Every finding on record at Heritage Manor of Mandeville

Based on observation, interviews, and record review, the facility failed to ensure the services provided met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 1 (#8) of 2 (#8 and #81) residents reviewed for insulin administration.Review of the Novolog insulin pen manufacturer's insert revealed the following, in part:Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units.Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #8's current Physician Orders revealed the following, in part:Order date: 07/09/2025; Novolog Flex Pen 100 unit/mL, inject per sliding scale, subcutaneously before meals and at bedtime. Resident #8's Novolog Insulin sliding scale order was 10 units of insulin for a blood glucose level of 301 to 350 mg/dL. An observation was made on 09/22/2025 at 11:52 a.m. of S4LPN administering Resident #8's Novolog insulin. Resident #8's blood glucose level was 303 mg/dL. S4LPN applied the insulin pen needle, dialed up 10 units of insulin, and administered the insulin. S4LPN did not prime the insulin pen needle prior to administering the insulin. An interview was conducted on 09/22/2025 at 11:53 a.m. with S4LPN. S4LPN confirmed she did not prime the insulin pen needle prior to administering insulin to Resident #8. She stated priming the insulin pen needle was not needed prior to insulin administration. An interview was conducted on 09/23/2025 at 9:30 a.m. with S2DON. She was made aware of the above mentioned observation. She stated insulin pen needles should be primed per the insulin pen and pen needles manufacturer's guidelines.

Based on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic medication was completed for 1 (#65) of 5 (#3, #9, #14, #65 and #98) residents reviewed for unnecessary medications. Review of Resident #47's clinical record revealed resident was admitted to the facility on [DATE].Review of Resident #47's Plan of Care Task revealed the following:Start Date- 01/06/2025- Assist Resident with inserting hearing aids in the morning and removing at night to put on charger. Further review revealed Resident #47 was assisted with placement of hearing aids on 09/01/2025, 09/08/2025, 09/12/2025, 09/17/2025, 09/21/2025, 09/22/2025 and 09/23/2025. On 09/24//2025 at 12:32 p.m., an interview was conducted with S3LPN. She stated Resident #47 was hard of hearing and did not wear hearing aids. She verified on 09/08/2025, 09/12/2025, 09/17/2025 and 09/22/2025 she documented she assisted Resident #47 with her hearing aids, and she did not. She confirmed she should not have documented she completed a task when she did not. On 09/24//2025 at 4:45p.m., an interview was conducted with S9LPN. She stated Resident #47 was hard of hearing and she did not wear hearing aids. She verified on 09/01/2025, 09/21/2025 and 09/23/2025 she documented she assisted Resident #47 with her hearing aids, and she did not. She confirmed she should not have documented she completed a task when she did not.On 09/24/2025 at 11:21 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #47's Plan of Care Task log for assisting resident with hearing aids and confirmed the above dates mentioned had been documented as complete. She confirmed staff should not document a task completed if it was not.

Based on observation, interviews, and record review, the facility failed to ensure medications were properly stored in 1 (Med Cart 2) of 3 (Med Cart 2, Med Cart 3, and Med Cart 4) medication carts observed for medication storage.Review of the Humalog medication insert revealed in part, the following:Storage information:Opened: Total of 28 days.An observation was made on 09/22/2025 at 8:45 a.m. of Med Cart 2 with S3LPN. Observed 1 opened Humalog insulin pen for Resident #81, with a written opened date of 08/09/2025.An interview was conducted on 09/22/2025 at 8:46 a.m. with S3LPN. She confirmed the open date on Resident #81's Humalog insulin pen read 08/09/2025. She stated opened insulin pens should be discarded after 28 days. She confirmed Resident #81's Humalog insulin pen should have been discarded and was available for resident use.An interview was conducted on 09/22/2025 at 12:02 p.m. with S2DON. She stated nurses are responsible for ensuring all insulin pens in their medication carts are discarded 28 days after the open date. She stated Resident #81's Humalog insulin pen with an open date of 08/09/2025 should not have been available for resident use.

Based on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic medication was completed for 1 (#65) of 5 (#3, #9, #14, #65 and #98) residents reviewed for unnecessary medications.Review of Resident 65's current Physician Orders revealed orders the following: 8/25/25- Escitalopram Oxalate Tablet 20mg give 1 tablet via PEG-Tube one time a day09/20/2025-Buspirone HCL Tablet 7.5 mg give 1 tablet via PEG-Tube three times a day09/20/2025-Clonazeepam Tablet 0.5mg give 1 tablet via PEG-Tube two times a day09/22/2025-Depakote Sprinkles Capsule Delayed Release Sprinkle 125mg give 1 capsule via PEG-Tube two times a dayReview of Resident #65's current medication administration record revealed Resident #65 had received the above medications as ordered for 09/01/2025- 09/23/2025. Further review revealed there was no documentation for monitoring psychotropic medication side effects for Resident #65. On 09/23/2025 at 9:12 a.m., an interview was conducted with S8LPN. She stated Resident #65 took psychotropic medications. She reviewed the clinical chart for Resident #65 and confirmed she had not been monitoring and documenting Resident #65's psychotropic medication side effects.On 09/23/2025 at 4:02 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #65's clinical record and confirmed there was no documentation of monitoring for side effects of Resident #65's psychotropic medications and should have been.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#5) resident out of a total of 23 sampled residents. The facility failed to ensure Resident #5 was coded accurately for fall with major injury. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Muscle Weakness, Lack of Coordination, Abnormalities of Gait and Mobility.Review of Resident #5's Annual Minimum Data Set (MDS) dated [DATE] revealed Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), Section C: Major Injury - bone fractures, joint dislocations, close head injuries with altered consciousness, subdural hematoma was coded as 2. Two or more. Review of Resident #5's fall log and fall investigations from January 2025 to current revealed no falls resulting in major injury. An interview was conducted on 09/24/2025 at 1:26 p.m. with S5CNA. She stated Resident #5 has never had any falls with major injury. An interview was conducted on 09/24/2025 at 11:55 a.m. with S6LPN. She stated Resident#5 has never had any falls with major injury. An interview was conducted on 09/24/2025 at 3:51 p.m. with S7MDS. She reviewed the MDS dated [DATE] Section J1900, Section C and confirmed it was not accurate, and it should have been modified and resubmitted to accurately reflect Resident #5's fall history. An interview was conducted on 09/24/2025 at 3:59 p.m. with S2DON. She stated the MDS was inaccurate, and she expected the MDS staff to code correctly.

