Every finding on record at Highlands Health and Rehabilitation Center

Based on policy review, review of the Diabetes Education Services Insulin Storage and Dispensing Info [Information] chart, medical record review, observation, and interview, the facility failed to ensure medications were properly stored in 1 of 11 (200 Hall Medication Cart #2) medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Administration dated [DATE], revealed .Medications are administered by licensed staff.in accordance with professional standards of practice.Identify expiration date. If expired, notify nurse manager. 2. Review of the Diabetes Education Services Insulin Storage and Dispensing Info chart, version 6, dated 2025, revealed vials of Lispro insulin should be discarded 28 days after opening when stored at room temperature up to 86 degrees. 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Dysphagia and Diabetes. Review of the Physician Order dated [DATE], and reviewed by Medical Director D on [DATE], revealed Resident #26 had an order for Lispro insulin (medication used for hyperglycemia) to be administered according to sliding scale (used to determine the insulin dosage, based results of blood sugar test). 4. Review of the medical record revealed Resident #156 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Epilepsy, and Diabetes. Review of the Physician's Order dated [DATE], revealed Resident #156 had an order for Lispro insulin to be administered according to sliding scale. 5. During an observation and interview on [DATE] at 11:16 AM, 2 expired insulin vials were observed in the top drawer of the 200 Hall Medication Cart #2. Registered Nurse (RN) B was asked about Resident #26's Lispro vial labeled with an open date of [DATE]. RN B stated, The insulin expires 30 days after opening. RN B was asked if Resident #26's Lispro was expired. RN B stated, It was opened [DATE] and today is [DATE]. The insulin should have been discarded on [DATE] and a new one opened. RN B was asked what staff should have done with Resident #156's Lispro labeled with an open date of [DATE]. RN B stated, The plan is to discard them both. During an interview on [DATE] at 6:05 PM, Assistant Director of Nurses (ADON) was asked when does insulin expire after it is opened. The ADON stated, 28 days after opening. ADON was asked what staff should do with expired insulin. The ADON stated, Staff should put expired insulin in the sharps container, get a new vial, and label it with the open date on the vial and the box. The ADON was asked should expired insulin be in the medication cart. ADON stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when staff failed to use Personal Protective Equipment (PPE) during medication administration for 1 of 6 (Resident #155) sampled residents reviewed.The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions dated 12/1/2024, revealed .It is the policy of this facility to implement enhanced barriers precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced Barrier Precautions (EBP) refer to an infection control intervention .that employs targeted gown and glove use during high contact resident care activities .All staff receive training on enhanced barrier precautions upon hire and at least annually.An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds.indwelling medical devices.PICC lines [peripherally inserted central catheter] .High-contact resident care activities include .Device care or use .PICC lines . 2. Review of the medical record revealed Resident #155 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Paraplegia, Pressure Ulcer Sacral Region, Chronic Pain, and Depression. Review of the Physician's Order dated 7/24/2026, revealed Ertapenem [antibiotic] Sodium Solution Reconstituted 1GM [gram] Use 1 gram intravenously every 24 hours for infection related to Osteomyelitis [a serious bone infection].for 6 weeks. Review of the Physician's Order dated 7/28/2026, revealed Enhanced barrier precautions r/t [related to] wounds, IV site [the part of the body where a needle or catheter is inserted to access a vein for intravenous therapy] and foley [indwelling urinary] catheter. Observation on 7/28/2026 at 11:10 AM, during medication administration, revealed Licensed Practical Nurse (LPN) A administered intravenous (in the vein) medication to Resident #155. LPN A knocked on the resident's door, performed hand hygiene, and explained the procedure to the resident. LPN A donned gloves and prepared Ertapenem 1 GM in a 100 milliliter (ml) bag of normal saline for IV administration. LPN A attached dial-a-flow IV tubing (a medical device used to control the flow of fluids, medications, or nutrients directly into a patient's vein) to the bag containing the Ertapenem, cleaned the PICC line hub (connection point on a peripherally inserted central catheter) with alcohol, flushed the PICC line with 10 ml of normal saline, connected the IV tubing to the PICC line hub and set the dial-a-flow to administer the medication over 30 minutes. LPN A doffed the gloves and performed hand hygiene. LPN A failed to wear a gown during medication administration through a PICC line. On 7/28/2026 at 11:48 AM, LPN A approached this surveyor to discuss the need for PPE in Resident #155's room during intravenous medication administration. LPN A stated, .I should be wearing a gown .I just wanted to go ahead and let you know I messed up. During an interview on 7/28/2026 at 2:00 PM, the Director of Nursing (DON) was asked would you expect your nurses to wear a gown when administering medications to a resident with a PICC line and in EBP. The DON stated, Yes ma'am, I would.

Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, National Weather Service website review, medical record review, facility video footage review, facility investigation review, hospital record review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #1) sampled residents assessed to be at risk for wandering and exit seeking behaviors. Immediate Jeopardy was identified when Resident #1 a vulnerable and cognitively impaired resident with a history of wandering behaviors, exited the building without staff knowledge or assistance on 1/31/2026. Resident #1 walked past the receptionist and followed a visitor through the first set of doors, passed a housekeeper, walked out the second set of doors, and exited the front entrance of the facility, with an outside temperature of 21 degrees Fahrenheit, without a coat or layered clothing, and traveled approximately 3 miles along ice- and snow-covered walkways and roads and across a 4-lane busy intersection. Resident #1 was picked up at an unknown time, in a private vehicle driven by an unknown person, and taken to a family member's home, where he fell on an icy surface while exiting the vehicle. The facility was not aware Resident #1 had exited the building without staff knowledge or assistance until a family member notified the facility at 11:30 AM, approximately 42 minutes later. Resident #1 was returned to the facility on 1/31/2026 at 1:40 PM, by facility staff in a private vehicle. After returning to the facility, radiology (Xray) results revealed Resident #1 sustained an acute intertrochanteric fracture of the right hip (a break in the long bone of the upper leg), was transferred to the hospital from the facility on 1/31/2026 and underwent a surgical repair on 2/1/2026. The facility's failure to supervise Resident #1 placed the resident and all residents with wandering behaviors in Immediate Jeopardy. 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 Administrator, the Regional Nurse Consultant, and the Director of Operations were notified of the Immediate Jeopardy (IJ) on 2/5/2026 at 3:02 PM, in the Conference 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 began on 1/31/2026 and continued through 2/3/2026. The IJ was removed on 2/4/2026 when the facility implemented a corrective action plan. The corrective actions were validated by the surveyor on 2/10/2026. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: 1. Review of the undated facility's policy titled, Elopement 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, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision.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.Adequate 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. 2. Review of the Administrator job description dated 6/25/2023, revealed .govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times.Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility.Ensure that all employees.follow the established policies and procedures.Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility. Review of the undated DON job description, revealed .plan, organize, develop and direct the overall operations of our Nursing Service Department.to ensure that the highest degree of quality of care is maintained at all times.Develop methods for coordination of nursing services with other resident services to ensure the continuity of the resident's total regimen of care. 3. Review of the National Weather Service.gov website dated 1/31/2026, revealed the temperature was 21 degrees Fahrenheit at 10:54 AM for the area where the facility was located. 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Wedge Compression Fracture (a fracture to the front part of the vertebra), Malnutrition, Traumatic Subarachnoid Hemorrhage (a critical brain injury caused from bleeding), Psychotic Disorder, Gastrostomy (a tube inserted directly into the stomach used for nutrients or medications), and Dysphasia. Review of the Care Plan dated 12/18/2025, revealed .a behavior problem.Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident #1's Care Plan did not address his wandering behaviors or interventions to address wandering until after an incident of elopement occurred on 1/31/2026. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #1 exhibited wandering behaviors for 1 to 3 days of the 7 day lookback period. Resident #1 required moderate assistance of staff when ambulating at least 10 feet. Review of the Nurse's Note dated 1/1/2026 at 8:36 PM, revealed Nursing Summary: pt. [patient-Resident #1] alert and verbal, He's able to make most of his needs known verbally. Pt. noted to be exit seeking several times this shift after his (Girlfriend and cousin) left. Wonder [Wander] guard bracelet [a device placed on the person that would sound if near an entrance/exit to alert staff] was put in place to his lower left leg. pt. stated (he was going to get out of here and go home when we were not looking.) pt's POA [Power of Attorney] notified of the pt's exit seeking attempts. Pt's a fall risk and not aware that it is not safe for him to stand up from his w/c [wheelchair] without locking the w/c brakes. He has been educated on why the w/c brakes should be in place and secure before attempting to go from a sitting to a standing position. The pt. just nodded his head as if he understood but he did not, by his actions. Review of the Elopement Risk assessment dated [DATE], revealed Resident #1 scored 31 and was at risk for elopement. Resident #1 was ambulatory/mobile with use of a device, and he was cognitively impaired with decreased safety awareness, disturbances in judgement, a history/risk of wandering, and a history of elopement with one or two elopement events. Further review revealed Resident #1 was .alert and verbal and tried several times to leave the facility this shift. Resident #1 stated he was going home, going to his girlfriend's house, I'm not sick so why am I here, and I'm going home tonight. Review of the Physician's Order dated 1/1/2026, revealed wonder [Wander] guard placement lower left leg every shift check for