastrostomy. Review of the Physician's Orders dated 6/12/2023, revealed Resident #6 had an indwelling urinary catheter (small tube that is inserted into the bladder to drain urine). Observation in the resident room with Certified Nursing Assistant (CNA) #1 on 10/25/2023 at 10:30 AM, revealed during indwelling catheter care Resident #6's catheter was not secured (catheter securement refers to the product and devices that help keep your indwelling catheter tube and bag stable) to Resident #6 thigh. During an observation and interview with the Assistant Director of Nursing (ADON) on 11/6/2023 at 9:09 AM, revealed Resident #6's indwelling catheter was not secure. The ADON was asked should a male resident with a indwelling catheter have a securement in place. The ADON stated, .Yes .

Based on policy review, weather website statistics review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent neglect for 1 of 11 sampled residents (Resident #1) reviewed for wandering/elopement behavior. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The temperature was approximately 64 degrees. The staff were unaware the resident was missing from the facility and the resident was outside the facility, unsupervised for approximately 20 minutes. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/20/2022 at 10:42 AM, in the Employee Breakroom. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/20/2022 through 4/20/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 4/21/2022 at 10:37 AM, and the Removal Plan was validated onsite by the surveyors on 4/21/2022 through observation, policy review, medical record review, review of education records, review of the audit tools, and staff interviews on various shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .'Neglect' means failure of a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Wandering/Elopement Risk Assessment tool revealed a scale with scores as follows: 0-8 indicates a low risk, 9-10 indicates at risk to wander, 11 and above indicates a high risk to wander. Review of the Fall Scale Risk assessment dated [DATE], revealed Resident #1 was a high risk for falling, had previous falls, had a weak gait, and would overestimate or forget limits. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #1 had an unsteady gait and required physical assistance for walking. The assessment revealed no wandering behaviors during this assessment period. Review of the quarterly Wandering/Elopement Risk assessment dated [DATE], revealed Resident #1 scored a 7, which indicated a low risk for wandering or elopement. Review of the Incident Report dated 2/20/2022, revealed Licensed Practical Nurse (LPN) #1 was administering medications on the 600 Hall and heard the exit door alarm sounding. LPN #1 went to the exit door, looked outside, and did not see anyone. LPN #1 did not go outside the facility to search for anyone. LPN #1 then yelled to staff members to check all elopement risks. Resident #1 was located at 4:20 PM, seated in a chair at the pavilion outside the 500 Hall. One on one was initiated with Resident #1 and the resident stated I don't want to be here. Resident #1 had no injuries. Review of the dateandtime.com weather website revealed the temperature was 64 degrees Fahrenheit and the weather was clear at 3:56 PM on 2/20/2022. Review of the Interdisciplinary Team Event Note dated 2/22/2022, revealed staff searched the outside area and inside the facility until Resident #1 was located safely. Staff sat one on one with Resident #1 until the 11:00 PM shift arrived, and the resident was in bed. Review of the Fall Scale Risk assessment dated [DATE], revealed Resident #1 was a high risk for falling, had previous falls, had a weak gait, and would overestimate or forget her limits. Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment and had wandering behaviors during this assessment period. Resident #1 had an unsteady gait and required physical assistance for walking. Observation and interview in the resident's room on 4/18/2022 at 11:45 AM, revealed Resident #1 was seated in a wheelchair. She was alert with confusion. She did not know the day, season of the year, or her location. When asked if she could walk, Resident #1 stated, I walk outside. Just going to stay inside today. Resident #1 did not recall the elopement incident. Observation at the end of the 500 Hall at the interior door (interior doors lead to a foyer, then the exit doors) on 4/18/2022 at 2:09 PM, revealed the surveyor pushed the interior door open and a chime sounded. Registered Nurse (RN) #1 was in room [ROOM NUMBER] next to the 500-Hall interior door and did not respond. She walked out of the room, turned toward the 500 Hall Nurses' Station, and proceeded up the hall toward the Nurses' Station. The surveyor then pushed on the 15 second exterior egress exit door, the alarm sounded, and the door opened. The surveyor walked through the door, looked back into the 500 Hall, and saw RN #1 and two other staff members down the 500 Hall near the Nurses' Station. They did not respond to the alarming exit door. Observation on 4/18/2022 at 2:32 PM, revealed the 100 Hall and 600 Hall interior doors had the same door chime tone. The 600 Hall door chime was audible at the interior door and 1/2 way up the hall. The 600 Hall and 500 Hall interior door chimes were not audible at the Nurses' Station. The 300 Hall and 400 Hall interior doors did not have a door chime as the other hall doors had. During an interview on 4/18/2022 at 3:00 PM, the Director of Maintenance stated, .yes, 600 and 100 [Hall] door chime is the same .600 Hall can hear the chime at the interior door area and halfway up the hall. When everyone is in the hall and at the Nurses' Station or in a resident's room the chime would be hard to hear .500 Hall interior door only sounds at the interior door and not loud .300 and 400 Halls do not have door chimes on the interior doors .I don't know why they don't have chimes . When asked if a resident could exit the 300 and 400 hall interior doors as easily as exiting the 500 and 600 interior doors, he stated, .yes they could . During a telephone interview on 4/19/2022 at 10:51 AM, Certified Nursing Assistant (CNA) #1 stated, I found [Named Resident #1] sitting outside in a chair. She walked to the rocks at the left by the window and there was a chair in the rocks. She was playing with a sign .One of my nurses came and asked me if I had seen her [Resident #1] . When asked if Code Silver had been called on the intercom, CNA #1 stated, No, I was at 300/400 hall desk. I didn't know of Code Silver until all clear was called . Observation at the 600 Hall exit door near the Dining Room on 4/19/2022 at 11:44 AM, revealed the surveyor opened the interior door to check the chime and the staff response to the chime. RN #2 came out of the Dining Room, did not look toward the door with the chime sounding, and went up the hallway toward the 600 Hall Nurses' Station. There were 3 Certified Nursing Assistants (CNA), a Speech Therapist, and the Business Office Manager in the Dining Room. No one responded to the chimes sounding. During an interview on 4/19/2022 beginning at 2:12 PM, the DON was asked what interventions were implemented after the elopement incident. The DON stated, To make sure residents are not congregated at the dining room after meals and activities. Do not leave her [Resident #1] in dining room after meals .Door chimes to alert staff, especially at night as an added layer . When asked if staff compliance for the intervention was documented/audited, the DON stated, It's not. We don't have documentation on that . During an interview on 4/19/2022 beginning at 2:12 PM, the Administrator was asked what interventions were implemented after the elopement incident. The Administrator stated, 600 Hall chime was there, and we adjusted the tone from one to more tone. They [staff] should look toward the door, even if they [staff] can't go to the door .We still have to look at it [interior door] because just like the exterior door we expect them to check it . When asked the reason there were no door chimes on the 300/400 Hall exit door the Administrator stated, I don't know. When asked about the 500 Hall door chimes, the Administrator stated, I don't know that there is one. I can't say if [staff] responding to chimes but can say they respond to door alarms. During an interview on 4/20/2022 at 10:20 AM, LPN #1 was asked if she was working at the time Resident #1 exited the building unsupervised. LPN #1 stated, I work 7 [7:00 AM] to 7 [7:00 PM]. Door alarm was sounding .I didn't hear the doorbells. Can't hear them in rooms . The surveyors verified the Removal Plan by: 1. On 2/20/2022, Resident #1 was assessed after re-entering the facility. On 2/20/2022, elopement education began. The surveyors reviewed the assessment and the in-service sign in sheets and interviewed staff on all shifts. 2. The interior set of doors on the 600 Hall and interior single doors on 300/400/500 Halls, where door chime alarms were located, were removed by the Maintenance Director on 4/19/2022. The surveyors observed the interior doors and chimes removed and interviewed the Maintenance Director. 3. An audit for all residents' clinical records was completed on 4/19/2022 by the DON and Assistant Director of Nursing (ADON) to review that there were current wandering/elopement risk evaluations completed, wandering behavior monitors were present on the Medication Administration Record (MAR) and Care Plans were present for those with elopement risks. The surveyors reviewed the medical records, the audits, and interviewed the DON and ADON. 4. The Licensed Nurse will complete Wandering/Elopement Risk evaluations on admission, readmission and quarterly. If the resident is at Risk to Wander or High Risk to Wander, the Social Service Director will place the residents face sheet and picture in the Wandering/Elopement Book. The MDS Coordinator will validate the Care Plan is reflective based on the Wandering/Elopement Risk evaluation. The surveyors reviewed the medical record, wandering/elopement book, and interviewed staff on all shifts. 