Based on interviews and record reviews, the facility failed to ensure resident's MDS assessments accurately reflected the resident's status for 5 (#17, #22, #26, #99, and #114) out of 31 residents reviewed in the final sample. The facility failed to ensure: 1. Resident #17 and Resident #22 were accurately coded for PASRR (Pre-admission Screening and Resident Review); 2. Resident #26 was not coded for anticoagulant use; 3. Resident #99 was coded correctly for Diabetic foot ulcers; and 4. Resident #114 was coded correctly for discharge. Findings: 1. Resident #17 Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder, Unspecified Psychosis, and Major Depressive Disorder, Single Episode Mild. Review of Resident #17's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 10/25/2023, revealed an approval for admission by the state Level II Authority for a temporary period effective 10/25/2023 through 10/23/2024. Review of Resident #17's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/2024 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Further review revealed section A1510: Serious Mental Illness was blank. Resident #22 Review of Resident #22's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Schizophrenia, Unspecified Dementia, Schizoaffective Disorder Bipolar Type, and Schizophreniform Disorder. Review of Resident #22's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 11/05/2013 revealed a permanent approval for admission by the state Level II Authority on 11/12/2013. Review of Resident #22's Annual MDS with an ARD of 09/09/2024 revealed Section A1500: Resident evaluated by PASRR was coded as 0. No. Further review revealed Section A1510: Serious Mental Illness was blank. On 10/08/2024 at 3:45 p.m., an interview was conducted with S5MDS. She verified Resident #17's Form 142 indicated Resident #17 was approved for admission by the state Level II Authority for a temporary period effective 10/25/2023 through 10/23/2024. She reviewed Resident #17's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 10/09/2024 at 8:50 a.m., an interview was conducted with S6MDS. She verified Form 142 indicated Resident #22 was approved for permanent Level II on 11/12/2013. She reviewed Resident #22 Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 10/09/2024 at 4:00 p.m., an interview was conducted with S4DON. She reviewed the aforementioned findings for Resident's #17 and #22. She confirmed the resident's Annual MDS assessments should have been coded correctly and were not. 2. Resident #26 Review of Resident #26's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #26's Quarterly MDS with an ARD of 06/20/2024 revealed Resident #26 was coded for anticoagulant use. Review of Resident #26's Physician Orders dated April 2024-October 2024 revealed no orders for anticoagulants. Review of Resident #26's MAR dated April 2024-October 2024 revealed the resident did not receive any anticoagulants. On 10/08/2024 at 3:40 p.m., an interview was conducted with S5MDS. She reviewed Resident #26's Quarterly MDS assessment with an ARD of 06/20/2024 then reviewed his MAR for that time. S5MDS confirmed Resident #26 was not taking anticoagulants at that time, and his 06/20/2024 MDS was coded for anticoagulant use and should not have been. On 10/08/2024 at 3:51 p.m., an interview was conducted with S4DON. She was notified of the aforementioned findings and confirmed Resident #26 should not have been coded for anticoagulant use. 3. Resident #99 Review of Resident #99's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Other Skin Ulcer. Review of Resident #99's Admission MDS with an ARD of 08/23/2024 revealed Section M0300. A. Number of Stage 1 Pressure Injuries- 1, Section M1040. B. Diabetic Foot Ulcer(s) - No, and M1200. I. Application of dressings to feet (with or without topical medications) - Yes. Review of Resident #99's Physician's Orders revealed the following in part: Diabetic ulcer to left posterior ankle: cleanse with wound cleanser, pat dry, apply silver antibacterial gel, apply non-adherent pad, apply black foam, apply no sting skin prep to periwound, secure transparent drape tape to form air tight seal, attach wound vac at 125mmHg and continuous setting every Monday and Friday and as needed until resolved. Start date: 08/19/2024. End date: 08/28/2024. Stage 1 Pressure Injury to Sacrum: cleanse with wound cleanser, apply barrier cream daily and as needed until resolved, every day shift and every 24 hours as needed. Start date: 08/19/2024. End date: 09/17/2024. On 10/09/2024 at 2:40 p.m., an interview was conducted with S5MDS. She reviewed Resident #99's wounds and confirmed Resident #99 had a Stage 1 Pressure Ulcer to her sacrum as well as a Diabetic foot ulcer to her left ankle. She reviewed Resident #99's Admission MDS with an ARD of 08/23/2024. S5MDS confirmed section M1040. B. Diabetic Foot ulcer(s) was coded no, and should have been coded yes since Resident #99 had a Diabetic Foot Ulcer. On 10/09/2024 at 3:45 p.m., an interview was conducted with S4DON. She reviewed Resident #99's wounds and confirmed Resident #99 had a Stage 1 Pressure Ulcer to her sacrum as well as a Diabetic foot ulcer. She reviewed Resident #99's Admission MDS with an ARD of 08/23/2024. S4DON confirmed section M1040. B. Diabetic Foot ulcer(s) was coded no and should have been coded yes since Resident #99 had a Diabetic Foot Ulcer. 4. Resident #114 Review of Resident #114's Clinical Record revealed she was admitted to the facility on [DATE] and was discharged on [DATE]. Review of Resident #114's Discharge MDS with an ARD of 07/31/2024 revealed Section A2105 Discharge Status: Short Term General Hospital. Review of Resident #114's Discharge Summary dated 07/31/2024 revealed the resident was discharged to home/community. On 10/08/2024 at 3:40 p.m., an interview was conducted with S5MDS. She stated she was responsible for the MDS Assessments. S5MDS verified Resident #114 was discharged to home with family. She reviewed Resident #114's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to the hospital, and should have been coded for discharged home with family. On 10/08/2024 at 3:51 p.m., an interview was conducted with S4DON. She verified Resident #114 was discharged home. She reviewed Resident #114's Discharge MDS and confirmed Section A2105 was coded for being discharged to the hospital and should have been coded for discharge to home. 47173 47191 49343

Based on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 2 (#27 and #101) of a total of 31 sampled residents reviewed for Resident Assessment. Findings: Resident #27 Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE]. On 10/07/2024, review of Resident #27's Quarterly MDS with an ARD of 09/03/2024 revealed the MDS assessment was incomplete and had a status of: In progress. On 10/08/2024, review of Resident #27's Quarterly MDS with an ARD of 09/03/2024 revealed a completion date of 10/08/2024, signed by S6MDS. Resident #101 Review of Resident #101's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #101 was discharged to the hospital on 09/07/2024 and returned to the facility on [DATE]. On 10/07/2024, review of Resident #101's Discharge MDS with an ARD of 09/07/2024 revealed it was incomplete and had a status of: In progress. On 10/08/2024, review of Resident #101's Discharge MDS with an ARD of 09/07/2024 revealed a completion date of 10/08/2024, signed by S5MDS. On 10/08/2024 at 3:40 p.m., an interview was conducted with S5MDS and S6MDS. They reviewed the above MDS assessments and confirmed they were not completed within the required 14 days after the ARD date, and had not been transmitted to CMS. On 10/08/2024 at 3:51 p.m., an interview was conducted with S4DON. She reviewed the above MDS assessments and confirmed they were not completed within the required 14 days after the ARD date, and had not been transmitted to CMS.

Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. Findings: On 10/07/2024 at 8:15 a.m., an interview was conducted with S12DM. S12DM stated she did not have a current food service management and safety certification. On 10/07/2024 at 3:30 p.m., an interview was conducted with S3ADM. S3ADM stated he or any other staff in the facility did not have a certificate or degree for food service or dietary management.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with accepted principles for 1 (Cart A) of 3 (Cart A, Cart B and Cart C) medication carts and 1(Medication Room A) of 1 medication room observed. The facility failed to ensure expired medications were not available for administration to residents. Findings: The following observations were made and verified by S8LPN on 10/08/2024 at 10:15 a.m. of Medication Room A: Two boxes of 5% Lidocaine Patches with an expiration date of July 2024. One box of 5% Lidocaine Patches with an expiration date of August 2024. The following observations were made and verified by S8LPN on 10/08/2024 at 11:00 p.m. of Medication Cart A: One box of 5% Lidocaine Patches with an expiration date of July 2024. On 10/08/2024 at 11:00 a.m. an interview was conducted with SS8LPN. SS8LPN stated she was responsible for checking the medication carts and the medication storage room monthly for expired medication. SS8LPN confirmed the above expired medications should have been discarded and not readily available for use. On 10/08/2024 at 11:40 a.m., an interview was conducted with S4DON. S4DON stated she was aware of the expired medication mentioned above. S4DON stated the medication carts and medication storage rooms were checked monthly for expired medications. S4DON confirmed the expired medications should not have been stored in the medication storage room or on Medication Cart A available for use.

Based on record review and interviews, the facility failed to ensure the resident's plan of care was revised when code status was changed from full code to Do Not Resuscitate (DNR) for 1 (#18) of 31 sampled residents reviewed for care plans. Findings: Review of Resident #18's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #18's care plan revealed the following, in part: Problem: Full code (09/22/2024). Intervention: Respect resident and family wishes. Review and update code status with resident and family as needed. Review of current physician orders for Resident #18 revealed the following, in part: Do Not Resuscitate (DNR). Order date-09/24/2024. An interview was conducted on 10/09/2024 at 8:15 a.m. with S5MDS. S5MDS stated the MDS (Minimum Data Set) nurses were responsible for revising resident care plans when there are changes in resident care. S5MDS stated the staff who completed the LaPOST (Louisiana Physician Orders for Scope of Treatment) document and had the resident/ responsible party sign the document were to notify the MDS nurse of the order change immediately, and did not. S5MDS reviewed Resident #18's current care plan and current physician orders, and confirmed the care plan should have been revised from full code to DNR and it was not. An interview was conducted on 10/09/2024 at 8:38 a.m. with S11SSD. S11SSD stated she completed Resident #18's LaPOST and had Resident #18's son sign the document. She confirmed she did not notify the MDS nurse of the code status change from full code to DNR. An interview was conducted on 10/09/2024 at 8:20 a.m. with S4DON. S4DON stated the process for a code status change was for the staff who had the LaPOST signed by the resident/responsible party to notify the MDS nurse immediately, and then the MDS nurse revised the resident's care plan. S4DON reviewed Resident #18's current care plan and current physician orders, and confirmed the care plan should have been revised from full code to DNR and it was not.