placement. Review of the Activities Note dated 1/30/2026 at 8:52 AM, revealed Resident [Resident #1] does participate in structured activities and 1:1 [one on one] activities. Resident did attend morning activities. Resident does require extensive cueing and assistance. Resident does require redirecting. Resident is alert with impaired cognition. Resident speech is impaired. Resident does use few words and gestures to communicate. Resident does ambulate. Resident requires assistance to and from activities. Review of the facility's video camera footage dated 1/31/2025 at 10:48 AM, revealed Resident #1 exited the facility without staff knowledge or assistance, through the front lobby door walking directly behind a visitor. Resident #1 was dressed in a long-sleeved shirt, pants, and shoes without layers or coat, no gloves, and no hat. Housekeeper H was cleaning the front entrance lobby foyer when the resident walked past her and exited the facility. Resident #1 was seen on the video camera footage walking to the left of the facility after exiting the building. Snow and ice were visible on the walkways and road. Review of the facility's investigation Incident Narrative dated 1/31/2026, revealed On 1/31/2026 at approximately 10:48 AM, a resident [Resident #1] exited the facility through the front entrance. The resident was later located approximately 2.6 miles from the facility at a family member's residence. Facility staff, Administrator, DON [Director of Nursing], and nursing staff arrived [at the family member's residence] at approximately 11:45 AM to assess the resident. Upon return to the facility, diagnostic imaging confirmed a right hip fracture, and the resident was transferred to the Emergency Department for higher level of care per physician orders. An internal investigation was initiated, and corrective actions were implemented. Review of the Nurse's Note dated 1/31/2026 at 1:40 PM, revealed Into room note R [right] elbow with a small abrasion to R elbow no bruising noted. Wound Nurse notified. Noted R wrist small amount of swelling no bruising noted. Small protrusion to R hip area. R leg shorter than L [Left] leg. Unable to move resident around for increase [increased] pain. B/P [blood pressure] 152/81, HR [Heart Rate] 80, RR [Respiration Rate] 18, Sat [oxygen saturation] 100% [percent] on RA [Room Air], Temp [Temperature] 98.2 [degrees Fahrenheit] forehead. Will continue [to] Monitor & [and] access [assess]. Review of the Nurse's Note dated 1/31/2026 at 1:45 PM, revealed Pain Evaluation Summary: Resident with facial grimacing when moving the right leg. will place hand to leg when touching the leg. no bruising or discoloration noted. Review of the Nurse's Note dated 1/31/2026 at 6:00 PM, revealed Send to [Named hospital] R/T [related to] Fall and right hip pain. Review of the Radiology Results dated 1/31/2026 at 6:04 PM, revealed .Hip.Findings: There is an acute intertrochanteric fracture [a break between the greater and lesser trochanters of the long bone of the leg] of the right hip. Review of the Care Plan dated 1/31/2026, revealed .an elopement risk/wanderer r/t impaired safety awareness.Identify pattern of wandering.Provide structured activities.Wander guard alert bracelet placed on left ankle. Review of the facility's incident report dated 1/31/2026, revealed .At approximately 10:48 AM, resident [Resident #1] exited the facility through the front entrance and was transported by a community member and experienced a fall while exiting the vehicle.Upon return to the facility, resident was assessed by nursing staff, the physician was notified, and diagnostic imaging was ordered. X-ray results confirmed a fracture to the right hip .Following receipt of results, the physician was notified, and the resident was transferred to the Emergency Department for a higher level of care per MD [Medical Director] orders.Injury Type: Fracture, Injury Location: Right Trochanter (hip).Mental Status: Oriented to Person, Oriented to Place.Level of Pain: Blank, Mobility: Blank, Predisposing Situation Factors: Active Exit Seeker, Ambulating without Assist, Wanderer.Other Info: Slipped on Icey [Icy] surface. Review of a hand-written statement dated 1/31/2026, revealed Registered Nurse (RN) E documented I last seen [saw] the resident [had] been redirected by [RN B] to come back down the first hall on 100 first floor! The alarm on the first floor at [the] nursing station was alarming, I asked what's that. The nurse informed me it was an alarm in a zone. She stated I'll take care of it. The alarming sound soon stopped. Shortly after a [call] came to the front receptionist desk stating [Resident #1] was at her house she was the niece. The receptionist came to his room, he wasn't there. A code white [a facility code for missing resident] was called. I [was] the supervising nurse, and started a check, had census printed. RN A left the building to go get the resident. I then called her to see what was going on and she stated I'm waiting on someone to let me in [the niece's house]. Review of the Care Plan dated on 2/1/2026, revealed .a behavior problem related to exit seeking.Wander guard bracelet applied to left ankle on 1/1/26. Wander guard will be monitored q-shift [every shift] for placement and functioning. 5. Review of the (Named) Hospital Surgical Documentation dated 2/1/2026, revealed .Preoperative diagnoses: R [Right] Peritrochanteric femur [between the greater and lesser trochanters of the thigh bone] fx [fracture].Procedures Performed: [NAME] [Closed Reduction Maneuver is a surgical procedure to repair the fractured bone] . 6. During a telephone interview on 2/4/2026 at 10:07 AM, Resident #1's niece was asked about the incident where Resident #1 left the facility. Resident #1's niece stated, I received a call at 11:30 AM [on 1/31/2026] from my mother stating he had fallen in front of our house .I tried to get him up by myself but he couldn't stand because his right leg was hurting .My sister and I dragged him into the house and assisted him onto the couch .His two sons arrived and a nurse from the facility came to our house. The niece was asked how Resident #1 got back to the facility. Resident #1's niece stated, 3 other people came from the facility and helped him get into a truck to be taken back to the facility. During an interview on 2/4/2026 at 12:10PM, the Maintenance Assistant was asked when he was made aware that a resident had exited the facility without staff knowledge or assistance. The Maintenance Assistant stated, The Administrator called [me] on 1/31/2026 around 1:00 [PM] and informed [me] that there had been an elopement and I was needed to check the doors of the facility.When I arrived to the facility, I noticed the cover of the wander guard system on the front entrance was misplaced and hanging with a screw missing, I replaced the screw and secured the cover, tested the system with a wander guard bracelet, and the alarm was working properly at that time.I contacted [Named company] for a service call and quote to assess the system, and they arrived on 2/2/2026 to repair the existing system and are upgrading it today. During a telephone interview on 2/4/2026 at 2:14 PM, RN A was asked when she was made aware Resident #1 had eloped. RN A stated, Around 11:00 [AM] that morning, the receptionist informed she received a call from the family that he was at the niece's house. I went to his room to check, and he was not in there. I informed his nurse about the call and drove to the niece's house. Once I got to the niece's house, the resident was sitting in a recliner. I assessed both legs, and the right leg was swollen near mid-thigh. [The resident] complained of pain to the right leg, and he could not lift or raise his leg up. I asked him what happened, [Resident #1] said he slipped and fell when he got out of the car onto his right side. I noticed his right wrist was swollen but he had full range of motion without pain. RN A stated, The DON, her spouse, and the Administrator arrived 15-20 minutes after me, they assisted the resident to the DON's truck, and the resident was taken back to the facility. RN A was asked why 911 was not dispatched since the resident had a fall with suspected injury. RN A stated, He did not want to go to the ER [Emergency Room]. RN A was asked if Resident #1's mental status indicated he was cognitively intact to make that decision safely. RN A stated, I am not sure of his mental status as I am not usually assigned to him. RN A was asked if the Resident's Responsible Party was contacted and asked regarding 911 being dispatched instead of transporting him by private vehicle back to the facility. RN A stated, I did not contact the responsible party. During an interview on 2/5/2026 at 8:32 AM, the Administrator was asked when did you initially learn Resident #1 had eloped from the facility. The Administrator stated, RN A called and reported that [Resident #1] had left the facility and went to his sister's house around 11:15 AM, and she was on her way to the sister's house. I spoke with the DON, and she confirmed that a code white was initiated at the facility and a head count was performed of all residents in the facility.I arrived at the niece's house around 11:45 AM, the resident was on the couch with a blanket over him, RN A reported that he was complaining of right hip pain from falling outside. The Administrator was asked how the resident got back to the facility. The Administrator stated, A male family member, the DON's spouse, and myself assisted [Resident #1] to ambulate to the truck, he did not groan or grimace from pain. The Administrator was asked to describe the weather that day. The Administrator stated, the temperature was in the 20's [degrees in Fahrenheit] with snow covered ice over on most of the ground. The Administrator was asked if 911 was considered while at the niece's residence. The Administrator stated, No, we were trying to get him back to the facility for [so] a more thorough assessment could be performed. The Administrator was asked how the resident got out of the facility without staff's knowledge. The Administrator stated, The wander guard was not working properly and failed to alarm when he exited the door.We have since identified and fixed the problem with the wander guard system to improve the system. During an interview on 2/5/2026 at 10:22 AM, the DON was asked if a resident is assessed for wandering behaviors on admission, should they be care planned for wandering behaviors. The DON said yes, they should be care planned for wandering. The DON was asked if Resident #1 was care planned for wandering or exit seeking behaviors prior to 1/31/2026. The DON stated, No, he was not. I added it when I noticed it was left off. The DON was asked should have Resident #1 been care planned before 1/31/2026 for wandering and exit seeking behaviors. The DON stated, Yes, he should have. During a telephone interview on 2/10/2026 at 9:03 AM, the Medical Director (MD) was asked if he expects the facility staff to monitor the functionality of a wander guard for resident exhibiting exit seeking behaviors. The MD stated, Yes, they should. The MD was asked if residents should be care planned if they have wandering or exit seeking behaviors. The MD stated, Yes. The MD was asked what should staff do if the resident was assessed to have increased pain, swelling, and decreased range of motion to an extremity after a fall onsite at a family member's house. The MD stated, Call 911. The facility's corrective actions for the removal plan were issued to the state surveyor on 2/10/2026 and validated while onsite. The corrective action plan included the following: Corrective Actions Implemented for Resident #1 on 1/31/2026 included a medical assessment completed by the charge nurse and notification of Physician/Nurse Practitioner (NP) by the Assistant Director of Nursing. The Physician was notified by the Administrator and pain medications were administered as ordered by the charge nurse. The charge nurse followed physician orders to obtain an X-Ray which revealed an acute fracture of the inner trochanteric right hip, the charge nurse notified Physician/NP, and Resident #1 was transferred to the hospital by the charge nurse. Corrective Actions Implemented for Current Residents Beginning 1/31/2026: a. Verification of resident census with confirmation of all residents present in facility completed by supervisor on duty b. Elopement Risk Assessments were updated on current residents by the Director of Nursing, Assistant Director of Nursing and the unit managers to determine high elopement/wandering risk residents. c. Director of Nursing, Assistant Director of Nursing and the unit managers reviewed and revised care plans for all high elopement/wandering risk residents. 