5. Education regarding Abuse and Neglect Prevention began 4/19/2022 by the DON for all staff members. Surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 6. Education was initiated on 4/19/2022 for all on duty staff on the elopements and Wandering Residents Policy and Post Test to include Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 7. Education will continue each shift until 100 percent (%) of the staff are educated on the above to include agency staff. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The surveyors interviewed staff on all shifts. 8. New employees will receive education by the DON, ADON and/or Administrator during orientation prior to working on the floor. The surveyors reviewed the orientation packet and interviewed staff. 9. Incident/Accident reports will be reviewed in the Morning Clinical Meeting by the Interdisciplinary Team (IDT). The team will review that those investigations are completed for those incidents/accidents requiring investigations. The team will review that interventions are implemented at the time of the incident to prevent further incidents/accidents and that interventions are care planned. The surveyors reviewed the Morning Clinical Meeting form and interviewed IDT members. 10. The DON and/or ADON will monitor during the Morning Clinical Meeting that residents Wandering/Elopement Risk evaluations are completed on admission, readmission, and quarterly along with their behavior monitoring on the MAR and that the Care Plan is reflective of the Wandering/Elopement Risk evaluation. The surveyors reviewed the morning Clinical Meeting Form and interviewed the DON. 11. The DON will report trends to the monthly Quality Assurance Performance Improvement (QAPI) Committee meeting. The surveyors reviewed the QAPI form and interviewed staff. Non-compliance of F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 11 sampled residents (Resident #1) reviewed for wandering/elopement behaviors. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The staff were unaware the resident was missing from the facility and the resident was outside the facility, unsupervised for approximately 20 minutes. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/20/2022 at 10:42 AM. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 2/20/2022 through 4/20/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 4/21/2022 at 10:37 AM, and was validated onsite by the surveyors on 4/21/2022 through observation, policy review, medical record review, review of education and audit tools, and staff interviews conducted on various shifts. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .Written procedures for investigation include: .Identifying staff responsible for the investigation .Identifying and interviewing all involved persons .Focusing the investigation on determining if abuse, neglect, or exploitation, and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . Review of the facility's undated policy titled Quality Assurance Performance Improvement [QAPI] Monitoring, revealed .'Adverse events' is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. The facility's QAA [Quality Assessment and Assurance] Committee analyzes data collected through planned and routine data collection activities. Performance indicators are established based on data analysis and monitored/evaluated in the QAA Committee meetings .An investigation will be conducted on each identified medical error or adverse event to analyze causes. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment for decision making. Resident #1 had an unsteady gait and required physical assistance when walking. The assessment revealed no wandering behaviors during this assessment period. Review of the quarterly Wandering/Elopement Risk assessment dated [DATE], revealed Resident #1 scored a 7, which indicated a low risk for wandering or eloping. Review of an Incident Report dated 2/20/2022, revealed .this nurse [Licensed practical Nurse (LPN) #1] was on med [medication] pass on 600 hall .I heard door alarm sounding. Immediately I went to the exit door looked outside seen [saw] no one, then yelled to staff members to check all elopement risks .Resident located at 420p [4:20 PM] sitting in a chair at pavilion outside 500 hall .resident stated 'I don't want to be here' . Resident #1 had no injuries. Review of a written statement by Certified Nursing Assistant (CNA #1) dated 2/20/2022, revealed .I walked out 500 hall by the Gazebo [pavilion] and found her [Resident #1] sitting in the chair outside by the 500 hall .I was at 300/400 hall desk. I didn't know of Code Silver until all clear was called . Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 had severe cognitive impairment, had wandering behaviors during that assessment period, had an unsteady gait, and required physical assistance when walking. During an interview on 4/18/2022 at 9:23 AM, when asked what the facility investigation had determined, the DON stated, [Named Resident #1] pushed the exit door on 600 Hall the 15 second alarmed [15 second egress door opens and alarms after pushed for 15 seconds]. Staff started looking in rooms .sometime between 2:00 [PM] and 3:00 [PM] [the alarm sounded at approximately 4:00 PM and was found at approximately 4:20 PM according to staff interviews from the surveyors and medical record documentation] . she was not a wanderer .We figured out she went out the door and sat down at the pavilion. When asked how this was determined, the DON stated, We don't know, but the walkway goes to the pavilion. We assume that she went down the walkway to the pavilion .She was sitting under the pavilion [the resident was sitting in a wrought iron chair in a rocky area according to staff interviews from the surveyors] . Observation and interview in the resident's room on 4/18/2022 at 11:45 AM, revealed Resident #1 was seated in a wheelchair. She was alert with confusion. She did not know the day, season of the year, or her location. When asked if she could walk, Resident #1 stated, I walk outside. Just going to stay inside today. Resident #1 did not recall the elopement incident. During an interview on 4/18/2022 at 1:23 PM, the DON was asked where Resident #1 was located outside the building on 2/20/2022. The DON stated, .[Named Activity Assistant] found her [CNA #1 found the resident according to the medical record and interview with CNA #1]. She was sitting under the pavilion . When asked if an investigation was conducted to determine the exact location the resident was located, the DON stated, That's what I was told by the nurse . During an interview on 4/19/2022 at 10:51 AM, CNA #1 confirmed her written statement dated 2/20/2022 stating that Resident #1 was found seated in a chair in the rocks at a window on the 500 hall. During an interview on 4/19/2022 at 2:12 PM, the DON stated .[Named Resident #7] saw her [Resident #1] going down the sidewalk from his room .[Named Resident #8] saw her pushing on the door and saw her going out to the sidewalk . Review of the significant change MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated no cognitive impairment. Observation and interview in the resident's room on 4/20/2022 at 12:00 PM, revealed Resident #7 was alert and oriented and had a severe hearing impairment. The privacy curtain was pulled from the wall to the end of the resident's bed. The surveyor wrote a note to the resident asking him if he had ever seen a woman walking by his window. Resident #7 stated, No, I can't see out. I keep my curtain closed. Can't see the window. When asked if the privacy curtain was pulled back sometimes. Resident #7 stated, No. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 15, which indicated no cognitive impairment. During an interview 4/19/2022 at 11:10 AM, Resident #8 was asked if he had seen a woman walking by his window at any time. Resident #8 stated, .Heard the door alarm go off and saw people run around looking in rooms. I saw a woman walk by my window. I went and told them. Then I went up front and they found her outside at the 500 Hall . When asked if he saw Resident #1 go outside the door, Resident #8 stated, No, I didn't see her at the door . Review of the Intake Information submitted by the facility to the State Agency, revealed .Other resident [Resident #8] notified staff that he witnessed this resident push on 600 hall exit door until it alarmed and disarmed and go around the building . Review of the facility's investigation of the elopement of Resident #1 revealed the facility obtained statements from the staff on duty at the time of the elopement and the shift prior to the elopement and completed an incident report. There was no further investigation conducted to clarify the details documented in the written statements and interviews with the involved staff and residents or determine the reason for the elopement. The facility failed to thoroughly investigate the elopement of Resident #1, failed to interview staff to determine Resident #1's behavior prior to the elopement, and failed to identify triggers that influenced the resident to elope from the facility. The surveyors verified the Removal Plan by: 1. The facility conducted an investigation on 2/20/2022, which involved obtaining employee statements and generating a timeline of the occurrence. The surveyor reviewed the investigation and interviewed staff. 2. On 2/20/2022, elopement education began. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 3. On 4/20/2022 the Administrator, DON, and/or Assistant Director of Nursing (ADON) began reviewing prior 30-day incidents/accidents to ensure thorough investigations were completed as required. The surveyors reviewed the audit tool, results of the audits, and interviewed staff. 4. On 4/20/2022 education on completing investigations thoroughly was presented to the Administrator, DON, and ADON by the Regional Director of Clinical Services. The surveyors reviewed the in-service sign in sheets and interviewed administration. 