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for residents and staff. The facility failed to ensure the walk-in cooler was free from pooling water. The facility had 109 residents who received meals out of the kitchen. Findings: On 10/07/2024 08:15 a.m., an initial tour of the kitchen was conducted with S12DM. An observation was made of a large amount of cloudy water pooled in the corner of the walk in cooler with a large saturated towel, in attempt to soak up the water. At this time, an interview was conducted with S12DM. S12DM stated she was aware of the pooling water and she had notified maintenance last week. S12DM confirmed the pooled water was unsanitary, unsafe and should not be on the floor of the cooler. On 10/07/2024 at 03:35 p.m., an interview was conducted with S13MD. S13MD stated he was notified last week of the pooling water in the walk in cooler. He stated last week he attempted to reseal the weather strip but it was unsuccessful. On 10/08/2024 at 12:57 p.m., an interview was conducted with S2AADM. S2AADM stated he was made aware of the pooling water in the walk in cooler two weeks ago. He confirmed pooling water should not be in the walk in cooler and was.

Based on record reviews and interviews, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#48) of 5 (#17, #22, #30, #48 and #59) residents reviewed for PASARR. Findings: A review of Resident #48's medical record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #48 received a new diagnosis of Psychotic Disorder with Delusions due to Known Physiological Condition on 06/07/2024. A review of Resident #48's Level 1 Pre-Admission Screening and Resident Review dated 06/04/2024 revealed Resident #48's new diagnosis of Psychotic Disorder with Delusions due to Known Physiological Condition was not included. Further review revealed no documented evidence a review had been submitted for a Level II evaluation and determination. On 10/08/2024 at 2:15 p.m., an interview was conducted with S4DON. She confirmed Resident #48 was diagnosed with Psychotic Disorder with Delusions on 06/07/2024. She stated a review to the appropriate state-designated authority for a Level II PASARR evaluation and determination was not completed after Resident #48's newly diagnosed condition on 06/07/2024 and should have been. On 10/08/2024 at 2:29 p.m., an interview was conducted with S8LPN. She confirmed she was responsible for submitting reviews to the appropriate state-designated authority when a resident had a new qualifying mental illness. S8LPN confirmed on 06/07/2024 Resident #48 had a new diagnosis of Psychotic Disorder with Delusions due to Known Physiological Condition, but she did not submit a review to the appropriate state-designated authority for a Level II PASARR evaluation and determination and should have.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#57) of 6 (#57, #62, #65, #102, #108, and #315) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing peri-care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions revised on 03/2024, revealed the following, in part: For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Changing briefs or assisting with toileting Review of Resident #57's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #57's current Physician Orders revealed the following, in part: Start date 09/14/2024: Enhanced Barrier Precautions-gown and gloves to be worn during high contact resident care activities due to wound. An observation was made on 10/08/2024 at 1:00 p.m., of the Enhanced Barrier Precautions sign posted on Resident #57's door and above the head of her bed revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Changing briefs or assisting with toileting. An observation was made on 10/08/2024 at 1:07 p.m. of S9CNA providing peri-care to Resident #57. S9CNA did not wear a gown while changing Resident #57's brief and providing peri-care. An interview was conducted on 10/08/2024 at 1:25 p.m. with S9CNA. S9CNA verified Resident #57 was on EBPs due to the wounds on her legs. She confirmed she did not wear a gown when changing Resident #57's brief and should have. An interview was conducted on 10/09/2024 at 9:30 a.m. with S4DON. She was notified of the above observation on 10/08/2024. S4DON confirmed when a resident was on EBPs, staff should wear a gown while providing peri-care and changing briefs.

Based on interviews and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies for 2 (#27 and #101) of a total of 31 sampled residents reviewed for Resident Assessment. Findings: Review of the facility's Correction Action Plan dated 07/01/2024 revealed the following, in part: 1. Problem identified: Multiple MDSs are not being completed timely. Projected Completion Date: 10/01/2024. 2. Plan of action: Immediate action: approval to hire another assessment nurse for office; reviewed open MDS with Case Manager, educated on competing MDSs timely; Opened MDSs that are overdue to be completed. Audit of: opened MDSs that are overdue to be completed. In-service Provided: completing documentation per policy. Other: discussed the impact on the MDS office since starting central admission with ID team. 3. Monitoring (who, what, when): DON/CM/designee will monitor for timely completion of MDS'. DON/CM will continue to obtain education on completing MDS' correctly in the new system. 4. Follow-up for effectiveness: Current plan of action effective: No If no, new plan or action: 126 late MDS' completed. System created to prevent additional late MDS' and attempting to minimize the problem. Reached out to PRN and other facilities' assessment nurses to help. Review of QAPI Root Cause Analysis (RCA) for MDS Timeliness Correction dated 07/01/2024 revealed the following: Concern: MDSs are not being completed timely per CMS's guidelines. Why? Increased number of MDS's required d/t increased number of admits and discharged . Why? Facility attempting to increase census to a higher level as instructed per corporate and running a high re-hospitalization rate. Root Causes: 1. Influx in the number of MDSs required. 2. High number of resident's being re-hospitalized . Possible solutions to concern based on Root Cause Analysis: 1. Increased staff (hired and trained new MDS nurse). 2. Increased hours devoted to completing MDS'. Review of the QA Tool revealed there were 42 resident's MDS assessments late upon surveyor entrance to facility. Resident #27 Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE]. On 10/07/2024, review of Resident #27's Quarterly MDS with an ARD of 09/03/2024 revealed the MDS assessment was incomplete and had a status of: In progress. Resident #101 Review of Resident #101's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #101 was discharged to the hospital on 09/07/2024 and returned to the facility on [DATE]. On 10/07/2024, review of Resident #101's Discharge MDS with an ARD of 09/07/2024 revealed it was incomplete and had a status of: In progress. On 10/08/2024 at 3:40 p.m., an interview was conducted with S5MDS. She reviewed and confirmed the Quarterly MDS with ARD of 09/03/2024 was not completed in the required 14 day timeframe. On 10/09/2024 at 3:20 p.m., an interview was conducted with S4DON. She stated the facility had an increase in admissions and re-hospitalization s. She stated the MDS staff could not keep up with completing and transmitting the MDS assessments. She verified there was a current QA open pertaining to the MDS assessments being completed timely and the QA completion date was 10/01/2024. She stated she was not able to close the QA on the projected date of 10/01/2024 due to the ongoing issue of MDS assessments not being completed timely. She confirmed the QA was not effective. On 10/09/2024 at 4:01 p.m., an interview was conducted with S4DON. She stated there was an open QA with audit tools for MDS assessments completion. S4DON confirmed they did not address the issues with the audit tools for MDS assessments completion and their QA was not effective.

Based on record review and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#69) of 1 (#69) sampled residents reviewed for compression stockings. Findings: Review of Resident #69's Clinical Record revealed Resident #69 was admitted to the facility on [DATE] with a diagnosis of Hypertension and Edema. Review of Resident #69's current Physician Orders revealed the following, in part: Apply compression stockings in the morning and remove at bedtime. Start date: 07/01/2024. Review of Resident #69's MAR dated October 2024 revealed S7LPN documented Resident #69 was wearing compression stockings on 10/08/2024 and 10/09/2024. On 10/08/2024 at 9:54 a.m., an observation was made of Resident #69. No compression stockings were observed to her bilateral lower extremities. On 10/08/2024 at 11:05 a.m., an observation was made of Resident #69. No compression stockings were observed to her bilateral lower extremities. On 10/08/2024 at 1:25 p.m., an observation was made of Resident #69. No compression stockings were observed to her bilateral lower extremities. On 10/09/2024 at 9:20 a.m., an observation was made of Resident #69. No compression stockings were observed to her bilateral lower extremities. On 10/09/2024 at 1:10 p.m., an observation was made of Resident #69. No compression stockings were observed to her bilateral lower extremities. On 10/09/2024 at 1:20 p.m., an interview was conducted with S7LPN. She stated Resident #69 had an order for compression stockings to be applied every morning. She was notified of the observations of Resident #69 not wearing the compression stockings on 10/08/2024 and 10/09/2024. She stated Resident #69 frequently refused for staff to apply the compression stockings to her bilateral lower extremities. She reviewed the resident's MAR and confirmed the MAR reflected the resident was wearing the compression stockings on 10/08/2024 and 10/09/2024. She stated when the resident refused to wear the compression stockings, she should have documented the refusal on the MAR. She confirmed the resident's MAR should not have reflected the resident was wearing compression stockings if she wasn't. On 10/09/2024 at 3:29 p.m., an interview was conducted with S4DON. She was made aware of the above observations. She stated Resident #69 often refused to wear her compression stockings. She stated it was the nurse's responsibility to ensure the compression stockings were in place and to document it on the MAR. She stated if the resident refused to wear the compression stockings, the nurse should chart the refusal on the MAR. She reviewed Resident #69's MAR and confirmed the compression stockings were documented as being on the resident, and not as being refused by the resident. She confirmed when Resident #69 refused to wear the compression stockings, a refusal should have been documented on the MAR and was not.