1 resident was identified with a high-risk elopement score when assessed - care plan updated with appropriate interventions including wander guard placement. d. Staff re-education provided on elopement and wandering residents' policy, timely response to alarms, supervision expectations and location of Wander Guard Elopement Risk Binder. The 13 pages of signatures is the education that was started on 1/31/2026 and completed on 2/3/2026, will continue until 100% staff have been educated. Staff will not be allowed to work without completed education. PRN (as needed) staff that could be contacted were educated by phone by Administrator, Director of Nursing, Assistant Director of Nursing and the unit managers. Staff that are on leave will receive education on return to work. The facility does not utilize agency staff. Weekend staff were educated at the beginning of their first shift of work. No staff member has been allowed to work without required education. This education was completed by Director of Nursing, Assistant Director of Nursing and the unit managers/supervisors. e. Administrator revised maintenance procedures for auditing Wander Guard doors to include inspection of Wander Guard alarm panel integrity and hardware. f. Residents assessed as high risk for elopement with wander guard bracelets had information to include pictures and profile placed in the Elopement Risk Binder at the Reception Desk and at each nurses' station. This was completed by the Director of Nursing. g. The Administrator gave 1:1 (one on one) education to the house-keeper present at door at time of the event regarding responsibilities of her job that include recognizing residents that are wanderers and/or at risk for elopement and being observant while working in the exit areas / Receptionist at door quit on the day of the event when she was interviewed regarding the event but did sign education presented by the administrator. h. 1:1 education was provided by the administrator for the Maintenance department to check structural integrity of the wander guard door alarm system in addition to normal testing. i. Elopement Drills were completed starting 1/31/2026 and continue until 100% staff have completed an elopement drill and understand the process. The facility currently does not utilize agency staff. The elopement drills were completed by the Administrator, Director of Nursing, Assistant Director of Nursing, Maintenance and the Unit Managers/Supervisors. j. Wander Guard Alarm testing and door checks including structural integrity will be completed 2 x (times) daily starting 1/31/2026 by Maintenance and/or Administrator. Results will be discussed in QAPI (Quality Assurance and Performance Improvement) monthly x 3 months and monitoring frequency will be evaluated and adjusted according to audit results. On 1/31/2026 a. Maintenance inspected Wander Guard system; front entrance panel identified as loose due to wear and tear and immediately repaired and the system was tested and found to be working correctly. b. The enhanced monitoring was initiated at reception area includes Front Desk Visitor Screening Audit Log and Back Up Monitoring Log were initiated on 1/31/2026 by the Administrator. The Administrator educated the Business Office Manager and the Reception Staff on these monitoring processes starting 1/31/2026 and complete by 2/3/2026. Employees that have not been educated will be educated on first day returned to work. QAPI (Quality and Performance Improvement) meeting held on 1/31/2026 a. Ad Hoc QAPI completed to review the incident, timeline of events, and immediate corrective actions necessary to achieve past non-compliance. b. QAPI team members present including Medical Director. c. Audits Implemented and On-going: Wander Guard Door Alarm Audit, Front Desk Visitor Screening Audit Log d. Wander Guard Alarm testing and door checks including structural integrity will be completed 2 x daily starting 1/31/2026 by Maintenance or designee. Results will be discussed in QAPI monthly x 3 months and monitoring frequency will be evaluated and adjusted according to audit results. The correction has been made on the original Adhoc (Ad hoc) (as needed) QAPI document. On 2/2/2026 a. Inspection and repair of the Wander Guard System by vendor State Systems was complete on Monday 2/2/2026. The invoice was received on 2/3/2026. The Removal Plan was validated onsite by the surveyor on 2/10/2026 which included review of the facility education to show each step was completed, staff interviews to confirm completion, review of care plans, review of new hire orientation training, review of audit logs for completion, and review of current wandering guard system for working order and staff response.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) during peg tube (a tube inserted into the stomach for the administration of medications or nutrients) care for 1 of 3 (Resident #9) sampled residents reviewed for peg tubes, and when 2 of 2 staff (LPN B and Certified Nursing Assistant (CNA) C) failed to perform hand hygiene during wound and urinary catheter (a tube placed in the bladder to drain urine) care for 2 of 2 (Residents #10 and #13) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 2/5/2025, revealed .It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission if multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities.An order for enhanced barrier precautions will be obtained for residents with any of the following.indwelling medical devices.feeding tubes.Implementation of Enhanced Barrier Precautions.PPE for enhanced barrier precautions is only necessary when performing high contact care activities .High-contact resident care activities include.Device care or use: feeding tubes. Review of the facility policy titled, Hand Hygiene, dated 3/27/2025, revealed .All staff will perform hand hygiene procedures to prevent the spread of infection.Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub.if your task requires gloves, perform hand hygiene prior to donning [putting on] and immediately after removing gloves. 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction (a condition where blood flow to the brain is interrupted), Diabetes, Dementia, and Dysphagia (difficulty swallowing). Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #9 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact and had a feeding tube. Review of the Physician's Order dated 10/10/2025, revealed Nutren 2.0 (tube feeding formula used for supplemental nutrition) to run at 60 milliliters per hour (ml/hour). Turn on at 6:00 AM and off at 6:00 PM. May give Jevity 1.5 (tube feeding formula used for supplemental nutrition). Observation on the 100 Hall on 10/13/2025 at 11:07 AM, revealed Resident #9 was in a geriatric recliner in the sitting area. LPN A raised Resident #9's shirt to access her peg tube site, moved resident's peg tube with her barehand to assess the insertion site, donned gloves, and attached the tube feeding to the resident's peg tube. LPN A removed the gloves and performed hand hygiene. LPN A failed to use appropriate PPE prior to the use of Resident #9's peg tube. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy (a condition that affects the function of the brain), Asthma, Malignant Neoplasm of Bladder, and Diabetes. Review of the Physician's Order dated 9/16/2025, revealed catheter care every shift. Review of the admission MDS dated [DATE], revealed Resident #10 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #10 had a feeding tube and an indwelling catheter. Observation in Resident #10's room on 10/14/2025 at 9:42 AM, CNA C performed hand hygiene, donned gown and gloves, raised the resident's bed, obtained wet wipes placed on side of resident's bed without a barrier, removed the resident's brief, placed 2 trash bags on top of the resident's bed, performed catheter care, removed gloves, discarded the trash bags into the resident's trash, and donned gloves without performing hand hygiene. CNA C failed to place wet wipes on a barrier and failed to perform hand hygiene after removing gloves. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Dementia, Depression, and Failure to Thrive. Review of the quarterly MDS dated [DATE], revealed Resident #13 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Physician's Order dated 7/25/2025, revealed clean left ankle with wound cleanser (used when performing wound care), apply calcium alginate (used in wound care for absorbing drainage) to wound bed, pat dry with 4 by 4 (4x4) gauze and cover with protective dressing every other day. During an observation and interview on 10/13/2025 at 2:00 PM, LPN B entered Resident # 13's room to perform wound care. The treatment cart was in the resident's room with supplies on a barrier on the top of the treatment cart. LPN B removed the soiled dressing from the resident's left ankle and cleansed the wound with gauze moistened with wound cleanser. LPN B removed gloves, performed hand hygiene, donned gloves and applied dressing. LPN B removed PPE, performed hand hygiene and discarded the barrier and supplies. LPN B pushed the treatment cart into the hallway. LPN B was asked if gloves should be changed and hand hygiene performed after the removal of a soiled dressing. LPN B stated Yes, gloves should be changed after removing the dressing. LPN B was asked if she should take the treatment cart into the resident's room when providing care. LPN B stated No, it should not but the resident did not have space for supplies on her over the bed table. LPN B was asked, would it be better to obtain an additional table if available instead of using the treatment cart in the resident's room. LPN B stated Yes, it would. LPN B failed to perform hand hygiene after the removal of the soiled dressing, used the treatment cart in the resident's room and failed to clean the outside of the treatment cart after use. During an interview on 10/13/2025 at 4:19 PM, the Director of Nursing (DON) was asked, when staff should wear PPE for EBP. The DON stated, Staff should wear PPE when providing care to residents with wounds, peg tubes, and catheters. The DON was asked if staff should perform hand hygiene after the removal of a soiled dressing. The DON stated, Yes, the nurse should change gloves and perform hand hygiene after removing the dressing. The DON was asked if staff should perform hand hygiene in between changing of gloves. The DON stated, Yes, staff should perform hand hygiene before and after the removal of gloves. The DON was asked if treatment carts should be taken into resident's rooms when performing care. The DON stated, No, they should not.