5. Incident/Accident reports will be reviewed in the Morning Clinical Meeting by the Interdisciplinary Team (IDT). The team will review the investigations to assure they are completed for those incidents/accidents requiring investigations. The team will determine that interventions are implemented at the time of the incident to prevent further incidents/accidents and assure interventions are care planned. The surveyors reviewed the Morning Clinical Meeting form and interviewed members of the IDT. 6. Weekly, the Regional Director of Clinical Services will track and review incidents requiring investigations to determine that they are complete. The Regional Director of Clinical Services will review the monthly QAPI documents for tracking, analysis, and action plans. The surveyors reviewed the audit forms. 7. The Administrator will report findings to the monthly QAPI Committee meeting. The surveyors reviewed the audit forms and interviewed the Administrator. 8. On 4/21/2022, education was initiated for Certified Nursing Assistants (CNA) that the interventions for elopement will be located on the Kardex (Care Plan for CNAs to alert them of the residents' needs) for at risk and high risk residents. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. Noncompliance of F-610 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, review of weather website statistics, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement, and failed to ensure residents at risk for wandering/elopement were identified in the Code Silver books (books placed at each Nurses' Station with the resident's face sheet and picture to identify them as a risk for wandering/elopement) for 4 of 11 sampled residents (Resident #1, #5, #6, and #11) reviewed for wandering/elopement behavior. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, eloped from the facility and was found 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The temperature was 64 degrees. The staff were unaware the resident was missing from the facility and the resident was unsupervised outside for approximately 20 minutes. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/20/2022 at 10:42 AM, in the Employee Breakroom. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey on 10/8/2020. The IJ existed from 2/20/2022 through 4/20/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 4/21/2022 at 10:37 AM, and the Removal Plan was validated onsite by the surveyors on 4/21/2022 through observation, policy review, medical record review, review of education records and audit tools, and staff interviews on various shifts. The findings include: Review of the facility's undated policy titled, Accidents and Supervision, revealed .each resident receives supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazards(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .Implementation of Interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes .Communicating the interventions to all relevant staff .Documenting interventions .Ensuring that the interventions are put into action .Facility-based interventions may include, but are not limited to .educating staff .developing or revising policies and procedures .The facility will provide supervision to prevent accidents .Based on the individual resident's assessed needs and identified hazards in the resident environment . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering .Residents will be assessed for risk of elopement and unsafe wandering upon admission/readmission and quarterly throughout their stay by the interdisciplinary care plan team .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .For the resident identified as a risk of elopement/wandering complete the Missing Resident Profile with the resident's picture and place it in a binder kept at the nursing stations and receptionist desk .Supervision will be provided to help prevent accidents or elopements .Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly .Wanderguard [a monitoring device to alert staff when a resident attempts to exit a door in the facility, if the facility has a Wanderguard system] Use .Resident will have an order for wanderguard along with reason for use .Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (Code color [silver]) . Review of the facility's Wandering/Elopement Risk Assessment Tool revealed a scale with scores as follows: 0-8 indicates a low risk, 9-10 indicates at risk to wander, 11 and above indicates a high risk to wander. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance, Cerebral Infarction, Anxiety Disorder, [CONDITION(S)], Unsteadiness on Feet, [CONDITION(S)], Essential Hypertension, and Muscle Weakness. Review of the Fall Scale Risk assessment dated [DATE], revealed Resident #1 was a high risk for falling, had previous falls, weak gait, and would overestimate or forget limits. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #1 had an unsteady gait and required physical assistance for walking. The assessment revealed no wandering behaviors during this assessment period. Review of the quarterly Wandering/Elopement Risk Assessment tool dated 2/10/2022, revealed Resident #1 scored a 7, which indicated a low risk for wandering/elopement. Review of the Incident Report dated 2/20/2022, revealed .this nurse [Licensed Practical Nurse (LPN) #1] was on med [medication] pass on 600 hall .I heard door alarm sounding. Immediately I went to the exit door looked outside seen [saw] no one, then yelled to staff members to check all elopement risks .Resident [Resident #1] located at 420p [4:20 PM] sitting in a chair at pavilion outside 500 hall .one on one initiated with resident .resident stated 'I don't want to be here' . Resident #1 had no injuries. Review of a Nurses' Note date 2/20/2022, revealed .at approximately 4:00pm this nurse was on med pass on 600 hall when I heard door alarm sounding. Immediately went to the exit door looked outside seen [saw] no one .resident located at 4:20p [4:20 PM] sitting in chair at pavilion outside 500 hall . Review of a SBAR (Situation, Background, Assessment, Recommendations) note dated 2/20/2022, revealed .one on one while resident [Resident #1] awake . Review of the dateandtime.com weather website revealed the temperature was 64 degrees Fahrenheit and the weather was clear at 3:56 PM on 2/20/2022. Review of the Interdisciplinary Team Event note dated 2/22/2022, revealed .Staff searched outside area and inside facility until resident was located safely. Staff sat 1:1 [one on one] with resident until the 11pm [11:00 PM] shift arrived and resident [Resident #1] was in bed . Review of the Fall Scale Risk assessment dated [DATE], revealed Resident #1 was a high risk for falling, had previous falls, weak gait, and would overestimate or forget limits. Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 6 which indicated severe cognitive impairment and had wandering behaviors during this assessment period. Resident #1 had an unsteady gait and required physical assistance for walking. During an interview on 4/18/2022 at 9:23 AM, when asked what the facility investigation had determined, the DON stated, [Named Resident #1] pushed the exit door on 600 Hall. The 15 second [delay] alarmed [15 second egress door opens and alarms after pushed for 15 seconds]. Staff started looking in rooms .sometime between 2:00 [PM] and 3:00 [PM] [the staff began looking for the resident at approximately 4:00 PM and located the resident at 4:20 PM according to the medical record and interviews] .she was not a wanderer .We figured out she went out the door and sat down at the pavilion. When asked how this was determined, the DON stated, We don't know, but the walkway goes to the pavilion. We assume that she went down the walkway to the pavilion .She was sitting under the pavilion [the resident was sitting in a wrought iron chair in a rocky area according to staff interviews from the surveyors] . Observation and interview in the resident's room on 4/18/2022 at 11:45 AM, revealed Resident #1 was seated in a wheelchair. She was alert with confusion. She did not know the day, season of the year, or location. When asked if she could walk, Resident #1 stated, I walk outside. Just going to stay inside today. Resident #1 did not recall the elopement incident. During an interview on 4/18/2022 at 12:43 PM, The Administrator was asked what residents have a Wanderguard implemented as stated in the facility policy. The Administrator stated, We do not have a Wanderguard system. I was not aware of it. Hadn't read that. Observation on the 500 Hall on 4/18/2022 at 2:09 PM, the surveyor held the exit door 15 second egress bar to disarm the locked door. The door alarm sounded after the 15 seconds. Observation of Registered Nurse (RN) #1 in the room at the end of the 500 Hall revealed no response to the alarming exit door as RN #1 walked away from the area toward the 500 Hall Nurses' Station. Three staff in the hallway were walking away toward the 500 Hall Nurses' Station. At approximately 2:12 PM, the MDS nurse responded to the alarming door. Observation on 4/18/2022 at 2:32 PM, revealed the 100 Hall and 600 Hall had the same door chime tone on the interior doors. The 600 Hall door chime was heard at the interior exit door and 1/2 way up the hall. The 600 Hall and 500 Hall interior door chimes were not heard at the Nurses' Station. The 300 Hall and 400 Hall interior doors had no door chime as on the other halls. During an interview on 4/18/2022 at 3:00 PM, the Director of Maintenance stated, .yes, 600 and 100 [Hall] door chime is the same .600 Hall can hear the chime at the interior door area and halfway up the hall. When everyone is in the hall and at the Nurses' Station or in a resident's room the chime would be hard to hear .500 Hall interior door only sounds at the interior door and not loud .300 and 400 halls do not have door chimes on the interior doors .I don't know why they don't have chimes . When asked could a resident exit the 300 and 400 hall interior doors just as easy as 500 and 600 doors, he stated, .yes they could . During a telephone interview on 4/19/2022 at 10:51 AM, Certified Nursing Assistant (CNA) #1 stated, I found [Named Resident #1] sitting outside in a chair. She walked to the rocks at the left by the window and there was a chair in the rocks. She was playing with a sign .One of my nurses came and asked me if I had seen her [Resident #1] . When asked if Code Silver had been called on the intercom, CNA #1 stated, No, I was at 300/400 hall desk. I didn't know of Code Silver until all clear was called . During an interview on 4/19/2022 at 2:12 PM, when asked what interventions were implemented after the elopement incident, the Administrator stated, 600 Hall chime was there, and we adjusted the tone from one to more tone. They [staff] should look toward the door, even if they [staff] can't go to the door. We don't have Wanderguards. When asked the reason there were no door chimes on the 300/400 Hall interior doors, the Administrator stated, I don't know. When asked about the 500 Hall interior door chimes the Administrator stated, I don't know that there is one. I can't say if [staff] responding to chimes but can say they [staff] respond to door alarms. During an interview on 4/19/2022 at 2:12 PM, when asked what interventions were implemented after the elopement incident, the DON stated, To make sure residents are not congregated at the dining room after meals and activities. Do not leave her [Resident #1] in dining room after meals .Door chimes to alert staff, especially at night as an added layer . When asked if staff compliance for the intervention was documented and audited, the DON stated, It's not. We don't have documentation on that . During an interview on 4/20/2022 at 10:20 AM, LPN #1 was asked if she was working at the time Resident #1 exited the building unsupervised. LPN #1 stated, I work 7 [7:00 AM] to 7 [7:00 PM]. Door alarm was sounding .I didn't hear the doorbells. Can't hear them in rooms. Brought her inside at 4:20 PM. I know because I looked at the clock as they came in the door .I know it was approximately 4:00 PM when the door alarmed . When asked what interventions were implemented to prevent Resident #1 or any other resident from exiting the building unsupervised, LPN #1 stated, Not allowed to leave anyone in the dining room after activities unattended . Observation at the 600 Hall exit door on 4/20/2022 at 12:27 PM, revealed the Maintenance Director used a rolling measuring device to measure the distance from the 600 Hall exit door to the location where Resident #1 was found in the rock area. The distance was 237 feet. Based on the facility's investigation, documentation, staff interviews, and interview with the DON, there was a discrepancy in facts stated by staff, written statements by staff, and documentation in the medical record of the events of the elopement when compared to the DON's interview and report to the State agency. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia Without Behavioral Disturbance, History of Falling, Type 2 Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)] due to Mental Disorder, and Nontraumatic Intracerebral Hemorrhage. Review of the facility's Wandering/Elopement Risk Assessment tool dated 1/27/2022, revealed Resident #2 scored a 12, which indicated high risk to wander. Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 3, which indicated severe cognitive impairment. The assessment revealed wandering behaviors occurred daily during this assessment period. Observation on the 600 Hall on 4/18/2022 at 1:32 PM, revealed Resident #2 walking independently up and down the 600 Hall, went to the 100 Hall then back to the 600 Hall. Observations at the breezeway of 300/400 Hall leading to the Courtyard on 4/18/2022 at 2:26 PM, Resident #2 pushed the exit door with an attempt to open the door. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Major Depressive Disorder, Epileptic Syndromes, Anxiety, Abnormalities of Gait and Mobility, History of Traumatic Fracture, Muscle Weakness, and [CONDITION(S)]. Review of the quarterly Wandering/Elopement risk assessment dated [DATE], revealed Resident #5 scored an 11, which indicated high risk for wandering/elopement. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Seizures, Type 2 Diabetes Mellitus, Anxiety Disorder, and [CONDITION(S)] Heart Disease. Review of the quarterly Wandering/Elopement risk assessment dated [DATE], revealed Resident #6 scored a 12, which indicated high risk for wandering/elopement. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease, Diabetes Mellitus Type 2, [CONDITION(S)], Hypertension and Paranoid [CONDITION(S)]. Review of the quarterly Wandering/Elopement risk assessment dated [DATE], revealed Resident #11 scored a 9 which indicated at risk for wandering/elopement. The quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 14 on the BIMS assessment, which indicated no cognitive impairment for daily decision-making tasks. Observation on 4/19/2022 at 11:44 AM, revealed Resident #11 was sitting in a rock in go wheelchair self-propelling throughout the dining room and into the 600 Hall without difficulty. Review of the facility's five Code Silver books on 4/18/2022, revealed Resident #5, #6 and #11's face sheet with picture were not in the book as stated in the facility policy titled Elopements and Wandering Residents. Resident #2's face sheet and picture were in the books. During an interview on 4/18/2022 at 12:43 PM, the DON was asked if the facility had a list of residents with wandering or exit seeking behaviors. The DON stated, Code Silver book at each Nurses' Station. The Social Worker keeps it updated by the scores . When asked what the scores were, the DON stated, 0-8 is low, 9-10 at risk to wander, 11 and higher is high risk to wander . During an interview on 4/18/2022 at 3:40 PM, CNA #3 was asked how would staff know which residents were at risk of wandering/elopement. CNA #3 stated, .They haven't told me who the residents are that might elope . When asked if there was a book with a list of residents that were at risk to wander/elope, CNA #3 stated, No, we are still going over that. During an interview on 4/18/2022 at 3:43 PM, Housekeeper #1 was asked how would staff know which residents were at risk of wandering/elopement and if there was a list of residents at risk for wandering/elopement. Housekeeper #1 stated, I don't know. I haven't been told about a list. During an interview on 4/18/2022 at 4:17 PM, CNA #2 was asked how would staff know which residents were at risk for wandering and/or elopement. She stated, .I find out in report if anyone has tried to get out or has fallen . When asked was there any other way to know which residents were at risk for wandering/elopement, she stated, .No . The surveyors verified the Removal Plan by: 1. The resident was assessed when she returned into the facility on [DATE]. The surveyors reviewed the medical record. 2. On 4/19/2022, the interior set of doors on the 600 Hall and interior single doors on 300/400/500 Halls where chime alarms were located were removed by the Maintenance Director. The surveyors observed interior doors and chimes removed and interviewed the Maintenance Director. 3. On 4/19/2022, an audit for all residents' clinical records was completed by the DON and Assistant Director of Nursing (ADON) to review that there were current Wandering/Elopement risk evaluations completed, wandering behavior monitors were present on the Medication Administration Record (MAR) and Care Plans were present for those residents with elopement risk. The surveyors reviewed the medical records, audits, and interviewed the DON and ADON. 4. The Licensed Nurse will complete Wandering/Elopement Risk evaluations on admission, readmission and quarterly. If the resident is at Risk to Wander or High Risk to Wander, the Social Service Director will place the residents face sheet and picture in the Wandering/Elopement Book (Code Silver book). The MDS Coordinator will validate that the Care Plan is reflective based on the Wandering/Elopement Risk evaluation. The surveyors reviewed the medical record, wandering/elopement book, and interviewed staff on various shifts. 5. Education began on 4/20/2022 to all staff members by the DON regarding Accidents/Supervision. The surveyors reviewed the in-service sign-in sheets and interviewed staff on all shifts. 6. On 4/19/2022, education began for all on duty staff on the Elopements and Residents Policy and Post Test to include Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The surveyors reviewed the in-service sign-in sheets, interviewed staff on all shifts, and observed staff promptly responding to alarms. 7. Education will continue each shift until 100 percent (%) of the staff are educated on the above to include agency staff. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The surveyors reviewed the plan and interviewed staff on all shifts. 8. Each resident at risk or high risk on the Wander/Elopement risk evaluation have had a Care Plan intervention added to observe for triggers for wandering/elopement and document. This intervention fires to each at risk or high risk resident's Kardex (a plan for each resident which alerts staff to the needs of the resident) to alert staff that a resident is a wander/elopement risk. The surveyors observed staff demonstrate how to access and document CNA Kardex, reviewed the medical record, and interviewed staff on all shifts. 9. Elopement intervention and prevention tips were posted for staff at each Nurses' Station. The education was initiated on 4/20/2022. The surveyors observed the tip sheets posted, reviewed the in-service sign-in sheets, and interviewed staff on all shifts. 10. New employees will receive the education by the DON, ADON and/or Administrator during orientation prior to working on the floor. The surveyors reviewed the orientation packet and interviewed staff on all shifts. 