Based on observations, interviews and record reviews, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to: 1. Maintain documentation of daily temperature and chemical sanitation checks for the dishwasher; and 2. Maintain documentation of freezer and refrigerator temperatures checks. This deficient practice had the potential to affect 109 residents who were served meals from the facility's kitchen. Findings: Review of the Daily Department Temperature & Chemical Monitoring Log revealed the following: 10/01/2024- No opening and midday temperature checks documented for the Walk-in Refrigerator, Other Refrigerator 1-3 or the Walk-in Freezer. No daily wash/rinse cycle temperatures and chemical sanitation checks documented for the dish machine. 10/03/2024- No daily wash/rinse cycle temperatures and chemical sanitation checks documented for the dish machine. 10/04/2024- No opening and midday temperature checks documented for the Walk-in Refrigerator, Other Refrigerator 1-3 or the Walk-in Freezer. No daily wash/rinse cycle temperatures and chemical sanitation checks documented for the dish machine. 10/05/2024- No opening and midday temperature checks documented for the Walk-in Refrigerator, Other Refrigerator 1-3 or the Walk-in Freezer. No daily wash/rinse cycle temperatures and chemical sanitation checks documented for the dish machine. 10/06/2024- No opening and midday temperature checks documented for the Walk in Refrigerator, Other Refrigerator 1-3 or the Walk-in Freezer. No daily wash/rinse cycle temperatures and chemical sanitation checks documented for the dish machine. On 10/07/2024 at 8:15 a.m., an interview was conducted with S12DM. S12DM confirmed the above mentioned refrigerator/freezer/dish machine temperature checks and chemical sanitation checks had not been completed and recorded and should have been. On 10/07/2024 at 4:00 p.m., an interview was conducted with S3ADM. S3ADM was made aware of the above mentioned incomplete temperature checks and incomplete chemical sanitation checks. He confirmed refrigerator/freezer/dish machine temperature checks and chemical sanitation checks should be recorded.

Based on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly labeled and dated; and 2. Food was not expired. There were a total of 103 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of Facility's Policy titled Storage of Refrigerated Food revealed the following, in part: Procedure: 5. All non-hazardous opened foods are labeled with name of food, date stored. 11. Food shall be stored base on use-by expiration date and facility recommended food storage chart. 1. On [DATE] at 9:15 a.m., a tour of the facility's kitchen was conducted with S6DM. The following observations were made in the facility's refrigerator: -2 turkey and cheese sandwiches not labeled or dated; and -3 ham and cheese sandwiches not labeled or dated. An interview was conducted on [DATE] at 9:20 a.m. with S6DM. She verified the above observations and confirmed the facility failed to store food properly. She confirmed she would expect all food products to be dated and they were not. 2. On [DATE] at 9:45 a.m., an observation was made of the nursing station's unit refrigerator which contained two cartons of no sugar added high calorie, high protein, vanilla flavored nutritional drinks with an expiration date of [DATE]. An interview was conducted on [DATE] at 9:45 a.m. with S8LPN. She confirmed the nursing station's unit refrigerator was for residents' food storage and available for consumption. She verified the above observation and confirmed there should not be any expired beverages ready for resident consumption in the unit refrigerator.

49343 Based on record review and interviews, the facility failed to ensure alleged violations of physical abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to other officials in accordance with State law for 2 (Resident #2 and #3) of 4 (Resident #1, #2, #3 and #4) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse/Crime Reporting revealed the following, in part Policy dated 07/2011: The law stipulates that staff members who witness suspicious activity that could result in serious bodily injury shall report that suspicion immediately but not later than two (2) hours after forming the suspicion. The staff must report the suspicion of an incident to the facility Administrator within the appropriate time frames. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of the Incident Report submitted to the state survey agency dated 02/14/2024 at 2:48 p.m., for Resident #2 revealed the following, in part: Incident Occurred: blank Incident Discovered: 02/14/2024 at 2:00 p.m. Incident Reported/Entered: 02/14/2024 at 2:48 p.m. Description of Incident: S1ADM met with S9CNA at 1:50pm on 02/14/2024 to discuss an incident that allegedly occurred on 02/11/2024. S9CNA stated that another CNA, S10CNA was rough with a resident during care Sunday night when she (S9CNA) was assisting her with a resident. S9CNA reported that S10CNA was assisting with ADL's and appeared frustrated and pulled on the residents' arms to try and transfer her. On 03/06/2024 at 1:10 p.m., an interview was conducted with S9CNA. S9CNA stated on 02/11/2024, she observed S10CNA assisting Resident #2 with ADL's and she appeared frustrated and pulled on the residents' arms to try and transfer her. She stated Resident #2 was resisting, so S10CNA let her go and Resident #2 sat back in her chair. S9CNA stated S10CNA walked out of the room, then returned to the room, pulled Resident #2's pants down while resident was yelling no. S9CNA stated S10CNA then grabbed Resident #2 by her wrist, put them against the resident's chest aggressively, put her in bed, and changed Resident #2 while she was resisting. She stated she sent an email on 02/14/2024 to the DON and S1ADM to report the incident. She stated she should have reported the incident of abuse immediately after it occurred to the supervisor and the administrator, and did not. Resident #3 Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Grievance report dated 02/18/2024 revealed, in part: Resident #3's daughter made a complaint. S1ADM registered the complaint. Explanation/Nature of Complaint: Resident #3's daughter stated a resident was fussing with S12CNA, the resident reported to her S12CNA was handling Resident #3 roughly, and Resident #3 was grabbed by the shoulders and shaken by S12CNA. The resident told Resident #3's daughter she was yelling out, crying, and her arms were flailing. The resident also told Resident #3's daughter S12CNA was pushing resident's arms down. Review of February 2024 Nurse's Note revealed no notes were documented pertaining to the grievance dated 02/18/2024. On 03/06/2024 at 2:25 p.m., an interview was conducted with S1ADM. She stated she was responsible for submitting allegations of abuse to the state survey agency. She stated on 02/14/2024, S9CNA reported observations of S10CNA grab Resident #2 by her arms aggressively to transfer her into her bed and change her against her will on 02/11/2024. She stated this was a form of physical abuse and should have been reported immediately, and was not. S1ADM stated it was also physical abuse when S12CNA grabbed and shook Resident #3. She stated both incidents should have been reported immediately, and were not.

Based on observations and interviews, the facility failed to ensure food was palatable to residents in taste and consistency for 4 (#R6, #R7, #R8, and #R9) of 8 (#1, #2,#3,#4,#R6, #R7, #R8, and #R9) residents reviewed for food. There were 103 residents that were served food from the kitchen. Findings: Review of Grievance Report dated 02/14/2024 revealed Resident #R7 complained the lunch was terrible and that he couldn't eat it. An observation of a regular diet test tray, on 03/06/2024 at 12:10 p.m., revealed the meal did not look or smell appetizing. The tray contained a thin light brown slab of meat with a small amount of clear sauce on top, a small bowl with brown lima beans in a clear liquid on a plate, and a bowl of clear cabbage in brown liquid. Two surveyors tasted the food and found the meat was tough to cut and dry with no taste and the cabbage and lima beans were bland with little no flavor. An interview was conducted on 03/06/2024 at 12:30 p.m. with Resident #R6. He stated he was not happy with his lunch because the meat didn't taste good. Observation was made on 03/06/2024 at 12:45 p.m. of Resident #R7's tray with 60% of his meal left on the plate. An interview was conducted on 03/06/2024 at 12:45 p.m. with Resident #R7. He stated his lunch did not taste good. He stated he was done eating. An interview was conducted on 03/06/2024 at 12:55 p.m. with Resident #R8. He stated the meat was not edible and hard to cut. He stated he was not satisfied with his lunch today. An interview was conducted on 03/06/2024 at 12:58 p.m. with Resident #R9. He stated the lunch was not good. He stated beans had no taste and the meat was tough with no taste. An interview was conducted on 03/06/2024 at 3:32 p.m. with S5CNA. She stated the residents complained often that the food was not good. An interview was conducted on 03/07/2024 at 12:30 p.m. with S6DM. She stated she had conducted resident interviews recently and some residents stated they did not like the food. An interview was conducted on 03/07/2024 at 1:00 p.m. with S1ADM. She stated she has received complaints about food from staff saying the food is not good.