Based on Centers for Disease Control (CDC) Guidance, policy review, medical record review, observation, camera footage, and interview, the facility failed to implement appropriate safety measures to ensure the highest practicable well-being for 1 resident (Resident #13) of 3 residents reviewed for elopement. Resident #13 eloped the facility without staff knowledge and supervision on 5/5/2023. Resident #13 was known for drug seeking and left the facility with a Peripherally inserted central catheter (PICC - a tube inserted in a large vein above the right side of the heart, used to administer medication by licensed professionals). The facility's failures placed Resident #13 in Immediate Jeopardy. 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 was notified of the Immediate Jeopardy (IJ) for F-684 during the complaint investigation on 5/11/2023 at 4:54 PM, in the Conference Room. The facility was cited Immediate Jeopardy at, F-684. The facility was cited at F-684 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 5/5/2023 and is ongoing. The findings include: 1. Review of CDC Guidelines for the Prevention of Intravascular (within a blood vessel) Catheter-Related Infections dated 2011, revealed .Central Venous Catheters Recommendations .Promptly remove any intravascular catheter that is no longer essential . Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2022, 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 .Reporting .The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services [APS] and to all other required agencies ( .law enforcement .) within specified timeframes .Immediately, but not later than 2 hours after the allegation is made . Review of the facility's policy titled Peripherally Inserted Central Catheter Flushing, Locking, Removal, dated 2022, revealed .It is the policy of this facility to ensure the peripherally inserted central catheters (PICC) .removed consisted with current standards of practice .Peripherally inserted central catheter removal will be performed by the practitioner or nurse in accordance with facility policy and your state's nurse practice act .Removal of a peripherally inserted central catheter will occur at the end of therapy .Obtain a physician's order for removal . Review of the facility's policy titled Elopement and Wandering Resident, dated 2/22/2022, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents, and receive care in accordance with their personal-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident .leaves the premises or a safe area without authorization ( .an order for discharge or leave of absence) and/or any necessary supervision to do so .Adequate supervision will be provided to help prevent .elopements .Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol .The designated facility staff will look for the resident .If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office .DON [Director of Nursing] .or designee shall notify the physician and family member or legal representative .Appropriate reporting requirements to the State Survey agency shall be conducted .Documentation in the medical record include: findings form nursing and social service assessments . 2. Review of medical record revealed Resident #13 was admitted on [DATE], with a diagnoses of Endocarditis, Sickle Cell Trait, Chronic Hepatitis, and Cocaine Abuse. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. The Discharge Plan for Resident #13 was blank and the Return to Community section was blank. Review of physician Orders dated 4/18/2023, revealed .Q [every] 4 hours nurse visual checks on resident related to history of substance abuse with accidental overdose . Review of the Social Service Note dated 5/2/2023, revealed .[Name Social Worker #1] This writer placed a call to [Name Resident #13 mother] .and/she stated [Named Resident #13] would b e [be] discharging home with her .[Named Resident #13] will discharge home on Sunday, mother is aware and ok with discharge. Social will continue to assist as needed . Review of Physician Orders dated 5/5/2023 at 11:00, revealed .Remove PICC Before Discharging Home on Saturday 5/6/2023 .No Narcotics to be sent home w/[with] resident at Discharge . Review of the Nurse Note dated 5/5/2023, and created on 5/8/2023 at 11:15 AM, revealed .Late Entry . [LPN #13] .Resident scheduled for discharge tomorrow 5/6/2023. I reminded resident that her last medication would be given at 10 am [10:00 AM]. Resident verbalized understanding and returned to her room. Resident is alert and oriented X [times] 4. Resident is able to make all of her needs known . Review of the Medication Administration record dated 5/1/2023-5/31/2023, revealed on 5/5/2023 on the 11:00 PM -7:00 AM shift, Resident #13 was charted as being in the building at 2:00 AM by LPN #5. At 6:00 AM there was no documentation of the residents whereabouts, the space was blank. Review of Resident #13's Release of Responsibility for leave of absence form was blank with no documentation Resident #13 went on a leave of absence. Review of the DAILY GROUP ASSIGNMENT dated 5/5/2023, revealed on the 11:00 PM-7:00 AM shift, LPN #5 was the only nurse working with 3 Certified Nursing Assistant (CNAs). There was no Registered Nurse (RN) scheduled in the facility on the 11:00 PM-7:00 AM shift. Review of the video footage for 5/5/2023, revealed the following: At 10:55 PM, [Name Receptionist #1] walked to the front desk. At 11:06 PM, unknown staff at the desk on her phone. At 11:10 PM, agency staff walked to the lobby and walked back down the 100 hallway. At 11:11 PM, Resident #13 walked to the lobby with her wheelchair full of her belongings. Resident #13 was dressed in a dark jogging suit and the resident was wearing a white ball cap. Resident #13 walked back down the 100 hallway. At 11:12 PM, Resident #13 left the wheelchair in the lobby with her belongings. At 11:15 PM, Resident #13 walked back in the lobby with 2 more bags of her belongings and placed them in the wheelchair. Receptionist #1 remained sitting at the front desk. At 11:17 PM, Resident #13 exited the building with her belonging in the wheelchair, At 11:17:42 PM, Resident #13 was outside of the facility. Resident #13 walked to the left and proceeded to walk down the sidewalk, out of sight of the camera and into the dark, as she was pushing the wheelchair with clothing and other belongings . Review of the 24-HOUR REPORT/CHANGE OF CONDITION REPORT, revealed on 5/5/2023, and 5/6/2023, there was no documentation of Resident #13 being discharged or that the resident had left the facility Against Medical Advice (AMA). During an interview on 5/9/2023 at 7:06 AM, with Receptionist #1 was asked if she was working on Friday 5/5/2023 when Resident #13 exited the building. Receptionist #1 stated .I didn't know .I thought it was somebody going home to be discharged .her face was turned so I couldn't really see who it was . Receptionist #1 was asked how did Resident #13 get out the front door without a code. Receptionist #1 .I don't remember .I said to myself they must be a discharge home .[Resident #13] kept her face turned away from where I could see it .if I had seen her face I would have known to not let her out . Receptionist #1 was asked if she had passed ice to Resident #13's room and was the Resident in the room at that time. Receptionist #1 stated .Yes [I passed ice] .it was around 2:00 AM .I thought [Resident #13] was in the bathroom . During an interview on 5/9/2023 at 7:27 AM, Agency Certified Nursing Assistant (CNA) #1, was asked what she knew about Resident #13 leaving the facility on the night of 5/5/2023. Agency CNA #1 stated .I do not know her name [Resident #13] she was not here .I was late .I got here around 12:00 AM or 12:15 AM .when I got here I took a picture of my assignment .there was only 1 nurse for down stairs .3 CNAs nobody noticed she [Resident #13] was gone .it did not come up until Monday when I came in .I told them I did not see anyone wandering .they said she [Resident #13] left around 11:15 PM .I wrote a statement on Monday around 1:00 PM .I told them I did to see her .when I went to her room .I thought and assumed that was her [Resident #13] it was a man .not her .she slipped through the cracks .I worked all Friday night and no one knew she was gone . During an interview on 5/9/2023 at 8:49 AM, the Assistant Director of Nursing (ADON) was asked if she was aware Resident #13 had left the building on the night of 5/5/2023. The ADON stated .[Resident #13] was due to be discharged on Saturday morning on 5/6/2023 .she left the night before . The ADON was asked if they had found Resident #13. The ADON stated .No .staff members looked next door .called police for a wellness check . The ADON was asked if a resident with a PICC line should discharge themselves. The ADON stated .No .that would have been pulled [the PICC removed by licensed professionals] . During an interview on 5/9/2023 at 9:23 AM, the DON was asked were the Police called about Resident #13 missing. The DON stated .Yes .later in the day on Saturday around 2:00 PM . The DON was asked when was she notified that Resident #13 was missing. The DON stated .around midnight .by LPN #5 . The DON was asked why the Police were not called at midnight once she was aware Resident #13 was missing and also had a PICC. The DON stated, .[Resident #13] was so adamant about leaving .she [Resident #13] would not allow them to take it out .she [Resident #13] was scheduled to be discharged home on Saturday after her IV [Intravenous] antibiotics .she said she was going to stay with her [Named Aunt] next door .we reached out to her mom as well . The DON was asked if LPN #5 documented that Resident #13 discharged her self or signed an AMA form. The DON stated .I will have to see if she did or not . The facility was unable to provide any documentation that Resident #13 was discharged or refused to sign the AMA form. During an interview on 5/9/2023 at 1:15 PM, Unit Manager #1 was asked if she worked on Saturday morning 5/6/2023. Unit Manager #1 stated .no I was [out of town] . Unit Manager #1 was asked when did she find out Resident #13 had left the facility with a PICC. Unit Manager #1 stated .Saturday [5/6/2023] .around 2:30 PM or 3:00 PM . Unit Manager #1 was asked who notified her. Unit Manager #1 stated .nobody .I was talking to LPN #14 on the phone she was working 3-11 [3:00 PM - 11:00 PM] .she called me to see where she was going [needed to be working that shift] .I did not write her on the schedule for Saturday . [LPN #14] told me that [Named Resident #13]had already left . Unit Manager #1 was asked if the nurses had removed Resident #13's PICC line prior to the resident leaving. Unit Manager #1 stated .that did not come up . Unit Manager #1 was asked if she had been notified on Saturday 5/6/2023 that Resident #13 was missing from the facility. Unit Manager #1 stated .think I did .when I talked to LPN #14 .the conversation came up that [RN #1] did not give her [Resident #13] antibiotic that day .she [RN #1] said the lady [Resident #13] had already left .[Named LPN #5] said she seen [Resident #13] and she never said anything about [Resident #13] leaving . Unit Manager #1 was asked what did you do when you found out Resident #13 was not in the facility. Unit Manager #1 stated .that is when I called [Named LPN #5] to see and ask her about [Named Resident #13] .she [LPN #5] said that [Named Resident #13] was here [at the facility] when she got here 5/5/2023 at 7:00 PM .that is all she [LPN #5] said .I asked her did [Resident #13] leave .she [LPN #5]] said yeah she had left . Unit Manager #1 was asked if she was told Resident #13 left without staff knowledge. Unit Manager #1 stated .not until I got here Monday [5/8/2023] .I was talking with [Named ADON] she said that they [Management] said [Resident #13] left at 11:00 PM [5/5/2023] that night .went next door . Unit Manager #1 was asked how did you know Resident #13 went next door. Unit Manager #1 stated .I am just going by what I was told .I was out of town . During a Telephone interview on 5/9/2023 at 3:15 PM, Resident #13's [Family Member #1] was asked if she [Family Member #1] had spoken with anyone at the facility regarding the night Resident #13 left without staff knowledge. Family Member #1 stated .No, not until Saturday [5/6/2023] .they [Administrator] called me .around 6:00 PM .they [Administrator] asked me if I had seen [Named Resident #13] .they [Administrator] asked if I had seen or spoken with her [Resident #13] .if I do to let them [Administrator] know .so they [Administrator] can know she [Resident #13] is alright . During an interview on 5/9/2023 at 3:26 PM, the DON was asked about the documentation on the Medication Administration Record (MAR)which showed that LPN #5 had visualized Resident #13 on 5/6/2023 at 2:00 AM. The DON stated .