11. Incident/Accident reports will be reviewed in the Morning Clinical Meeting by the Interdisciplinary Team (IDT). The team will review that those investigations are completed for those incidents/accidents requiring investigations. The team will review that interventions are put into place at the time of the incident to prevent further incidents/accidents and interventions are care planned. The surveyors reviewed the Morning Clinical Meeting form and interviewed members of the IDT. 12. The DON and/or ADON will monitor during the Morning Clinical Meeting that residents' Wandering/Elopement Risk evaluations are completed on admission, readmission, and quarterly along with their behavior monitoring on the MAR and that Care Plan is reflective of the Wandering/Elopement Risk evaluation. The surveyors reviewed the Morning Clinical Meeting form and interviewed the DON. 13. The DON will report findings in the monthly Quality Assurance Performance Improvement (QAPI) Committee meeting. The surveyors reviewed the QAPI form and interviewed staff on various shifts. Noncompliance of F-689 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, observation, and interview, facility Administration failed to provide administration and oversight of its resources effectively to attain and maintain the highest practicable well-being of residents with wandering/elopement behaviors. Administration failed to provide oversight and training of staff to prevent neglect and provide appropriate care to meet resident's needs, and complete a thorough investigation of a resident elopement when a resident exited the facility without staff knowledge, and failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 11 sampled residents (Resident #1) reviewed for wandering elopement behavior. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The staff was unaware the resident was missing from the facility and the resident was outside unsupervised for approximately 20 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 4/20/2022 at 10:42 AM, in the Employee Breakroom. The facility was cited Immediate Jeopardy (IJ) at F-600, F-610, F-689, F-835 and F-867. The facility was cited an Immediate Jeopardy at F-600, F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/20/2022 through 4/20/2022. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on 4/21/2022 at 10:37 AM, and was validated onsite by the surveyors on 4/21/2022 through observations, review of audits and meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Administration of Facility, revealed .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .For the resident identified as a risk of elopement/wandering complete the Missing Resident Profile with the resident's picture and place it in a binder kept at the nursing stations and receptionist desk .Supervision will be provided to help prevent accidents or elopements .Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly .Wanderguard [a monitoring device to alert staff when a resident attempts to exit a door in the facility, if the facility has a Wanderguard system] Use .Resident will have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (Code color [silver]) . Review of the facility's undated Administrator job description, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement [QAPI] process throughout the facility. Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions related to the facility's outcomes, regulatory compliance and/or customer satisfaction .Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc .Knows and understands general nursing practices and procedures, OBRA [Omnibus Budget Reconciliation Act] regulations, Code of Federal Regulations, Appendix PP State Operations Manual .and all regulatory entities that may apply .Understands, continues to learn, and teaches others about new CMS [Centers for Medicare and Medicaid Services] program initiatives such as Quality Measures, Nursing Home Compare .Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff .and optimal resident functioning-physically and psychosocially .Identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or resolve issues .Makes written and oral reports/recommendations to the governing board concerning the operation of the facility .Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services . The facility's undated Director of Nursing (DON) job description, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. Interprets and communicates policies and procedures to nursing staff, and monitors staff practice and implementation .Participates in daily or weekly management team meetings to discuss census changes, resident changes in status, complaints or concerns. Evaluates work performance of all nursing personnel and implements discipline according to operational policies .Facilitates, serves, attends or participates in various committees of the facility as appointed. Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. Collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify and resolve issues and improve the quality of services. Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met. Performs rounds to observe residents and ensure nursing needs are being met. Conduct observations of nursing care and supervises development of in-service education to ensure nursing staff is competent in current knowledge and skills .Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns. Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action. Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process Review of the facility's Wandering/Elopement risk assessment tool revealed a scale with scores as follows: 0-8 indicates a low risk, 9-10 indicates at risk to wander, 11 and above indicates a high risk to wander. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Incident Report dated 2/20/2022, revealed .this nurse [Licensed Practical Nurse (LPN) #1] was on med [medication] pass on 600 hall .I heard door alarm sounding. Immediately I went to the exit door looked outside seen [saw] no one, then yelled to staff members to check all elopement risks .Resident [Resident #1] located at 420p [4:20 PM] sitting in a chair at pavilion outside 500 hall .one on one initiated with resident [Resident #1] .resident stated 'I don't want to be here' . Resident #1 had no injuries. Review of a nurse's SBAR (Situation, Background, Assessment, Recommendations) note dated 2/20/2022, revealed .one on one while resident awake . Review of the Interdisciplinary Team Event note dated 2/22/2022, revealed .Staff searched outside area and inside facility until resident was located safely. Staff sat 1:1 [one on one] with resident until the 11pm [11:00 PM] shift arrived and resident was in bed . During an interview on 4/18/2022 at 9:23 AM, when asked what the facility investigation had determined, the DON stated, [Named Resident #1] pushed the exit door on 600 Hall. The 15 second [delay] alarmed [15 second egress door opens and alarms after pushed for 15 seconds]. Staff started looking in rooms .sometime between 2:00 [PM] and 3:00 [PM] [the staff began looking for the resident at approximately 4:00 PM and located the resident at 4:20 PM according to the medical record and interviews] .she was not a wanderer .We figured out she went out the door and sat down at the pavilion. When asked how this was determined, the DON stated, We don't know, but the walkway goes to the pavilion. We assume that she went down the walkway to the pavilion .She was sitting under the pavilion . During an interview on 4/18/2022 at 12:43 PM, when asked what residents have a Wanderguard implemented as stated in the facility policy, the Administrator stated, We do not have a Wanderguard system. I was not aware of it. Hadn't read that. Observation on the 500 Hall on 4/18/2022 at 2:09 PM, the surveyor held the exit door 15 second egress bar to disarm the locked door. The door alarm sounded after the 15 seconds. Registered Nurse (RN) #1 was in a resident's room at the end of the 500 hall and revealed no response to the alarming exit door as the RN walked away from the area toward the 500 hall Nurses' Station. Three staff in the hallway were walking away toward the 500 Hall Nurses' Station. Observation on 4/18/2022 at 2:32 PM, revealed the 100 Hall and 600 Hall had the same door chime tone on the interior doors. The 600 Hall door chime was heard at the interior exit door and 1/2 way up the hall. The 600 Hall and 500 Hall interior door chimes were not heard at the Nurse's Station. The 300 Hall and 400 Hall interior doors had no door chime as on the other halls. During an interview on 4/18/2022 at 3:00 PM, the Maintenance Director stated, .yes, 600 and 100 door chime is the same .600 Hall can hear the chime at the interior door area and halfway up the hall. When everyone is in the hall and at the Nurses' Station or in a resident's room the chime would be hard to hear .500 Hall interior door only sounds at the interior door and not loud .300 and 400 Halls do not have door chimes on the interior doors .I don't know why they don't have chimes . When asked if a resident could exit the 300 and 400 Hall interior doors just as easy as 500 and 600 interior doors, he stated, .yes they could . During a telephone interview on 4/19/2022 at 10:51 AM, Certified Nursing Assistant (CNA) #1 stated, I found [Named Resident #1] sitting outside in a chair. She walked to the rocks at the left by the window and there was a chair in the rocks. She was playing with a sign .One of my nurses came and asked me if I had seen her [Resident #1] . When asked if a Code Silver had been called on the intercom, CNA #1 stated, No, I was at 300/400 Hall desk. I didn't know of Code Silver until all clear was called . During an interview on 4/19/2022 beginning at 2:12 PM, when asked what interventions were implemented after the elopement incident, the DON stated, To make sure residents are not congregated at the dining room after meals and activities. Do not leave her [Resident #1] in dining room after meals .Door chimes to alert staff, especially at night as an added layer . When asked if staff compliance for the intervention was documented/audited, the DON stated, It's not. We don't have documentation on that . During an interview on 4/19/2022 beginning at 2:12 PM, when asked what interventions were implemented after the elopement incident, the Administrator stated, 600 Hall chime was there, and