Based on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 2 (#2 and #3) of 8 ( #2, #3, #4, R1, R2, R3, R4, and R5) residents reviewed for incontinent care. Finding: Review of the facility's policy labeled, Hand Hygiene with a revision date of 01/2024 revealed the following: Procedure: Indications for Hand Washing 2. Hand hygiene should be performed between all contacts with residents or when entering and exiting a resident's room. 4. Before and after applying gloves. 5. When hands are visibly soiled. 9. Wearing gloves does not replace the need to perform hand hygiene. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. On 03/07/2024 at 11:14 a.m., an observation was made of S11CNA performing peri-care on Resident #3. With clean gloves, S11CNA assisted Resident #3 to stand up. While Resident #3 was standing, S11CNA pulled down Resident #3's pants, removed the stool soiled brief, and threw it in the garbage. The CNA proceeded to wipe the stool off Resident #3's buttocks with wipes. S11CNA disposed of the soiled wipes in the garbage, then touched her N95 mask to adjust it. S11CNA applied a clean brief to Resident #3 and pulled up her pants. S11CNA assisted Resident #3 back into her wheelchair. S11CNA was not observed to perform hand hygiene during the above observation. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. On 03/07/2024 at 11:19 a.m., an observation was made of S11CNA performing peri-care on Resident #2. With clean gloves, S11CNA removed Resident #2's urine soiled brief, wiped the perineal area and sacrum, and disposed of the soiled brief and wipes in the garbage. S11CNA then touched her N95 mask, picked up a clean brief, and set it on the bed. S11CNA removed her soiled gloves and applied a clean pair of gloves. She then began to apply the same brief she touched with the soiled gloves. S11CNA covered Resident #2 with covers and elevated the head of the bed with the bed control. S11CNA then removed her gloves and disposed of them in the garbage. Without performing hand hygiene, S11CNA touched the door knob to exit the room and retrieved more gloves. The CNA reentered Resident #2's room, applied new gloves, removed the garbage bag from the room and placed it in the garbage bin outside of Resident #2's room. S11CNA was not observed to perform hand hygiene during the observation. An interview was conducted with S11CNA immediately following the above observations. S11CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observations of pericare on Resident #2 and #3. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief and before applying a new one. She stated she should not have touched her N95 mask or the residents, resident's covers and bed control with soiled gloves. She stated she should have completed hand hygiene prior to exiting the room. S11CNA stated she should have performed hand hygiene after removing the soiled brief and prior to applying a clean one. On 03/07/2024 at 12:00 p.m., an interview was conducted with S2DON. She stated staff should perform hang hygiene and apply clean gloves upon entering a resident's room, when going from soiled to clean during incontinence care, after completing incontinence care, and prior to exiting the resident's room. S2DON confirmed staff should not touch their mask or the resident with soiled gloves.