[LPN #5] was just clicking [checking the boxes] .just clicking . The DON was asked if LPN #5 was the only nurse working on the first floor the night Resident #13 went missing. The DON stated, I'm not sure. The DON was asked what was the census on the first floor the night Resident #13 went missing. The DON stated .I'm not sure . The DON was asked if LPN #5 told her Resident #13 had left at 12:03 AM on 5/5/2023. The DON stated .Yes .I told her [LPN #5] there is nothing we can do . The DON was asked if it was acceptable for Resident #13 to be discharged or leave AMA with a PICC line. The DON stated .LPN #5 did not mention the PICC line . The DON was asked if it was safe for Resident #13 a known IV drug user to leave the facility with a PICC line. The DON stated .I certainly did not want her [Resident #13] to . During an interview on 5/9/2023 at 4:14 PM, the Activity Director was asked who called the Code Doctor Find (the facilities code for missing residents). The Activity Director stated .[Name LPN #14] did . The Activity Director was asked what time of day was it. The Activity Director stated .it was probably around 3:30 or 4:00 PM .on Saturday .5/6/2023 . The Activity Director was asked what areas were searched for Resident #13. The Activity Director stated .we did the normal up and down the street .some got in the car and went around the corner .after a while we decided to look over there [the towers an apartments next door to the facility] . The Activity Director was asked if it was the first time they [LPN #14 and Activity Director] were alerted that Resident #13 was not in the building. The Activity Director stated .I was the manager on duty .I didn't come in until around 3:00 PM .on 5/6/2023 . During an interview on 5/9/2023 at 4:39 PM, LPN #14 was asked if Resident #13 was in the facility when she came to work on 5/6/2023 on the 7:00 AM shift. LPN #14 stated .nope . LPN #14 was asked how did she know Resident #13 was not in the facility. LPN #14 stated .I counted [medication cart] with [Name RN #1] on the first floor .she worked medication cart 3 .I called [Named Unit Manager #1] for something .I told her I did not want to work on the first floor .she sent me upstairs .[Named Unit Manager #1] asked me to ask [Named RN #1] if she pulled [removed] the midline [PICC Line] before Resident #13 left .[Named RN #1] said she hadn't seen her [Resident #13] .I called [Named Unit Manager #1] back .[Named RN #1] said she wasn't here .[Named Unit Manager #1] told me to do a Doctor Find .we all looked in the bathrooms .resident rooms .a little enclosed area off the dining room .[Resident #13] would sit on the couch back there .all over the building .outside .me .[Activity Director] I went next door [to the tower apartment building] . During a Telephone interview on 5/9/2023 at 5:57 PM, RN #1 was asked when did you know Resident #13 was not in the building. RN #1 stated .when I arrived [5/6/2023 at 7:06 AM] .I never put my eyes on her [Resident #13] .I asked her [Resident #13's]roommates about her .they [roommates] said she [Resident #13] was gone . RN #1 was asked if she notified the DON that Resident #13 was not in the facility. RN #1 stated .Yes .she [DON] told me she was discharged . During a Telephone interview on 5/10/2023 at 8:27 PM, CNA #7 was asked if she worked on 5/5/2023 - 5/6/2023 on the 11:00 PM - 7:00 AM shift. CNA #7 stated, .Yes on the first floor . CNA #7 was asked when did she find out Resident #13 was missing. CNA #7 stated .[Named Unit Manger #1] called me .that night [5/6/2023] .she asked me if I had [ provided care to Resident #13] .I told her I did not know who she was .I worked the front end [of the hallway] .I did not hear anything [about Resident #13 leaving] till Sunday [5/7/2023] night when [Named Unit Manager #1] called me and asked if worked Saturday night .she told me she [Resident #13] was missing .it was around 6:05 PM on [5/7/2023] . CNA #7 was asked if the staff knew she was to be discharged or missing from the facility on Saturday. CNA #7 stated .I don't think no one knew she was missing .we did not hear anything that night about a resident being missing . During an 5/10/2023 at 8:59 AM, the Medical Director and Family Nurse Practitioner (FNP) were asked if they were aware Resident #13 went missing from the facility on the night of 5/5/2023. The Medical Director stated .Yes .I already know about it .she left the building with IV line . The Medical Director was asked when was the last time he saw Resident #13. The Medical Director stated 7 days ago. The Medical Director was asked if Resident #13 told him she was going to leave the building. The Medical Director stated .No, [Resident #13] said 'I'm happy' .she was pleasant .the resident never mentioned that [she was leaving] . The Medical Director was asked if he was aware Resident #13 left the facility with her PICC line and was it safe. The Medical Director stated .No .it is not safe .not with the line . The Medical Director was asked would he consider Resident #13's exit from the facility as an elopement. The Medical Director stated .Yes .because of the PICC line [Resident #13] had planned to be discharged on Saturday [5/6/2023] .the danger is [Resident #13] will put drugs in the PICC line .that is the reason she came here for ATB [Antibiotics] because it was not safe for her to receive them at home . During an interview on 5/10/2023 at 10:27 AM, Unit Manager #2 was showed the 24-hour report sheet for 5/5/203 and 5/6/2023. Unit Manager #2 was asked if she can see where there was anything documented on 5/5/2023 or 5/6/2023, that Resident #13 was discharged , or had left AMA. Unit Manager stated .I do not .it should be documented on the 24-hour report sheet it is the same thing as someone going home . During an interview on 5/10/2023 at 5:40 PM, the DON was asked was she aware the staff had called a Doctor Find for Resident #13. The DON stated .no .I did not . During an interview on 5/11/2023 at 11:46 AM, Unit Manager #2 was asked if was it safe to have one nurse working on the 11:00 PM - 7:00 AM shift with 51 resident and 3 CNAs. Unit Manager #2 stated .No .I have to say no . Unit Manager #2 was asked if she was informed LPN #5 had a new admission at 12:00 AM. Unit Manager #2 stated .No .that is a lot .I was not informed as the Unit Manager . Unit Manager #2 was asked when she was made aware that LPN #5 was the only nurse working on the 11:00 - 7:00 AM shift on 5/5/2023 - 5/6/2023. Unit Manager #2 stated .the next day when we were discussing [Named Resident #13] .when we learned [Resident #13] had left the building . Unit Manager #2 was asked when did she find out Resident #13 was missing from the facility. Unit Manager #2 stated .when I got the call on Saturday around 3:30 PM or 4:00 PM .[Name Unit Manager #1] called me .she said were you aware [Named Resident #13] was missing from the facility .left the building . I said no .I was not aware of that . Unit Manager #2 was asked should a resident be discharged or signed out AMA with a PICC line. Unit Manager #2 stated .if [Resident #13] knows she was leaving .[the Resident] will be informed to wait for a RN to come and pull [remove] the PICC line . Unit Manager #2 was asked if you have a resident who refused to sign the AMA form should that be documented in the resident chart. Unit Manager #2 stated .it should be documented in the medical records .yes . During a interview on 5/11/2023 at 4:35 PM, the Administrator and DON were asked if they called the police when they were notified Resident #13 was missing . The Administrator stated .Yes .for a wellness check .to see if she was ok .to do a follow-up .we do follow-ups sometimes . The DON was asked if the nursing staff would document [an AMA or was discharge] on the 24-hour report sheet. The DON stated .it is hit or miss it may or may not . The DON was asked if it safe for a resident to leave the facility with a PICC line. The DON stated .I don't consider it to be safe but apparently she [Resident #13] decided otherwise . The DON was asked should the nursing staff document in the resident chart they checked them at 2:00 AM on the MAR if she was not in the facility. The DON stated .No .she should not have gone through there just clicking . The DON was asked if the Medical Director was notified of the AMA. The DON stated .they did not communicate .[Named RN #1] knew [Resident #13 left the building] .she [RN #1] was the supervisor . The DON was asked should a resident be discharged or allowed to leave AMA with a PICC line. The DON stated .I did not think about the PICC line . The Administrator was asked if you have a resident with a known history of IV drug use with a PICC line is she safe exiting the facility. The Administrator stated .I can't say she is not unsafe . The Administrator was asked who was responsible for the safety of the residents in this building. The Administrator stated .every employee takes on the responsibility of the residents .the management team . During a telephone interview on a 5/14/2023 at 3:32 PM, LPN #5 was asked if she discharged Resident #13. LPN #5 stated .no ma'am .I saw this lady [Resident #13] walking out with clothes .I asked [Resident #13] where was she going .[Resident #13] said she was going up front [lobby] .give to family or friend [her belongings] .so she [Resident #13] won't have so much to take out in the morning .[Resident #13] was still in the facility .[Resident #13] never told me she was leaving the facility .I would have called [Name DON] .I'm a smart nurse .I told [Named DON] .I saw her throughout the night .I saw Resident #13 lying on the couch up front .saw her [Resident #13] throughout the night multiple times .the same thing I told .[Named DON] .I did not know that [Resident #13 was missing] until [Named DON] called [On 5/6/2023] .I was so busy dealing with staff .It was so much on my mind that night .at 12:00 AM .I got a new admission . LPN #5 was asked if she called the DON around on 5/6/2023 at 12:00 AM to tell her Resident #13 was missing. LPN #5 stated .No .Never .I did not tell her [DON] she [Resident #13] was gone .no ma'am .she [Named DON] .[Named DON] tried to get me to say that [Resident #13 was discharged or left AMA] . LPN #5 was asked when did she talk with the DON about Resident #13. LPN #5 stated .I spoke to [Named DON] at 5:00 PM on Saturday [5/6/2023] .she [DON] was just dump founded [in shock] .I told her it [Resident #13 was missing] can't be true .I thought I seen her [Resident #13] throughout the night .walking through the hall .not 100 % [percent] sure .I would not have clicked on 2:00 AM .if I felt in my heart she was not there .if I made a mistake it was an honest mistake .when I left I was happy I made it through the night . LPN #5 was asked if a resident with a PICC line should be allowed to leave the facility with the PICC line. LPN #5 stated .as a LPN I don't think I would . it's a RN duty .no .never I know better than that . LPN #5 was asked if she called the police. LPN #5 stated .No .I did not have no reason to .we did not know nothing about this till 5:00 PM .the next evening .it was me and . CNAs [ Named CNA #7, CNA #13] .for 58 residents .[Named LPN #12] told me .just focus on tube feedings .blood sugar checks .pain meds [medication] .so I focused on the tube feedings .there was at least 20 tube feedings .I have to do what I have to do .if a resident called for pain meds .I took care of them .making sure everyone was breathing .checking on my hospice patient .it was hard mentally .I could not leave . LPN #5 was asked if any of the nurses upstairs came down to help her. LPN #5 stated .No ma'am .I told them I was by myself .I talked to [Named LPN #6] .I had no orientation .I asked for help .they [LPN #12 and #21] would not help me .