we adjusted the tone from one to more tone. They [staff] should look toward the door, even if they [staff] can't go to the door .We still have to look at it because just like the exterior door, expect them to check it. We don't have Wanderguards. When asked the reason there were no door chimes on the 300/400 Hall interior doors the Administrator stated, I don't know. When asked about the 500 Hall door chimes the Administrator stated, I don't know that there is one. I can't say if responding to chimes but can say they [staff] respond to door alarms. During an interview on 4/20/2022 at 10:20 AM, when asked if she was working at the time Resident #1 exited the building unsupervised, LPN #1 stated, I work 7 [7:00 AM] to 7 [7:00 PM]. Door alarm was sounding .I didn't hear the doorbells. Can't hear them [doorbells/chimes] in rooms. Brought her inside at 4:20 PM. I know because I looked at the clock as they came in the door .I know it was approximately 4:00 PM when the door alarmed . When asked what interventions were implemented to prevent Resident #1 or any other resident from exiting the building unsupervised, LPN #1 stated, Not allowed to leave anyone in the dining room after activities unattended . Based on the facility's investigation, documentation, staff interviews and interview with the DON, there was a discrepancy in facts stated by staff, written statements by staff, and documentation in the medical record of the events of the elopement when compared to the DON's interview and report to the State agency. Review of the facility's Wandering/Elopement risk assessment tool dated 1/27/2022 revealed Resident #2 scored 12 which indicated high risk to wander. Observation on 4/18/2022 at 1:32 PM, revealed Resident #2 was walking independently up and down the 600 Hall, went to the 100 Hall, then back to the 600 Hall. Observation at the breezeway of 300/400 Hall leading to the Courtyard on 4/18/2022 at 2:26 PM, revealed Resident #2 pushed the exit door with an attempt to open the door. Review of Resident #5, #6, and #11's Wander Risk Assessment tool revealed the following: Resident #5 with a wandering/elopement risk score of 11 (high risk), #6 with a wandering/elopement risk score of 12 (high risk) and #11 with a wandering/elopement risk score of 9 (at risk to wander). Review of the facility's five Code Silver binders (Code Silver book) on 4/18/2022, revealed Residents #5, #6, and #11 did not have a face sheet with a picture in the book as stated in the facility policy titled Elopements and Wandering Residents. During an interview on 4/18/2022 at 12:43 PM, when asked if the facility had a list of residents that had wandering or exit seeking behaviors, the DON stated Code Silver book at each Nurses' Station. The Social Worker keeps it updated by the scores. When asked what the scores were, the DON stated 0-8 is low, 9-10 at risk to wander, 11 and higher is high risk to wander . During an interview on 4/18/2022 at 3:40 PM, when asked how would staff know which residents were at risk of wandering/elopement, CNA #3 stated, .They haven't told me who the residents are that might elope . When asked if there was a book with a list of residents that were at risk to wander/elope, CNA #3 stated, No, we are still going over that. During an interview on 4/18/2022 at 3:43 PM, when asked how would staff know which residents were at risk of wandering/elopement and if there was a list of residents, Housekeeper #1 stated, I don't know. I haven't been told about a list. During an interview on 4/18/2022 at 4:17 PM, CNA #2 was asked would staff know which residents were at risk for wandering and/or elopement. She stated, .I find out in report if anyone has tried to get out or has fallen . When asked is there any other way she could find out, she stated, .No . The surveyors verified the Removal Plan by: 1. The facility did complete an investigation on 2/20/2022 with staff statements and timeline. 2. Education began 4/20/2022 to the Administrator, DON and ADON by the Regional Director of Clinical Services regarding using administrative resources effectively. The surveyors reviewed the in-service sign in sheets and interviewed Administration. 3. Incident/Accident reports will be reviewed in the Morning Clinical Meeting by the Interdisciplinary Team. The team will review that those investigations are completed for those incidents/accidents requiring investigations. The team will review that interventions are put into place at the time of the incident to prevent further incidents/accidents and that interventions are care planned. The surveyors reviewed the Morning Clinical Meeting form and interviewed Administration. 4. The DON and/or ADON will monitor during the Morning Clinical Meeting that residents' Wandering/Elopement Risk evaluations are completed on admission, readmission and quarterly along with their behavior monitoring monitors on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the Morning Clinical Meeting form and interviewed staff. 5. Incidents requiring investigation will be tracked and reviewed that they are completed by the Regional Director of Clinical Services weekly. The Regional Director of Clinical Services will review the monthly QAPI documents for tracking, analysis and actions plans to prevent. The Regional Director of Clinical Services will attend QAPI meetings quarterly and will make an onsite monthly visit to oversee administrative duties and QAPI. The surveyors reviewed the audit forms and interviewed Administration. 6. The Administrator will report findings to the monthly QAPI Committee meeting. The surveyors reviewed the audit forms and interviewed Administration. Noncompliance of F-835 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, Quality Assurance Performance Improvement (QAPI) minutes, observation, and interview, the QAPI committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to wandering and elopement behaviors. The QAPI committee failed to ensure a thorough investigation of a resident elopement was completed, failed to identify quality deficiencies and effective interventions and monitoring the effectiveness of interventions and staff knowledge of care of residents with wandering elopement behaviors in order to identify deviations and adverse events when a resident exited the facility without staff knowledge, and failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 11 sampled residents (Resident #1) reviewed for wandering/elopement behavior. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The staff were unaware the resident was missing from the facility and the resident was outside unsupervised for approximately 20 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-867 on 4/20/2022 at 10:42 AM, in the Employee Breakroom. The facility was cited Immediate Jeopardy (IJ) at F-600, F-610, F-689, F-835, and F-867. The facility was cited an Immediate Jeopardy at F-600, F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey on 10/8/2020. The Immediate Jeopardy existed from 2/20/2022 through 4/20/2022. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on 4/21/2022 at 10:37 AM, and was validated onsite by the surveyors on 4/21/2022 through review of in-service sign in sheets, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled Quality Assurance Performance Improvement Monitoring, revealed .It is the policy of this facility to systematically monitor performance indicators as part of the QAPI program. 'Performance Indicator' is an indicator that enables staff to assess progress towards the achievement of intended outputs, outcomes, goals and objectives. 'Adverse events' is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. The facility's QAA [Quality Assessment and Assurance] Committee analyzes data collected through planned and routine data collection activities. Performance indicators are established based on data analysis and monitored/evaluated in the QAA Committee meetings, which take place on a monthly basis and as needed .Medical errors and adverse events will be tracked. Residents will be monitored for medical errors and adverse events in accordance with established procedures for the type of adverse event. An investigation will be conducted on each identified medical error or adverse event to analyze causes. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education . The facility's undated policy titled QAPI Change Process, revealed .The facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained .QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QA is the specification of (1) standards for quality of care, service and outcomes, and (2) systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards. PI is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement .The facility has in operation a Quality Assessment and Assurance (QAA) Committee that is responsible for coordinating and evaluating activities under the facility's QAPI program. The QAA Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action, and performance tracking. Data analysis - The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. This data is reported to the QAA committee. The QAA committee analyzes the data in order to identify or better understand a problem. Once a potential problem is identified, the committee utilizes the Five Whys Method (specify one or more methods) to help identify the root cause of the problem. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes. Corrective action - Once the root cause of a problem is identified, the QAA committee develops appropriate corrective actions plans. Appropriate means the actions address the underlying cause of the issue comprehensively, at the systems level. Corrective action plans include A definition of the problem or opportunity for improvement. Measurable goals or targets. Step-by-step interventions to correct the problem and achieve established goals. A description of how the QAA committee will monitor to ensure changes yield the expected results .The QAA committee uses the Plan, Do, Study, Act (PDSA) cycle of improvement for testing any changes. Plan: developing a plan related to the change that will be tested . Do: carrying out the plan. Study: observing and analyzing data collected, learning from any consequences. Act: making a decision regarding the change, such as to adopt, modify, or abandon the change and start over. Multiple PDSA cycles may be implemented until the desired performance goals have been met. Performance Tracking - Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained . Review of the facility's undated policy titled, Administration of Facility, revealed, .