Based on observations, record review, and interviews, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#1) of 4 (#1, #3, #4, and #6) residents reviewed. This deficient practice resulted in an immediate jeopardy situation for Resident #1, who had severe cognitive impairment and a history of exit seeking behavior, on 06/28/2023 at 8:22 p.m. after Resident #1 was observed on video surveillance entering another resident's room and did not exit the room. Resident #1 had eloped from the facility premises, and was found wandering across a four-lane roadway yelling for help. A concerned citizen contacted the facility and asked if they were missing a resident. While the facility was searching for Resident #1, Law enforcement arrived at the facility with the resident on 6/28/2023 at approximately 8:58 p.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE], placed on the memory care unit, with diagnoses of Dementia, Delirium, and Depression. Review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/27/2023 revealed Resident #1 had a BIMS (Brief Interview Mental Status) of 6, which indicated the resident had severe cognitive impairment. Review of the Care Plan for Resident #1 revealed the following: Onset 06/15/2023 Problem: Resident has altered thought process related to severely impaired cognition diagnosis of dementia; diagnosis of delirium; Exit seeking. Onset 06/15/2023 Problem: Resident wanders. Resident resides in the special care unit. Exit seeking 06/28/2023 wandered from facility. A review of the Nurse's Note for Resident #1 revealed the following: 06/15/2023 Resident #1 arrived to facility. Resident noted to wander neighborhood at night per family members. 06/22/2023- Resident in Room (a) approached S11CNA stating I don't know what's going on, the woman in my room was saying someone was coming for us Requesting assistance. S11CNA found Resident #1 in Room (a), sweating, and redirected her to the day room. Resident returned to S11CNA requesting someone come see something in Room (a), window noted open with the screen pushed out. When this nurse went to leave skilled care unit, Resident #1 attempted to push past S8LPN, and was caught by S11CNA. S3ADON was contacted by S8LPN regarding window and increase in resident agitation/irritability, Resident #1 sent to local hospital for evaluation. 06/28/2023- At 9:15 p.m., Police Officer rang the front doorbell. He was informing the staff that a woman was found at the gas station screaming for help. This resident was identified to be Resident #1. Two other officers arrived with the ambulance, and the resident was medically cleared. Per the officer, the resident was walking down the side of the road yelling for help until patrons of the gas station called 911. After examining resident's room, it was noted there was a 6 inch gap between the window and the opening. The screen frame remains on the left side, but the mesh part was missing. The resident admitted to the police she carefully pushed the mesh out and did it quietly. Per S1Admin, SN will call the coroner to have the resident PEC'd. Will monitor her constantly. Review of a written statement from S11CNA revealed the following: Earlier in the day, I was in Resident #1's room checking on her, and she asked if there was a ladder or chair to look out the window. I told her there was not. She thanked me and I left the room. She kept pacing and asking me the same questions throughout the shift. I redirected her and she was okay. Later in the evening, I was in the common area, wanted to check on the resident, and asked S12CNA in the hall if she had seen her. She said, No. We then went to check on the resident in her room and noted she was not there. Then we began checking rooms down the hall and noted the resident was not there either. At that point, the doorbell rang and the police department was at the front door with the resident. Review of a written statement from S12CNA revealed the following: I was at the computer charting, and Resident #1 stayed by me in the hallway the whole time. She was pacing back and forth, and I redirected her and she was okay. Then, she told me she needed to leave because her significant other was waiting on her, and he would be mad/punish her because she wasn't there. She said she needed to make sure to get to her friend's party, a friend she met in hair school. Then she left and walked into the common area. She came back and was standing over me talking to me while I charted. Resident #1 pushed on the back door, which was locked, then walked to the front door and pushed which was also locked. She was knocking on the front door, and continued pacing when no one answered. I continued charting until S11CNA came and asked me if I had seen her, and we started checking her room and then other rooms in the hall. Then I heard the front doorbell ring and the police were there with the resident. Review of the 24 hour Nursing Report revealed the following: Date: 06/24/2023 Resident #1 returned from the hospital at 5:00 p.m. Notes: Resident #1- increase supervision, provide activity, redirect, offer snacks and fluids A review of the Registered Nurse Assessment completed by S6RN revealed the following: Observation Date/Time: 06/25/2023 at 7:20 a.m. Additional Comments: Resident #1 returned from the hospital for treatment of aggressive and agitated behavior. Case manager explained resident was admitted on medical floor and not psych since there were no psych beds available. Resident was positive for UTI. On 08/14/2023 at 4:27 p.m., an interview was conducted with S11CNA. She stated on 06/28/2023, she recalled Resident #1 pacing back and forth and remembered her asking for a ladder. She stated she informed the resident she couldn't get her a ladder and redirected the resident. She stated the resident kept asking the same question. She reported these behaviors as her baseline since admission and often asked for random things. She stated she identified Resident #1 as missing on her round. She stated she rounded every 2 hours, but was more often due to the unit being small and residents up and down all day and night. She recalled seeing Resident #1 about 30 minutes prior to identifying she eloped. On 08/14/2023 at 4:47 p.m., an interview was conducted with S12CNA. She stated on 06/28/2023, Resident #1 kept wanting to call her significant other because he was picking her up for a party. She stated this continued all day and at some point during the day the resident came to her asking her to open a window. She informed the resident she could not do that and redirected the resident. She stated later in the shift Resident #1 kept saying her significant other was here to pick her and another resident up. She stated Resident #1 asked where her room was. She stated at this time she assisted the resident back to her room and put her to bed. S12CNA stated she returned to the dining area to oversee other residents. She stated S13CNA alerted her Resident #1 was missing. On 08/14/2023 at 5:11 p.m., an interview was conducted with S13CNA. She stated she worked on Hall (a) and was sitting at the nursing station when a call was received by an unknown source stating a resident had been found in the middle of the road and was currently at a store. She stated upon this notification she notified the SCU (a) immediately. She stated the facility conducted a full body count for all residents revealing Resident #1 was not present. She stated during the search the police department also called asking if the facility was missing a Resident. She stated the police department was able to identify it was Resident #1. On 08/14/2023 at 3:25 p.m., an interview was conducted with S8LPN. She described Resident #1 as exhibiting agitated behaviors with no aggression and hard to redirect when she was agitated. She stated Resident #1 had to be redirected frequently since she was admitted to the facility. She stated the agitation seemed to occur later in the evening during 2:00 p.m. - 10:00 p.m. shift. She stated on 06/22/2023, when she entered the locked unit to administer medications, Resident #1 was exhibiting exit seeking behaviors at the main entrance to the unit. She stated S11CNA had to redirect Resident #1 so she could enter the locked unit. She stated S11CNA found Resident #1 in Room (a). She stated Resident #1 was assisted to the dining/day room area. She stated she returned to Room (a), and observed the window in Room (a) was raised up a little with the mesh screen pushed out. She stated S3ADON was made aware of the findings and she was informed to send Resident #1 to the hospital for psych evaluation. She stated Resident #1 returned to the facility on [DATE] with a diagnosis of UTI. On 08/14/2023 at 5:31 p.m., an interview was conducted with S10LPN. She stated she was at the nursing station when she received a call from an unknown concerned citizen voicing their concern a resident of the facility could possibly be missing. She stated the concerned citizen voiced resident was saying she was being held hostage. She stated a body count was conducted by staff confirming Resident #1 was missing. She stated during this time the police department called, and were able to identify the person as being Resident #1. On 08/16/2023 at 4:05 p.m., an interview was conducted with S9LPN. She stated she was working the day Resident #1 returned to the facility on [DATE]. She stated all direct care staff were made aware by S6RN to increase monitoring of Resident #1. She stated S6RN also made frequent rounds on the locked unit when Resident #1 returned. She stated staff was educated to redirect, offer fluids/snacks, and provide diversional activities to change Resident #1 focus if she were to present any behaviors. She stated increased supervision was verbally discussed for all staff to keep a closer eye on Resident #1. She stated there was no order for increased rounding frequency. She stated a 24 hour nursing report sheet was handed off to the oncoming nurse which identified Resident #1 requiring closer supervision. On 08/14/2023 at 4:11 p.m., an interview was conducted with S7RN. She reported Resident #1 constantly asked to go home. She stated she visualized Resident #1 about 30 minutes prior to realizing she was not present in the facility. She reported Resident #1 was found at a gas station and was observed by patrons screaming and hollering for help. She stated a concerned citizen contacted 911. She stated the nursing aides realized Resident #1 was missing prior to being notified by the police department. She stated Resident #1 was placed on 1:1 supervision until the Coroner PEC'd Resident #1 the following day. On 08/14/2023 at 3:53 p.m., an interview was conducted with S5MD. He stated he recalled the incident on 06/22/2023. He stated he replaced the mesh screen found to be out of place. He stated a full facility assessment of all windows was performed to ensure all windows only allowed the 7-10 inch clearance when opened. On 08/16/2023 at 11:10 a.m., an interview was conducted with S3ADON. He stated on 06/22/2023, he was notified by staff Resident #1 had become increasingly irritable and had shown signs of exit seeking behaviors. He stated staff were notified by another resident on the locked unit Resident #1 opened the window in Room (a) and pushed out the screen. He stated Resident #1 was admitted to the hospital for observation and was diagnosed with a Urinary Tract Infection. He stated on 06/24/2023 Resident #1 returned to the facility. On 08/16/2023 at 3:50 p.m., an interview was conducted with S2DON. She stated after Resident #1 returned from the hospital on 06/24/2023, staff were encouraged to increase activities, offer snacks, perform diversional activities and redirection as needed. She stated increased supervision and awareness was warranted as well. She identified increased supervision as being more alert and on the lookout for things out of the normal. She stated staff were not directed to increase frequency of rounds. She stated all residents on the locked unit were already considered needing increased supervision and rounds were made more often than the minimal requirements of every 2 hours. On 08/16/2023 at 11:56 a.m., an interview was conducted with S1Admin. He recalled the incident occurring on 06/22/2023 as exit seeking behaviors by Resident #1, but voiced Resident #1 did not exit the facility premises. He stated the open window was identified when another resident brought it to his staff's attention. He stated Resident #1 was immediately placed in the dining room for increased supervision until she was sent out to the hospital for evaluation. He stated Resident #1 was diagnosed with a UTI and sent back to the facility on [DATE]. He stated Resident #1 was not placed on 1:1 supervision at that time, but staff were notified to be more alert and increase awareness. He stated on 06/28/2023 he was made aware Resident #1 eloped from the facility. He stated Resident #1 was placed on 1:1 supervision upon return to the facility. He stated per police reports Resident #1 was found at the gas station at the intersection of the main highway. He stated after reviewing the video surveillance footage, Resident #1 exited her room and entered the neighboring Room (a), and she never exited Room (a). He stated an observation was made of Room (a) window open. He stated upon exiting this window, the resident would have been enclosed in the courtyard area with a chain linked hurricane gate fence. He stated the double gate of the hurricane gate fence was observed to be ajar with a lock still present and a pole was noted to be bent. He stated slack was observed to be between the closing of the two gates when closed and alleged this was possibly where Resident #1 slipped through to exit the courtyard area. He stated upon exiting the courtyard area there was an additional wooden fence gate to the rear of the facility. He stated this gate was not locked due to it being a pick up entrance for the facility biohazard waste company. He stated upon exiting this gate she would have been able to exit the facility premises. The facility had implemented the following actions to correct the deficient practice which was completed by S1Admin, S2DON, S4QI and S14RS. 1.) Immediate Corrective actions implemented post elopement as followed: a.) On 06/28/2023, Resident #1 was placed immediately on 1:1 supervision b.) On 06/28/2023, an assessment of all windows on the secured locked unit conducted by S1Admin to ensure all security locks were present only allowing 10 inches of clearance when in the open position. c.) On 06/28/2023, an assessment of security doors on the secured locked unit performed by S1Admin to ensure proper functioning. d.) On 06/28/2023, a fence assessment performed by S1Admin in the courtyard area where a chain was added with the preexisting key lock. e.) On 06/28/2023, a combination lock added to the wooden gate at the rear of the facility by S1Admin. 2.) Corrective actions were accomplished for all residents who potentially could be affected by the alleged deficient practice: a.) On 06/29/2023, a complete window security assessment was performed by S5MD with modifications made to all resident windows only allowing a 4.5 inch clearance when in the open positon. b.) On 06/29/2023, a Quality Assurance window inspection was performed thereafter weekly for four weeks by S5MD. c.) On 06/29/2023, a fencing repair company was summoned by S1Admin to the facility for fence repair and modification adjustments. 3.) The following measures were put in place to ensure the alleged deficient practice does not recur: a.) All facility staff was educated by S1Admin, S2DON, S3ADON and S6RN on identifying elopement risk residents and behaviors may present as exit seeking behaviors throughout the Quality Assurance process with a completion date of 07/27/2023. b.) On 06/29/2023 and 06/30/2023, a wandering resident drill was conducted by S1Admin. On 07/01/2023, a wandering resident drill was conducted by S6RN. Per S1Admin all staff had completed in-service by 07/01/2023. c.) On 06/29/2023, staff was educated by S1Admin, S2DON and S3ADON to notify appropriate team member immediately of any identified exit seeking behaviors so appropriate actions can be performed. 4) Quality Assessment and Assurance Committee Start Date: 06/29/2023; Completion Date: 07/27/2023 Review action plans/results: 1.) Resident Elopement 2.) Gate Code In services 3.) Window Security 4.) Fence Assessment 5) QA Window inspection performed weekly 4 times a week as followed: On 06/29/2023, 07/06/2023, 07/13/2023, 07/20/2023, and 07/27/2023 during the 4 week Quality Assurance corrective action process. In-service training 1.) Nurse documentation and accuracy 2.) Gate Code In-service 3.) Elopement/Wandering Resident Drill Started 06/29/2023; Completed- All staff in serviced by 07/01/2023 Review of the Code W Drill in-service training revealed ongoing drills being performed since 07/09/2022. Last in-service conducted as followed: 07/07/2023, 07/01/2023, 06/30/2023, 06/29/2023, 06/19/2023, and 05/30/2023 Throughout the survey from 08/14/2023 to 08/16/2023, random staff interviews revealed staff received training on the facilities elopement risk policy and procedure, dealing with Dementia care residents, how to identify exit seeking behaviors, and notifying the appropriate staff immediately so an appropriate action could be taken to ensure the safety of all residents. Observations were made of staff making frequent rounds on the locked unit with a total of 6 residents. When all residents were in the day room, 2 CNA's remained in the area. When a resident left the day room to go in the hall or their room, 1 of the CNA's remained in the day room and the other CNA remained on the hall to keep close observation of the residents. The nurse remained in the locked unit after medication pass was completed on Hall (a) to help with increased supervision needs for residents on SCU (a).