Based on policy review, medical record review, observation, video footage review and interview, the facility failed to ensure a safe environment and provide supervision and oversight to prevent the potential for serious injury for 2 residents (Resident #2 and Resident #12) of 6 residents reviewed with a known history of substance abuse, who overdosed in the facility and failed to implement an effective fall prevention program for 3 residents (Resident #8, #9, and #15) reviewed for falls. On [DATE], Resident #8, a resident with a history of seizures, was left alone during a seizure with his bed in a high position. The resident fell from the bed and sustained a fractured neck, which resulted in the resident's death on [DATE]. The facility's failures placed Resident #2, #8, #12, and #15 in Immediate Jeopardy. 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 and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-689, during the complaint investigation on [DATE] at 9:37 AM, and on [DATE] at 10:44 AM, in the Conference Room. The Administrator was notified of the Immediate Jeopardy (IJ) for F-835 during the complaint investigation on [DATE] at 12:37 PM, in the Conference 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 Immediate Jeopardy existed from [DATE] and is ongoing. The findings include: 1. Review of the facility's policy titled Opioid Overdose Management, dated 2022, revealed .The facility will review the residents' medications and history to determine if opioids are in use or they have a history of addiction, opioid use disorder .The facility will keep naloxone (Narcan) readily available and located in a designated area to be administered as per facility protocol and physician order . Review of the facility's policy titled Resident Possession and Use of Illegal Substances, dated [DATE], revealed .To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bring illegal substances into the facility . Review of the facility's undated policy titled, Fall Risk Assessment, revealed, It is the policy of this facility to provide 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 .The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified .An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly .the At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk for an accident .Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice . Review of the facility's undated policy titled, Head Injury, revealed, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury .Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician . Review of the facility's policy titled, Assessing Falls and Their Causes, revised ,d+[DATE], revealed, .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .After a Fall .If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to head, neck ,spine and extremities . 2. Review of medical record, showed Resident #2 was admitted on [DATE], and readmitted on [DATE] with diagnoses of Paraplegia, Substance abuse, Neuromuscular Dysfunction of Bladder, Anxiety Disorder, and Chronic Pain. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #2 was assessed with a Brief Interview for Mental Status score (BIMs) of 15, indicating he was cognitively intact, and a history of substance abuse. The facility failed to care plan Resident #2 who had a known drug abuse history. Review of the Progress Notes dated [DATE], revealed .This nurse was call to resident room .Upon entering his room, I observe [Resident #2] laying in bed. His name was call [called]. No response. I check the .pulse. No pulsation was felt. No breathing noted. His skin warm to touch. This nurse initiated the emergency response code blue was called on the unit. 911 was call! [exclamation point] We initiate CPR [Cardiopulmonary resuscitation] until defibrillator was available. No shock was advise. CPR was continued for two minutes, check for circulation. The cardiac rhythm was reassess to determine the need for further countershock. This nurse felt carotid pulse. Compression was stop. We continue rescue breaths. First responders arrive on site, along with MPD [Memphis Police Department]. We explain the above situation to paramedic. His emergency contact [Name Contact] wasn't available. We notified FNP [Family Nurse Practitioner] and DON [Director of Nursing]. [Resident #2] was taken to [Named Hospital] . Review of the Physician's Orders date [DATE], revealed .Send to ER [emergency room ] for Evaluation [due to the staff finding the resident unresponsive and requiring CPR] . Review of the Hospital Records dated [DATE], revealed Resident #2 was .sent from nursing home for overdose .given total 6mg [milligrams] Narcan by EMS .pt [Resident #2] awake and answering question at arrival .Opiate [narcotic pain medication] overdose .UDS [urine drug screen] positive for opiates .Given 6mg of Narcan prior to arrival . During an interview on [DATE] at 2:07 PM, the Administrator and the Director of Nursing (DON) were asked about finding Resident #2 unresponsive and requiring CPR. The DON stated .we called 911 .he was sent to the hospital .we notified police .they came and took the drugs on the table and tested it .was later told it was fentanyl .we looked at the sign in sheet .gave the office the name who came to see him that day . The DON was asked if the facility gathered any witness statements. The DON confirmed they did not have any witness statements, did not complete an incident report, and did not complete an investigation as to how the resident obtained opiate medications to overdose. During an interview on [DATE] at 3:05 PM, Licensed Practical Nurse (LPN) #11 was asked if she could tell what happened when Resident #2 overdosed in the facility. LPN #11 stated . the CNA [Certified Nursing Assistant] was making round .she call me said something going on . he [Resident #2] not responding .I rushed to the room .I called his name checked his pulse and no pulse .I called RT [Respiratory Therapy] to the room .he was not responding or breathing .I called a code blue .called 911 .got the crash cart .started CPR .EMS [Emergency Medical Services] . the police had arrived .he was sent to the hospital . LPN #11 was asked if she filled out an incident report or wrote a statement. LPN#11 stated .because it was an emergency, I did not think about an incident report or statements .I just wrote a nursing note . The facility failed to monitor and put appropriate interventions in place for Resident #2 who had a known history of drug overdose in the facility and had a history of substance abuse. 3. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] from an acute care hospital, with diagnoses of Lupus, Protein Calorie Malnutrition, Adult Failure to Thrive, Chronic Pain, Hypertension, Diabetes and Sarcoidosis. Review of Resident #12's hospital discharge medications dated [DATE], revealed .naloxone [Narcan] 4mg .nasal spray .1 spray .Nasal Every 2 min [minutes] prn [as needed] . Review of the 5-day MDS dated [DATE], revealed Resident #12 was assessed with a Brief Interview for Mental Status score (BIMs) of 14, indicating he was cognitively intact, and no indication of substance abuse. Review of the Progress Note dated [DATE], revealed .Resident found in room unresponsive snoring loud skin cool and clammy. Attempted to awaken the resident but no response. Resident was position in a upright position. Narcan 4mg adm [administered] via [by] nasal spray in each nostril. Begin sternum rubs, resident became responsive and was moving extremities. 911 was contacted. EMT [Emergency Medical Technician] arrived and transported resident to hospital via stretcher 2 assistants . Review of the Physician's Orders dated [DATE], revealed .Transfer to ER [emergency room ] for evaluation [due to staff finding the resident unresponsive] . Review of Resident #12's Physician's orders dated [DATE] - [DATE], showed no order for Narcan administration. Review of the Hospital records for Resident #12 dated [DATE], revealed .[Named Resident #12] .was admitted with an accidental overdose with oxycodone and Benadryl .He had reportedly saved his pain medication and then was found to have altered mental status due to an accidental overdose. He was given Narcan . During an interview on [DATE] at 5:17 PM, Licensed Practical Nurse (LPN) #17 was asked if she knew when Resident #12 overdosed in the facility. LPN #17 stated .he [Resident #12] overdosed in December I was not working .I did hear of the issues [drug overdose] of him having that issue before .he was drug seeking .he was on a pain medication .prn [as needed] medication .he would request the drug every 4 hour on the clock . During an interview on [DATE] at 9:54 AM, the DON was asked if Resident #12 had a history of substance abuse. The DON stated .Yes .he did . The DON was asked if she completed an investigation. The DON stated .No .it's not unusual anymore (drug abuse) these young people .they do drugs . 4. Review of the medical record revealed Resident #8 was admitted on [DATE], with diagnoses of Polyneuropathy, Cerebral Infarction, Hypertension, Seizures, and Aneurysm. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was assessed with a Brief Interview for Mental Status score (BIMs) of 15, which indicated that Resident #8 was cognitively intact, required limited assistance from 1 staff member for bed mobility, and had Range of Motion (ROM) limitations to both sides on the lower extremities. Review of Resident #8's Care Plan dated [DATE], revealed .anticoagulant therapy with potential complications .at risk for falls due to impaired balance, and HX [history of] falls .keep bed in low position and brakes locked when in bed .ADL [activities of daily living] self-care performance deficit .has a seizure disorder with potential for complications .Advance Directive on record .Resuscitate/Full code/CPR .Initiate CPR if I am found without respiration and /or pulse . Review of an Unwitnessed Fall Incident Report for Resident #8 dated [DATE], revealed .Unwitnessed .Date XXX[DATE] 22:28 [10:28 PM] .Incident Location .Resident's Room .Incident Description .At the 2000 [8:00 PM] hour the aide [CNA #11] yelled out for me to come and assist with resident in room [Resident #8's room]. Once I entered the room I observed resident on the floor unresponsive and blood near the resident's head. I asked aide what happened, aide stated he was yelling out to alert me of a status change in [Resident #8]. He stated that he stepped to the door to call for me and when he turned around resident was on the floor .Resident Description .Resident Unable to give Description .Immediate Action Taken .I called for the second nurse, who alerted the 3rd nurse to get crash cart, code was called and CPR was started, 911 [emergency call number] and CPR was continued until the paramedics arrived .Level of Consciousness .Comatose [Un-arousable to verbal or physical stimuli] . Review of the video footage dated [DATE], revealed CNA #11 at 7:50:29 PM entered Resident #8's room. At 7:51:06 PM, a nurse exited the resident's room with a white piece of paper in her hand. At 7:51:47 PM, CNA #11 was in hallway by the linen cart and then he reentered Resident #8's room. At 7:52:40 PM, CNA #11 exited Resident #8's room, entered the room next door, walked out of the room with sheets in his hand and reentered Resident #8's room at 7:53:10 PM. At 8:01:04 PM, CNA #11 exited Resident #8's room walking fast down the hallway passing the nursing station and turned the corner to the left out of the camera sight. At 8:01:26 PM, CNA #11 walked back around the corner with a nurse behind him and both entered Resident #8's room [ROOM NUMBER]:01:37. At 8:02 PM, a nurse and another staff member entered the resident's room. At 8:03 PM, a nurse exited Resident #8's room, the nurse turned to the left and entered the nursing station. At 8:08 PM, a nursing staff member was observed walking down the hallway with the crash cart. At 8:14 PM, EMS arrived in Resident #8's room. At 8:35 EMS exited the resident's room with Resident #8 on a stretcher. Review of the facility's Skilled Nursing Facility (SNF) / Nursing Facility (NF) Hospital Transfer Form dated [DATE], revealed Resident #8's vital signs were .BP [blood pressure] ,d+[DATE] .HR [heart rate] 76 .Temp [temperature] 97.4 .Sent To .