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident . Review of the facility's undated Administrator job description, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions related to the facility's outcomes, regulatory compliance and/or customer satisfaction .Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc .Knows and understands general nursing practices and procedures, OBRA[Omnibus Budget Reconciliation Act] regulations, Code of Federal Regulations, Appendix PP State Operations Manual .and all regulatory entities that may apply .Understands, continues to learn, and teaches others about new CMS [Centers for Medicare and Medicaid Services] program initiatives such as Quality Measures, Nursing Home Compare .Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff .and optimal resident functioning-physically and psychosocially .Identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or resolve issues .Makes written and oral reports/recommendations to the governing board concerning the operation of the facility .Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services . The facility's undated Director of Nursing (DON) job description, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. Interprets and communicates policies and procedures to nursing staff, and monitors staff practice and implementation .Participates in daily or weekly management team meetings to discuss census changes, resident changes in status, complaints or concerns. Evaluates work performance of all nursing personnel and implements discipline according to operational policies. Participate in QAPI or facility assessment activities as needed, such as carrying out duties assigned as part of a performance improvement committee. Facilitates, serves, attends or participates in various committees of the facility as appointed. Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. Collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify and resolve issues and improve the quality of services. Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met. Performs rounds to observe residents and ensure nursing needs are being met. Conduct observations of nursing care and supervises development of in-service education to ensure nursing staff is competent in current knowledge and skills .Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns. Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action. Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process The facility's undated Registered Nurse (RN) Unit Manager job description, revealed .Plans, develops, organizes, implements, and directs nursing services for residents on the unit assigned. Ensure compliance with current applicable federal, state and local regulations and facility policies and procedures .Assists in the development of written preliminary and comprehensive assessments of the nursing needs of each resident .Review nurses' notes to ensure they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes .Establishes a culture of compliance by adhering to all facility policies and procedures, complies with standards of business conduct, and state/federal regulations and guidelines. Follows appropriate safety and hygiene measures at all times to protect residents and themselves .Participates in QAPI or facility assessment activities as needed, such as carrying out duties assigned as part of a performance improvement committee . Review of the QAPI minutes dated 3/26/2022, revealed .On February 20th, a pt [patient] got outside and one on one provided . Observation on the 500 Hall on 4/18/2022 at 2:09 PM, the surveyor held the exit door 15 second egress bar to disarm the locked door. The door alarm sounded after the 15 seconds. Observation of Registered Nurse (RN) #1 in the room at the end of the 500 Hall revealed no response to the alarming exit door as RN #1 walked away from the area toward the 500 Hall Nurses' Station. Three staff in the hallway were walking away toward the 500 Hall Nurses' Station. At approximately 2:12 PM, the Minimum Data Set (MDS) nurse responded to the alarming door. During an interview on 4/19/2022 at 2:12 PM, when asked what interventions were implemented after the elopement incident, the DON stated, To make sure residents are not congregated at the dining room after meals and activities. Do not leave her [Resident #1] in dining room after meals .Door chimes to alert staff, especially at night as an added layer . When asked if staff compliance for the intervention was documented/audited, the DON stated, It's not. We don't have documentation on that . During an interview on 4/19/2022 at 2:12 PM, the Assistant Director of Nursing (ADON) confirmed there was no other documentation in the 3/2022 QAPI meeting minutes concerning the elopement of Resident #1 on 2/20/2022. She stated, .No ma'am . The ADON confirmed there was no documentation of data collection, or a root cause analysis completed to identify or better understand the problem as stated in their QAPI policies. She was asked if an action plan was put into effect and monitored to assess its effectiveness related to the elopement of a resident. She stated, .No ma'am .we did not do a root cause analysis and have not monitored to see if any intervention was put in place and was effective and if staff is complying . Refer to F-600, F-610, F-689 and F-835. The surveyors verified the Removal Plan by: 1. The facility did hold an Ad Hoc QAPI meeting on 2/20/2022 to discuss the incident/accident and plans to correct. 2. Education began 4/20/2022 to the Administrator, DON and ADON by the Regional Director of Clinical Services regarding QAPI process for tracking and trending for QAPI. The surveyors reviewed the in-service sign in sheets and interviewed Administration. 3. Incident analysis will be reviewed and analyzed monthly by the DON or ADON and report trends to the QAPI Committee monthly. When there are reportable events and trends in incidents/accidents, the QAPI will review that there are action plans developed to prevent reoccurrence. The surveyors reviewed the audit form and interviewed Administration. 4. Incidents requiring investigation will be tracked and reviewed that they are completed by the Regional Director of Clinical Services weekly. The Regional Director of Clinical Services will review the monthly QAPI documents for tracking, analysis, and actions plans to prevent. The Regional Director of Clinical Services will attend QAPI meetings quarterly and will make an onsite monthly visit to oversee administrative duties and QAPI. The surveyors reviewed the audit forms and interviewed Administration. 5. The DON or ADON will report tracking and trending to the QAPI Committee monthly and develop plans of action as needed for submission to the QAPI Committee. The surveyors reviewed the audit forms and interviewed Administration. Noncompliance of F-867 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the safety of 1 of 5 sampled residents (Resident #1) reviewed for wandering/elopement. The facility's failure resulted in Immediate Jeopardy when Resident #1 was observed by a staff member off the facility property, unsupervised, approximately 0.1 mile from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Nurse Consultant (RNC), and Regional Director of Operations (RDO) were notified of the Immediate Jeopardy on 10/8/2020 at 3:04 PM, in the Break Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/25/2020 through 9/28/2020. The facility's corrective action plan, which removed the immediacy of the jeopardy at F-689 J, was received and corrective actions were validated onsite by the surveyors on 10/1/2020 through 10/8/2020. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Accident-Incident-Elopement - Wandering Resident, showed, .Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .The resident's care plan will be modified to indicate the resident is at risk for wandering/elopement episodes .Interventions into wandering/elopement episodes will be entered onto the resident's care plan and medical record . Review of the closed medical record, showed Resident #1 was admitted to the facility on [DATE] with diagnoses of Metabolic [CONDITION(S)], [CONDITION(S)], Hypertension, [MEDICATION(S)] Dependence, Convulsions, Unsteadiness on Feet, and Pain. Resident #1 was discharged to another Long-Term Care facility on 9/26/2020. Review of the Wandering/Elopement assessment dated [DATE], showed Resident #1 wandered within the facility and scored a 10 on the assessment, which indicated Resident #1 was at risk to wander. Review of the Admission Fall Scale and the Physical Therapy Evaluation Notes dated 9/14/2020, showed Resident #1 was at moderate risk for falling, had poor safety awareness, visual impairment, and an unsteady gait. Review of the Baseline Care Plan dated 9/15/2020, showed, .9/15/2020: Resident out of building on bench .Monitor resident q [every] shift x [times] 3 days for exit seeking behaviors .Resident re-educated on allowing staff to assist with smoke break . Review of a Social Progress Note dated 9/16/2020, showed Resident #1 was not oriented to place and didn't know the correct month, day and year. Resident #1 was restless and fidgety at times. Resident #1 wandered about the hallway and on 9/15/2020 .got outside the facility but was assisted back . Review of the admission Minimum Data Set (MDS) dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9, which indicated moderate cognitive impairment and was unable to recall the correct year, month, and date. Resident #1 had visual impairment but had no corrective lenses. Resident #1 wandered daily, had an unsteady gait with mobility and required one-person physical assistance for walking but did not use an assistive device. Review of an Incident Note, Situation Background Assessment and Recommendation document dated 9/25/2020, showed, .reported to this nurse res [resident] was outside the facility and [Named Certified Nursing Assistant (CNA) #1] found res .Res was brought back into the facility, assessed, no issues noted VSS [Vital Signs Stable] .Res stated he was going to get some cigarettes and beer . Review of the Care Plan dated 9/25/2020, showed Resident #1 had an elopement from the facility on 9/25/2020. Interventions included, .