Based on interview and record review, the facility failed to provide adequate supervision and monitoring to prevent a fall for 1(#2) of 5(#1,#2,#3,#4,#5) sampled residents. The facility failed to: 1) Ensure that a resident (#2) identified by the facility as having an impaired cognition, gait and balance was not left unattended while sitting in the dining room. 2) Ensure that interventions were put in place to increase monitoring and supervision for a resident (#2) identified by the facility as requiring staff assistance with ambulation and transfers. This failed practice resulted in a harm to the resident when the Certified Nursing Assistant (CNA) departed the dining room leaving the resident by herself sitting at the dining table. The resident stood up from the chair, attempted to walk and fell . The resident sustained [REDACTED]. Findings: Review of the facility's policy and procedure entitled Fall Prevention and Management Program revealed in part, the following: Prevention: A Fall Risk Screening shall be completed on all residents admitted ... The staff will identify and implement interventions related to a resident's specific risk factors to try to prevent falls from occurring. Management: Should falling occur despite initial interventions the underlying cause will be investigated and the resident will be included in the Fall Management Program. Residents in the Fall Management Program will be identified by a falling leaf placed on the outside of the door. Review of the clinical record for Resident#2 revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident#2's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/9/13, revealed the resident was assessed by the facility, in part, as follows: Section C - Cognition: Severely impaired cognitively- never/rarely made decisions with long and short term memory problems. Section G - Functional Status: a) Transfer: self performance, staff provide guided maneuvering of limbs - one person physical assist; b) Walk in room/corridor: self performance, staff provide guided maneuvering of limbs - one person physical assist, Supervision - oversight; c) Balance (moving from seated to standing position, walking, turning around while walking, moving on and off toilet, surface to surface transfer) - Not steady, only able to stabilize with staff assistance. A review of Resident#2's Fall Risk Screening revealed the following (High risk for falls if score is 7 or greater): Date: 12/12/13 Score 13 - fall on 12/11/13 Date: 2/5/14 Score 15 - fall on 2/4/14 A review of Resident #2's Care Plan revealed, in part, the following: Problem Onset: 8/22/13 - At risk for falls related to decreased safety awareness, impaired balance secondary to Alzheimer's Disease. (goal date of 3/14/14) 12/11/13 - Unobserved fall - laceration/bruise 2/4/14 - fall Approaches: Ensure environment is spill and clutter free; Administer psychiatric medications as ordered and notify doctor of any adverse side effects; Ensure wears non-skid socks/shoes when ambulating/transferring; Handheld or manual assist x 1 2/4/14 - fall - Send to emergency room (ER), new orders to hold psychiatric medications, doctor consulted regarding medication. Problem Onset: 8/22/13 - Resides on Secure Care Unit (SCU) due to wandering related to [DIAGNOSES REDACTED]. Approaches: Supervise resident on the unit every shift A review of the Resident Incident Follow Up regarding Resident #2's fall on 12/11/13 revealed, in part, the following: 12/11/13: Continue to reside on SCU with increased supervision. A review of the Resident Incident Report dated 2/4/14 at 10:55 p.m. revealed, in part, the following: Resident #2 Incident Type: Unobserved fall Location: SCU - Unit Lobby Narrative of incident and description of injuries: Resident found in supine position on floor of SCU dining room. 7 centimeter (cm) skin tear noted to left forearm; 8 cm laceration noted to left side of head. A review of the Departmental Notes attached to the Incident Report dated 2/4/14 revealed, in part, the following: The Certified Nursing Assistant (CNA) on SCU making rounds and assisting another resident in their room, while Resident #2 was in SCU dining room at 10:55pm. Upon returning to SCU dining area, resident was found in supine position on dining area floor. Large hematoma with laceration noted to left side of scalp, large skin tear noted to left forearm. Resident in pain and lethargic. At 4:00am resident returned to facility, hematoma with 4 staples noted to left side of scalp. A review of the Fall Evaluation Tool attached to the Incident Report dated 2/4/14 revealed, in part, the following: Factors observed at the time of the fall: One CNA on SCU. While CNA was in room caring for a resident, Resident #2 attempted to self transfer in SCU dining area. A review of the Resident Incident Follow Up report dated 2/12/14 revealed, in part, the following: Mobility: Ambulates - staff assist Mental: Disoriented - not follow commands Additional Follow-ups: 2/5/14 - Therapy evaluation form completed 2/5/14 - New orders from ER to hold sedatives for 2 days and psychiatric doctor that follows resident contacted for a consult 2/5/14 - Continue to monitor for pain and administer pain medication as needed 2/5/14 - Treatment nurse to treat laceration to head and remove staples as ordered A review of the Physical Therapy Screen dated 2/8/14 regarding Resident #2 revealed, in part, the following: Fall Intervention/Prevention: Recent fall: no Safety: impaired Balance: impaired Patient observed and therapy is not recommended. Patient is at baseline. A review of Resident #2's Psychiatric Progress Notes dated 12/12/13 and 2/12/14 revealed, in part, the following: 12/12/13 - Resident #2. speaks in word salad with intermittent phrases of lucidity. There has been some concern per staff that patient is sedated - she currently is most definitely not. Severe memory impairment. Continue current medication regimen. Staff trained to accommodate dementia. 2/12/14 - Resident #2 grossly confused ... Continue current medication orders. On 2/13/14 at 8:45am an observation was made of Resident #2 in the combined dining/lobby area on the locked SCU. She was sitting in a recliner chair, with her feet elevated with non-skin socks on her feet. The resident was non-interviewable secondary to her Dementia. On 2/13/14 at 8:45am an interview was conducted with S2LPN. She stated that Resident #2 has Dementia and can say a few words, but can't hold a conversation. She stated that the resident has a history of falling and wears non-skid socks. She stated that Resident #2 was on fall precautions. She stated that fall precautions is making sure that residents wear non-skid socks and shoes and receive assistance with walking for residents who have a difficult time with walking. She stated that 80% of the time Resident #2 can talk and walk by herself, without assistance. She stated other days the resident is unsteady. On 2/13/14 at 9:00am an observation was made of Resident #2's room with S2LPN. A leaf was observed outside the door next to Resident #2's name. On 2/13/14 at 11:00am an observation was made of Resident #2 as she was assisted by S4CNA walking to the bathroom for toileting. The resident's gait was slow and unsteady. S4CNA held the resident's arm during this observation. On 2/13/14 at 11:30am an observation was made of S5CNA and a nursing student assisting Resident #2 up from her chair. They walked one on each side of the resident, holding onto her arms during this observation. On 2/13/14 at 1:20pm an interview was conducted with S4CNA for Resident #2. She stated that Resident #2 is not on any supervision for falls. She stated that the resident can walk from her room to the dining room and walk around the unit without supervision. She stated that she did not remember Resident #2 falling and that the resident has not had any falls when she worked with her. She stated that sometimes Resident #2 is unsteady when she walks and sometimes she's not. On 2/13/14 at 1:47pm an interview was conducted with S1ADON. She stated that Resident #2 resides on the locked SCU. She stated that the residents residing in the SCU area have Alzheimer's Disease and end stage Dementia. She stated that the SCU provided Resident #2 with more supervision, in a smaller area, than out in the hall. She stated that on the day and evening shifts there are two CNAs assigned on the SCU who provide supervision of the residents. She stated that on the night shift there is one CNA assigned on the SCU. She stated that the nurse doesn't stay in the SCU at all times. She stated that if one CNA is working with a resident, then there would be the other CNA working in the common area with the other residents. She stated that the common area is the dining/lobby area in SCU. She stated that a leaf placed outside a resident's door signifies to the staff that the resident is a high fall risk. She stated that Resident #2 is ambulatory and that staff walk by her side because it is safer for the resident. She stated that on 12/11/13, Resident #2 had an unwitnessed fall when she got out of bed unassisted and was found on the floor next to her roommate's bed. She stated the resident sustained [REDACTED]. She stated that on 2/4/14 at 10:55pm (night shift) Resident #2 fell again. She stated that Resident #2 fell in the SCU dining room. She stated that the CNA was in another resident's room when the resident fell . She stated that the nurse was not on the hall at that time. She stated that when the resident fell , she sustained a head laceration which required staples. She stated that on 2/4/14 at 10:55pm, the CNA did not call and ask for a nurse or other staff to come to SCU to help her when she had to leave Resident #2 by herself in the dining room. She stated that the staff know that Resident #2 is not able to walk by herself, they know to watch her a little bit closer. She stated that supervision for Resident #2 was someone would be with her when she got up and direct her with walking. On 2/13/14 at 4:03pm an interview was conducted with S3DON. She stated that the nurse assigned to (SCU) also has the hall outside of the locked unit. She stated that sometimes some of the residents in SCU are brought into the dining room to give them extra supervision at night. She stated that the staff member in SCU on the night shift could be helping a resident when another resident needs something. She stated that all of the residents in the SCU area are a high risk for falls. She stated that the CNA knew better than to leave Resident #2 unsupervised when she left the resident in the dining room on 2/4/14. S3DON confirmed that on 2/4/14 at 10:55pm, a nurse was not in the SCU. She further confirmed that the one CNA working on SCU left the dining room to assist another resident.leaving Resident #2 unsupervised in the dining room.