[Named Hospital] .Date of Transfer XXX[DATE] 20:41 [8:41 PM] .Date Transferred to hospital XXX[DATE] . Review of the facility's Situation, Background, Assessment, Recommendation (SBAR) Communication Form revealed .Mental Status Evaluation .Increased confusion or disorientation . Review of the facility's Nurses Note dated [DATE], revealed .THIS NURSE CALLED TO [Resident #8's] ROOM BY HIS NURSE STATES [the resident] HAD FALLEN OUT OF BED, NURSE AND CNA [certified nursing assistant] AT BEDSIDE WITH RESIDENT, RESIDENT NOTED LYING ON THE BED ON HIS BACK NEXT TO BED, BLEEDING NOTED FROM HEAD, RESIDENT WAS NOT BREATHING NO PULSE NOTED CPR STARTED, OTHER SECOND FLOOR NURSE ENTERED ROOM WITH CRASH CART AND CPR CONTINUED USING COMPRESSIONS .911 CALLED AT BEDSIDE PER THIS NURSE AT 8:03 PM, CPR CONTINUED UNTIL PARAMEDICS ARRIVED AND TOOK OVER, RESIDENT TRANSFERRED TO [named hospital] AT 2037 [8:37 PM], RESIDENTS NURSE SPOKE WITH RESIDENTS BROTHER .THIS NURSE CALLED AND INFORMED DON OF FALL AND TRANSFER . Review of a Hospital's Emergency / Urgent Care Record Addendum for Resident #8 dated [DATE], revealed .[Resident #8] in the emergency department and critically ill with cervical spine fracture and on ventilator .History of Present Illness .was brought to the emergency department by EMS after cardiac arrest, EMS reports that the nursing home staff states they were changing the patient and he fell and hit his head. They found the patient to be in cardiac arrest when they checked on him. CPR was started by nursing home staff. EMS reports that once they arrived on the scene 2 epis [epinephrine- a medication given during CPR to stimulate the heart] and 1 bicarb [sodium bicarbonate-medication given during CPR to maintain carbon monoxide levels] were given .after approximately 20 minutes of downtime .EMS reported that the patient arrested again shortly prior to arrival to the emergency department .They state that the resident was in PEA [pulseless electrical activity] (a serious medical condition characterized by unresponsiveness and no pulse) .HEAD .Hematoma and abrasion right forehead .Procedure .Endotracheal intubation [a medical procedure where a plastic tube is placed in the airway to promote air for a patient that cannot breath on their own] .Indication .Respiratory failure, Airway protection .CT [computed tomography scan - an in depth xray of the body] of head shows no acute findings .Differential Diagnosis .Intracranial hemorrhage [bleeding within the brain], cervical spine fracture .CT scan of head shows no obvious acute findings. CT cervical spine shows C2 fracture with dislocation as well as C1 fracture .Disposition .Patient is being admitted to ICU [Intensive Care Unit]. Patient is in neurogenic shock [a condition caused from a injury or condition that cause central nervous system damage or spinal cord injury, which regulates breathing and other automatic bodily functions] .Patient has significant cervical spine fracture and dislocation. Very poor prognosis .Impression / Plan .Cervical spine fracture, Cardiac arrest, Neurogenic shock . Review of Consultation Notes dated [DATE], revealed, .Assessment .[Resident #8] with a C2 fracture .and fracture .C1 and C2 s/p [status post] fall with devastating quadriplegia secondary to traumatic subluxation [joint dislocation] and code event in the field .given patient age and devastating neurologic injury, he is not a candidate for surgical intervention .Recommend palliative care and consideration of withdrawal of life supporting measures .palliative care once family is ready . Review of Resident #8's hospital Discharge Summary, dated [DATE], revealed, .Date of Admission XXX[DATE] .Date of Discharge XXX[DATE] 0345 TOD [time of death] .Discharge Diagnosis .Traumatic subluxation and presumed cord injury s/p fall at nursing home with C2 Cervical spine fracture and . C,d+[DATE] .fractures .Cardiac arrest with prolonged downtime .Neurogenic shock .Acute Hypoxic Respiratory Failure-intubated . Review of Resident #8's medical record revealed no documentation the facility completed a Root Cause Analysis for the fall that occurred on [DATE] until [DATE], 4 days later after the surveyors brought it to their attention. 5. Review of the medical record revealed Resident #9 was readmitted to the facility on [DATE], with diagnoses of Metabolic Encephalopathy, Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, Dementia, Difficulty Walking, Psychosis, and Lack of Coordination. Review of Resident #9's Care Plan dated [DATE], revealed, .High risk for falls r/t [related to] Confusion, and Gait/Balance problems . Review of a Fall Report for Resident #9 dated [DATE], revealed, .Witnessed .Incident Location .Resident's Room .9:35 AM .Incident Description .Resident fall backwards while standing in the doorway .large laceration to scalp w [with]/ excessive amount of blood noted under head .Notified [family member] .requested be transferred to hospital .Immediate Action Taken .ROM . Pressure applied to laceration back of head scalp . Review of the Hospital's Emergency Department (ED) Report for Resident #9 dated [DATE], confirmed Resident #9 was sent to the ED for a laceration to the scalp and received 7 staples. Review of the facility's investigation for Resident #9's fall that occurred on [DATE], revealed the facility failed to complete neuro checks upon the resident's return from the hospital on [DATE]. Review of a Unwitnessed Fall Incident Report, dated [DATE] at 6:00 AM .Incident Location .Hallway .Incident Description .at 6 AM this writer heard a loud thump, turned around and noted Resident lying on the floor in the hallway with head lying in a small pool of blood .NP notified .Resident being sent to [named hospital] d/t [due to] deep laceration to the back of head .[family member] called no response .Immediate Action Taken .laceration cleansed with soap and water and kerlix was wrapped around Resident's head .PEARL [pupils equal active round to light] .Returned from the hospital on [DATE] at 15:09 [3:09 PM] .N/O [New Order] for orthostatic b/p [blood pressure] . Review of Resident #9's Comprehensive Care Plan dated revealed the intervention for the [DATE] fall was to encourage resident to mobilize in wheelchair when out of room. Review of the facility's investigation for Resident #9's fall on [DATE], revealed the facility failed to continue with neurological checks upon the residents return from the hospital on [DATE], and failed to complete a Pain Assessment Tool. Review of Resident #9's Nurses Note dated [DATE], revealed, Unable to arouse resident .unable to get resident to stand .NP present and new order to send resident out to ER [emergency room ] .Neurology appointment canceled and sending resident to [named hospital] . Review of the medical record revealed Resident #9 was transferred out to the hospital on [DATE] and returned on [DATE] with diagnoses of head trauma. Review of a Witnessed Fall Incident Report for Resident #9 dated [DATE], revealed, .Incident Location .Hallway .Incident Description .per Nurse .resident observed falling on the floor. Resident observed laying on right side. Blood noted coming out of open area on right temporal .Immediate Action Taken .911 activated . Review of Resident #9's Comprehensive Care Plan, revealed the intervention for the fall on [DATE], included maintenance to evaluate wheelchair for drop seat. Review of the facility investigation documentation revealed the facility failed to ensure maintenance evaluated the wheelchair for a drop seat. Review of the Hospital's ED Hospital Admission and Discharge report for Resident #9 revealed, .Adm [admit] [DATE], DC [discharge] [DATE] .She was found down on the ground this morning and sent here via [by] ambulance for evaluation .sustained a laceration to her right scalp with bleeding .Clinical Impression .Fall .Syncope .Scalp Laceration .no intracranial hemorrhage . Review of an Unwitnessed Fall Incident Report, dated [DATE] revealed, .Incident Location .Resident's Room .Incident Description .Resident in the hallway with wander guard alarm attached to clothing. The Resident noted quickly falling to the floor. The nurse approached resident and checked the resident for any injuries and or skin tears neuro checks began .Immediate Action Taken .Checked resident skin and began neuro checks . Review of the medical record revealed the facility failed to complete neuro checks as per the facility policy. 6. Review of the medical record revealed Resident #15 was readmitted on [DATE], with diagnoses of Displaced Comminuted Fracture of Shaft of Right Femur, Orthopedic Aftercare, Anxiety, Adult Failure to Thrive, Disorder of Bone, Fall, Lack of Coordination, and Dementia. Review of a facility's Witnessed Fall Report dated [DATE], revealed .Incident Location .Resident's Room .Incident Description .Notified by CNA [Certified Nursing Assistant] that resident fell from bed when she [CNA] was turning resident over while dressing her and she fell out of bed. It was noted that a hematoma [hematoma] developed on left side of forehead. NP [Nurse Practitioner] notified .new order noted to obtain a X-ray of skull .Resident unable to give description . Review of a Nurses Note dated [DATE], revealed Notified by CNA that resident fell from bed when she [CNA] was turning resident over while dressing her and she fell out of bed. It was noted that a hematoma developed on left side of forehead . Review of the Resident#15's comprehensive care plan, revealed . Witness Fall from bed [DATE]. Intervention: Educate Staff on staff positioning of resident when providing care . The facility was unable to provide documentation that education or in services were conducted with staff as the intervention for the fall that occurred on [DATE], when the resident fell out of bed during care and sustained a hematoma to the left side of her head. 7. During an interview on [DATE] at 4:11 PM, Certified Nursing Assistant (CNA) #11 was asked what occurred on [DATE], when Resident #8 fell out of the bed onto the floor. CNA #11 confirmed entered Resident #8's room after gathering supplies for incontinence care and raised the bed up and provided care. CNA #11 confirmed the resident began shaking and his eyes rolled back. The CNA stated he stepped out of the room to contact the nurse and then returned to the room. The CNA stated when he returned to the room, Resident #8 was laying on the floor on his left side and blood was on his forehead. CNA # 11 was asked what did he do at that moment. CNA #11 stated that Resident #8 was still shaking and he rolled him onto his back and the resident's eyes remained closed. The CNA stated he called the Resident's named several times trying to wake him up and that is when the nurse entered the room. CNA #11 was asked what condition was Resident #8 in when you left the room to get assistance. CNA #11 confirmed on [DATE], the resident was not acting himself. The CNA stated the resident had the bed control in his mouth, was not his usual self. The CNA stated he removed the bed control from the resident's hands and mouth and walked toward the door while letting the bed down with the bed remote. CNA #11 was asked did he use the call light for assistance. CNA #11 stated that staff don't always answer the call lights in a timely manner and that is why he went to find assistance. CNA #11 confirmed Resident #8 was shaking like he was cold. CNA #11 was asked had the facility given any type of education or inservices on residents with history of seizures and what to do in an emergency. CNA #11 confirmed that he had never attended any inservices on seizures and what to do prior to that day or if any resident that has a history of seizures and what to do if they were having a seizure. CNA #11 was asked how would he be informed if there was a resident at risk for falls and what interventions that are in place to prevent a resident from having a fall. CNA #11 stated the Unit Managers and nurses would inform the CNAs and the information is on the kiosk. The CNA stated all residents' bed should