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: milk in coffee as snack .one on one with CNA when available; placed on 15 min [minute] checks .Smoking schedule posted in resident's room . Review of the facility's investigation dated 9/25/2020-10/7/2020, showed that on 9/25/2020 at 8:45 PM, CNA #1 observed Resident #1 standing near a stop sign approximately 0.1 mile from the facility property. Resident #1 stated he was going over to the gas station to buy cigarettes and beer. Resident #1 could not recall how he exited the facility. The investigation showed Resident #1 may have followed a Dietary staff member out of the building or may have exited through the 100 Hall secured exit door. The 100 Hall was closed due to COVID-19 which would have made it difficult for staff to hear the alarm on the exit door. Review of a Social Progress Note dated 9/27/2020, showed, .SW [Social Worker] informed that pt [patient Resident #1] exited the facility on 9/25/20 [2020] and staff brought pt back into facility .RP [Responsible Party] was made aware and staff monitoring one on one .9/26/20 RP was made aware .alternative placement needed to be explored for pt safety. RP voiced understanding and okay with pt going to another facility .Pt was transported to [Named facility] with personal belongings on 9/26/20. RP was satisfied with arrangement for pt . During an interview on 10/1/2020 at 12:28 PM, the ADON stated, .Resident #1 had left the building [on 9/15/2020] before this incident [elopement on 9/25/2020]. The staff observed him as he exited through the secured doors and sat on the bench in the front of the building .it was witnessed by staff when he exited through the doors and the door alarm sounded .he was brought back in .therapy staff brought him back in . The ADON stated this incident was not reported to the State Survey Agency because it was a witnessed event. During an interview on 10/1/2020 at 1:05 PM, the ADON stated that when Resident #1 exited the facility and sat on a bench right outside the door on 9/15/2020, .staff saw him go to the door and before they could reach him he went out the door .I heard alarm sound .he was brought in . The ADON stated Resident #1 was reoriented to the facility, he was educated that staff should go with him outside, and every 15 minute checks were performed. During a telephone interview on 10/1/2020 at 3:25 PM, CNA #1, stated, .I went on break about 8:30 [PM] .and on [MEDICATION(S)] back to the facility, I was in the turning lane when I saw a person on my left side at the stop sign. He had a red hat on and that is how I recognized it was [Named Resident #1] .I stopped and asked him to come over to the car .I asked him where he was going .he said he was walking to the [Named] Gas Station to get cigarettes and beer .he was acting like he was not going to get in my car .he kept saying he would just walk .I called the facility and talked to [Named Licensed Practical Nurse (LPN) #1] .she told me to bring him back to facility .I finally got him in the car .I drove him back to the facility and LPN #1 met us at the front door . During an interview on 10/1/2020 at 3:35 PM, the DON stated, .when he [Resident #1] went out to the bench on the 15th [9/15/2020], staff saw him but couldn't get to him in time, he went out and sat on a bench .we monitored him for 3 days for behaviors, he had no other incidents . During a telephone interview on 10/2/2020 at 3:48 PM, LPN #1 confirmed her written statement and stated, .I saw him [Resident #1] at the beginning of the shift .gave his [Resident #1's] meds [medications] .he was sitting by the fish tank/TV [television] area .I went to the 500 Hall to pass medications .there was an announcement over head that I had a phone call .it was [Named CNA #1], she said she had him in the car .didn't know he was gone .the closer I got to the front that's when I heard the alarm at the end of 100 Hall going off .I reset the alarm .then went out to meet [Named CNA #1] to get [Named Resident #1] .he smoked a cigarette before he came in .I couldn't hear the alarm when I was on the 500 Hall because the doors are closed [the 100 Hall had been closed due to COVID-19] . Observation on 10/4/2020 at 8:00 PM of the area where Resident #1 was located on 9/25/2020 by CNA #1, showed the area to be next to a paved road with low cut grass, a drainage ditch with sloped embankments that was filled with large rocks on each side. The (Named) Gas Station was across the 3 lane highly traveled road and was 380 feet from the stop sign where he was found. The stop sign was approximately 25 feet from the 3 lane highly traveled road. During a telephone interview on 10/5/2020 at 9:49 AM, CNA #2, who was assigned the care of Resident #1 on 9/25/20, stated, .I seen [saw] him on the hall between 7:45-8:00 PM then I went to another hall .I did not know he had eloped until he was returned . During an interview on 10/5/2020 at 11:25 AM, the DON stated, .wanted to send him [Resident #1] to the ER [emergency room ] but the Responsible Party refused to allow him to go .we also discussed transferring him to another facility to monitor him for behaviors and the responsible party was agreeable to the transfer . During an interview on 10/5/2020 at 2:45 PM, the RNC stated, .the other facility can provide a better quality of life because of more frequent smoke breaks and 'happy hour' where alcohol is served .the family agreed to the transfer . The facility's corrective action plan included the following: 1. On 9/25/2020, the facility implemented the following: A. Registered Nurse (RN) Supervisor #1 notified the ADON, COO (Chief Operating Officer), and RNC of the elopement by telephone at approximately 9:35 PM on 9/25/2020. The surveyors confirmed this information through interviews with the ADON and RNC. B. RN Supervisor #1 completed an audit which included checking all doors to make sure they were secure, the door alarms were sounding, and ensuring alarms were functioning properly. The surveyors reviewed the documentation of the door audits and confirmed the door audits were completed through interview with RN Supervisor #1. A door audit was completed on 10/6/2020 by the surveyors with no issues related to the lock engagement or alarms identified. C. A head count of all residents was conducted and accounted for all residents. A new elopement assessment was completed on all residents and all at risk residents identified were updated in the Code Silver Book. The surveyors reviewed the new elopement assessments and interviewed staff. The surveyors reviewed the Code Silver Book to ensure all at risk residents were included. D. Inservice education was done for all staff on duty related to the Elopement policy/procedure, ensuring doors/locks were engaged, and staff were aware of residents that exited the facility. All staff were to be educated prior to reporting to duty. The sign in sheets and information provided to the staff were reviewed. The surveyors confirmed the information through interviews with multiple staff members across all shifts, RN Supervisor #1, the staff on leave, and the as needed staff. Multiple observations were made of staff entering and exiting the front entrance of facility and staff were noted to not walk away from the door until the lock engaged on the door. E. Signage was posted on all exit doors for staff to monitor the lock engagement of the door. The surveyors confirmed this through observation of the signage on exit doors. 2. On 9/28/2020, the facility implemented the following: A. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Maintenance Supervisor and Regional Director of Operations. The surveyors reviewed the QAPI meeting minutes. B. The Administrator and Maintenance staff completed a facility walk through for risks. The surveyors confirmed this through interview with the Administrator and the Maintenance Supervisor. C. A door chime was installed on the 100 Hall fire doors 9/28/2020 to alert staff when doors are open and prompt them to check the 100 Hall. This was confirmed through multiple observations onsite 10/1/2020-10/8/2020. Multiple staff interviews were conducted across all shifts and disciplines related to their responsibility to responding to the door chime sounding. D. Staff will be at the front entrance area at all times (to monitor the front entrance and the 100 Hall). The surveyors confirmed this through multiple staff interviews across all shifts related to their job responsibility regarding monitoring of the front entrance and the 100 Hall and what to do when the door chime sounded. E. Care plans were reviewed on all residents at risk for elopement. The surveyors confirmed this through record review and interview. F. All exit door codes were changed. The surveyors reviewed documentation of the code changes and interviewed the Maintenance Director. G. A list of smokers was placed at each nurse's station and staff in-services were completed related to the smoking policy. The surveyors reviewed the list of smokers and interviewed staff on all shifts. H. Elopement history was added to the Admission packet. The surveyors reviewed the Admission packet. I. Wiring of the exit door alarms allows the alarm to sound at all nurse station panels. This was confirmed through interview with the Maintenance Director by reviewing the purchase order for the wiring and supplies. The tentative completion date is 10/16/2020.