Based on interview and record review, the facility failed to provide sufficient numbers of nursing staff to provide supervision and monitoring for 1(#2) of 5(#1,#2,#3,#4,#5) sampled residents. The facility failed to ensure that staff were consistently available in sufficient numbers to provide supervision and monitoring of a resident (#2) identified by the facility as requiring staff assistance with ambulation and transfers on the locked Secure Care Unit (SCU), during the night shift (10p-6a). This failed practice resulted in a harm to the resident (#2) on 2/4/14 at 10:55pm. The one Certified Nursing Assistant (CNA) working in SCU departed the dining room leaving the resident (#2) by herself sitting at the dining table. The resident stood up from the chair, attempted to walk and fell . The resident sustained [REDACTED]. Findings: A review of the facility's Census List dated 2/13/14 revealed a total of 36 residents resided in the facility's SCU. A review of the clinical record for Resident#2 revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of Resident #2's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/9/13, revealed the resident was assessed by the facility, in part, as follows: Section C - Cognition: Severely impaired cognitively- never/rarely made decisions with long and short term memory problems. Section G - Functional Status: a) Transfer: self performance with staff provide guided maneuvering of limbs - one person physical assist; b) Walk in room/corridor: self performance with staff provide guided maneuvering of limbs - one person physical assist, Supervision - oversight; c) Balance (moving from seated to standing position, walking, turning around while walking, moving on and off toilet, surface to surface transfer) - Not steady, only able to stabilize with staff assistance. A review of Resident#2's Fall Risk Screening revealed the following (High risk for falls if score is 7 or greater): Date: 12/12/13 Score 13 - fall on 12/11/13 Date: 2/5/14 Score 15 - fall on 2/4/14 A review of Resident #2's Care Plan revealed, in part, the following: Problem Onset: 8/22/13 - At risk for falls related to decreased safety awareness, impaired balance secondary to [MEDICAL CONDITION]. (goal date of 3/14/14) 12/11/13 - Unobserved fall - laceration/bruise 2/4/14 - fall Approaches: Ensure environment is spill and clutter free; Administer psychiatric medications as ordered and notify doctor of any adverse side effects; Ensure wears non-skid socks/shoes when ambulating/transferring; Handheld or manual assist x 1 2/4/14 - fall - Send to emergency room (ER), new orders to hold psychiatric medications, doctor consulted regarding medication. Problem Onset: 8/22/13 - Resides on SCU due to wandering related to [DIAGNOSES REDACTED]. Approaches: Supervise resident on the unit every shift. A review of the Resident Incident Follow Up regarding Resident #2's fall on 12/11/13 revealed, in part, the following: 12/11/13: Continue to reside on SCU with increased supervision. A review of the Resident Incident Report dated 2/4/14 at 10:55 p.m. revealed, in part, the following: Resident #2 Incident Type: Unobserved fall Location: SCU - Unit Lobby Narrative of incident and description of injuries: Resident found in supine position on floor of SCU dining room. 7 centimeter (cm) skin tear noted to left forearm; 8 cm laceration noted to left side of head. 911 contacted, resident sent to ER for evaluation and treatment of [REDACTED]. A review of the Departmental Notes attached to the Incident Report dated 2/4/14 revealed, in part, the following: The Certified Nursing Assistant (CNA) on SCU making rounds and assisting another resident in their room, while Resident #2 was in SCU dining room at 10:55pm. Upon returning to SCU dining area, resident was found in supine position on dining area floor. Large hematoma with laceration noted to left side of scalp, large skin tear noted to left forearm. Resident in pain, lethargic and unable to respond to pain level inquiry. At 4:00am resident returned to facility, hematoma with 4 staples noted to left side of scalp. A review of the Fall Evaluation Tool attached to the Incident Report dated 2/4/14 revealed, in part, the following: Factors observed at the time of the fall: One CNA on SCU. While CNA was in room caring for a resident, Resident #2 attempted to self transfer in SCU dining area. A review of the Resident Incident Follow Up report dated 2/12/14 revealed, in part, the following: Mobility: Ambulates - staff assist Mental: Disoriented - not follow commands On 2/13/14 at 8:45am an observation was made of Resident #2 in the combined dining/lobby area on the locked SCU. She was sitting in a recliner chair, with her feet elevated with non-skin socks on her feet. The resident was non-interviewable secondary to her Dementia. On 2/13/13 at 11:00am an observation was made of Resident #2 as she was assisted by S4CNA to the bathroom for toileting. The resident's gait was slow and unsteady. S4CNA held the resident's arm, leading her to the bathroom during this observation. On 2/13/14 at 11:30am an observation was made of S5CNA and a nursing student assisting Resident #2 up from her chair. They walked one on each side of the resident, holding onto her arms during this observation. On 2/13/14 at 8:45am an interview was conducted with S2LPN. She stated that Resident #2 has Dementia and can say a few words, but can't hold a conversation. She stated that the resident has a history of falling and wears non-skid socks. She stated that Resident #2 was on fall precautions. She stated that fall precautions is making sure that residents wear non-skid socks and shoes and those residents who have a difficult time with walking receive assistance. She stated that 80% of the time Resident #2 can talk and walk by herself, without assistance and other days she is unsteady. On 2/13/14 at 1:20pm an interview was conducted with S4CNA for Resident #2. She stated that Resident #2 is not on any supervision for falls. She stated that the resident can walk from her room to the dining room and walk around the unit without supervision. She stated that she did not remember the resident falling and that the resident has not had any falls when she worked with her. She stated that sometimes Resident #2 is unsteady when she walks and sometimes she's not. On 2/13/14 at 1:47pm an interview was conducted with S1ADON. She stated that the residents in SCU have [MEDICAL CONDITION] and end stage Dementia. She stated it is a locked, smaller unit with more supervision than the hall units. She stated that on the day and evening shifts there are 2 CNAs assigned to SCU and on the night shift there is one CNA assigned to the SCU. She stated that the nurse goes to the SCU when needed and for medication pass, but doesn't stay in the SCU at all times. She stated that Resident #2 is ambulatory and that staff walk by her side because it is safer for the resident. She stated that the staff know that Resident #2 is not able to walk by herself, they know to watch her a little bit closer. She stated that if the staff see Resident #2 trying to get up the staff will ask her if she needs anything. She stated that at night if the CNA is in another room then Resident #2 might get up and walk by herself. She stated that on the days they have 2 CNAs who provide the supervision that the residents on SCU need. She stated that if one CNA is working with a resident then there would be the other CNA working in the common area with the other residents. She stated that on 2/4/14, 10:55pm , Resident #2 fell in the dining room while the CNA was in another resident's room. She stated that the nurse was not on the hall at that time. She stated that the CNA did not call and ask for a nurse or anyone else to come to SCU and help when she had to leave Resident #2 by herself in the dining room. On 2/13/14 at 3:13pm an interview was conducted with S7CNA supervisor. She stated that she makes the CNA assignments. She stated that there is one CNA assigned to the SCU on the night shift, 10p-6a. She stated that if the CNA on SCU needed assistance she would use the intercom and call for assistance. She stated that the night aide on SCU might need help with a resident or to have another CNA stay in the dining room with a resident. She stated that someone needs to be back there at all times, because the residents might try to get up by themselves. She stated that the residents need to be redirected so that they don't hurt themselves. On 2/13/14 at 4:03pm an interview was conducted with S3DON. She stated that on the night shift,10p-6a, there is one CNA assigned to the SCU. She stated that the nurse assigned to (SCU) also has the hall outside of the locked unit. She stated that sometimes some of the residents in SCU are brought into the dining room to give them extra supervision at night. She stated that the residents will sometimes fall asleep in the reclining chairs. She stated that the staff member in SCU on the night shift could be helping a resident when another resident needs something. She stated that all of the residents in the SCU are a high risk for falls. She stated that the CNA knew better than to leave Resident #2 unsupervised when she left the dining room on 2/4/14. S3DON confirmed that at the time of Resident #2's fall on 2/4/14 at 10:55pm, the CNA was working alone on the SCU.