be in a low position. During an interview on [DATE] at 5:03 PM, Licensed Practical Nurse (LPN) #14 confirmed she was working on [DATE], and that she was in giving care to a resident when she heard someone yell that the resident had fallen out of bed and was bleeding, I heard her yelling for me. LPN #14 was asked what did you do then. LPN #14 confirmed when she got to the room he was laying on his back on the floor with a blank stare, and that she bent over him and saw he was unresponsive and yelled code blue and I yelled for them to get [Named LPN #13] who was the 3rd nurse. LPN #14 confirmed that the Resident's assigned nurse, LPN #18, and CNA #11 both were in the room when she arrived. LPN #14 was asked where was the resident positioned. LPN #14 confirmed the resident was on his back in between his bed and the middle roommate's bed, and she had to push Resident #8's bed over toward the wall with her back and buttocks so that she could get down bedside the resident on his left side. LPN #14 confirmed that when she pushed the bed over the bed was in high position and that it hit the lower portion of her back and her buttocks when she pushed it over. LPN #14 was asked what did she do after she pushed the bed over. LPN #14 confirmed she began checking for a pulse both radial and LPN #18 was checking his carotid for a pulse and both her and LPN #13 was calling the resident's name. LPN #14 was asked what condition was the resident in at this time. LPN #14 confirmed the resident had a blank stare. LPN #14 was asked did it appear Resident #8 was having a seizure. LPN #14 confirmed that Resident #8's condition was similar, had a stare but no shaking. LPN #14 was asked if the resident had a pulse. LPN #14 confirmed no pulse was found and instructed LPN #13 to bring the crash cart and begin doing chest compressions. LPN #14 confirmed they performed CPR until EMS arrived and they then took over the process. LPN #14 was asked did he have any visible injuries. LPN #14 confirmed there was blood on the floor from his forehead but did not move him to look for any other injuries. LPN #14 was asked are staff supposed to move a resident when they find them on the floor. LPN #14 confirmed that staff are supposed to come get a nurse and let them assess the resident for injury and then if no injury and no issues the nurse and staff will assist the resident to a safe position in the bed or the chair. LPN #14 was asked if she was aware CNA #10 found Resident #8 on his left side, positioned him on his back, and then called for assistance. LPN #14 confirmed when she arrived that the resident was on his back and she was unaware that he had been laying on his left side prior. LPN #14 confirmed that if staff suspect a seizure that they are to put on call light, yell for assistance, put the bed in low position, and remain with the resident until someone arrives. During a telephone interview on [DATE] at 2:31 PM, Physician #2 was interviewed regarding Resident #8's hospital Discharge Summary and death note. Physician #2 was asked if the multiple cervical fractures contributed to or caused the death of Resident #8. Physician #2 stated the cervical fractures contributed to and ended up causing the death and definitely caused Neurogenic Shock and a devastating quadriplegia. During an interview on [DATE] at 10:50 AM, LPN #19, confirmed that if a resident falls, the resident should remain in the position found until the nurse arrives to assess and when it is determined they can be moved then the resident is assisted back into the bed or the chair or a safe position, if they are not able to move then they are to remain in the position until the EMS arrive and they will assess and move the resident to a safe position. LPN #19 was asked what if you suspect a seizure or the resident is have seizure like symptoms, lower the bed if they are in the bed, yell for help, and do not leave them alone. During an interview on [DATE] at 2:53 PM, the Assistant Director of Nursing (ADON) was asked what is the facility process when a resident falls. The ADON confirmed that the nurse will assess the resident for injury before returning the resident a safe position. The ADON confirmed that the nurse will attempt to find the root cause of the fall or injury by determining if the resident is cognitive able to report what occurred of if there was a witness to the occurrence to prevent any future falls or injury, a pain assessment will be conducted, neurological checks will be initiated if the resident had an unwitnessed fall or if it was determined that the resident hit their head, and incident report will be completed, the family and/or responsible party will well notified along with the physician. The ADON confirmed an intervention will be put into place and the care plan will be updated and revised to reflect the intervention. The ADON confirmed the nurse will also document in the progress notes what occurred and the DON will be notified of the occurrence and will give further instructions. The ADON confirmed that the fall will be discussed in the daily morning meeting with the interdisciplinary team members that include all department heads and the intervention reviewed and changed if need be and all residents that fall will receive a therapy screening. The ADON confirmed that witness statements from all staff members whether they witnessed the incident or not is part of the investigation for a thorough investigation to determine the root cause of the occurrence. The ADON was asked are these steps just for a fall or for any occurrence that a resident experiences that is unusual or out of the ordinary. The ADON confirmed that the steps are for all occurrences, falls and anything that is un[TRUNCATED]

Based on policy review, medical record review, and interview, the facility failed to develop a care plan for 5 of 10 sampled residents (Resident #2, #3, #7, #12 and #14) reviewed for history of substance abuse. The findings included: 1. Review of the facility's policy titled Opioid Overdose Management, dated 2022, revealed .The facility will review the residents' medications and history to determine if opioids are in use or they have a history of addiction, opioid use disorder .The facility will keep naloxone (Narcan) readily available and located in a designated area to be administered as per facility protocol and physician order . Review of the facility's policy titled Resident Possession and Use of Illegal Substances, dated October 2022, revealed .To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility . Review of the facility's policy titled, Comprehensive Care Plan, dated 2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet the resident's .needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . 2. Review of medical record, showed Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Substance Abuse, Neuromuscular Dysfunction of Bladder, Anxiety Disorder, and Chronic Pain. Review of quarterly MDS assessment dated [DATE], revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Continued review showed the resident had a history of substance abuse. Review of Resident #2's comprehensive care plan showed no interventions to address the resident's history of substance abuse. 3. Review of medical record, showed Resident #3 was admitted on [DATE] with diagnoses of Dysphasia, Acute Respiratory Failure, Hypertension, Tracheotomy, Cocaine Use, Acute Kidney Failure, and Gastronomy. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 06, which indicated severe cognitive impairment. Review of Resident #3's comprehensive care plan showed no interventions to address the resident's history of substance abuse. Review of the Care Plan dated 5/4/2022, revealed .Actual fall 05/02/22 [5/2/2022] .Floor mat to both sides of bed . Observation in the resident's room on 4/18/2023 at 1:42 PM, 4/19/2023 at 8:13 AM, 4/20/2023 at 3:37 PM, 4/21/2022 at 9:47 AM, revealed Resident #3 had no fall mats at his bedside. Observation in the resident's room on 4/21/2023 at 11:45 AM, with the Assistant Director of Nursing (ADON), the ADON was asked if the Resident #3 had any fall mats at his bedside. The ADON stated .No . The ADON was asked if resident is care planned for floor mats to both sides of the bed should the fall mats be in place. The ADON stated .Yes . 4. Review of medical record, showed Resident #7 was admitted on [DATE], with diagnoses of Spinal Stenosis, Pressure Ulcer Sacral Stage 4, Major Depression, Paraplegia, Protein Calorie Malnutrition and Substance Abuse. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated he was cognitively intact. Continued review showed the resident had a history of substance abuse. Review of Resident #7's comprehensive care plan showed no interventions to address the resident's history of substance dependence. 5. Review of the medical record, showed Resident #12 showed Resident #12 was admitted to the facility on [DATE] from an acute care hospital, with diagnosis of Lupus, Protein Calorie Malnutrition, Adult Failure to Thrive, Chronic Pain, Hypertension and Sarcoidosis. Review of the 5-day MDS assessment dated [DATE], revealed Resident #12 was assessed with a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact. Review of Resident #12's comprehensive care plan showed no interventions to address the resident's history of substance dependence. 6. Review of medical record, showed Resident #14 was admitted on [DATE], with diagnoses of Hypertension, Dysphasia, Cocaine Abuse, and Hemiplegia and Hemiparesis. Review of the annual MDS assessment dated [DATE], revealed Resident #14 had a BIMS score of 15, which indicated he was cognitively intact. Continued review showed the resident had a history of substance abuse. Review of Resident #14's comprehensive care plan showed no interventions to address the resident's history of substance dependence. During an interview on 4/12/2023 at 4:03 PM, the Administrator confirmed the resident at risk for substance abuse should be monitored and care planned.

Based on policy review, medical record review, and interview, the facility failed to notify the Responsible Party (RP) for 1 of 3 (Resident #6) sampled residents reviewed for notification of changes. The findings included: 1. Review of the facility's policy titled, Notification of Changes dated 2022, revealed .The Facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. The facility must make multiple attempts to contact the family or legal representative for notification of resident's change in condition .Accidents .Resulting in injury .A transfer or discharge of the resident from the facility . 2. Review of medical record, showed Resident #6 was admitted on [DATE], with diagnoses of Chronic Kidney Failure Stage 3, Diabetes, Major Depression, Hypertension, Dementia, and Gastroesophageal Reflux. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score 15, indicating intact cognition. During a telephone interview on 4/19/2023 at 8:19 AM, the RP was asked if the facility notified her of Resident #6's missed scheduled appointments and the RP stated .No . The RP stated the facility had trouble getting the resident to the doctor appointments. During an interview on 4/20/2023 at 11:07 AM, and on 4/21/2023 at 11:24 PM, the Social Worker confirmed missed appointments should be documented in the resident's chart and the RP should be notified timely. The Social worker stated .I been doing this a long time .if it's not document it's not done . When asked about the missed appointments for Resident #6, the Social Worker stated, .On 3/13/2023 transportation left and rescheduled for the next day on 3/14/2023 at 2:40 PM .on 3/14/2023 transportation was late and did not come .reschedule for 3/16/2023 .there are no notes documented the RP was notified on 3/14/2023 .he was seen on 3/16/2023 .on 3/29/2023 he had a 6 AM [6:00 AM] pick up and transportation did not show .I called the doctor's office to validate the time and date .the RP was not notified of changes rescheduled for 4/4/2023 .he went to that one [appointment] and the clinic canceled .the doctor .rescheduled for the next day .RP was not notified of the change .4/5/2023 he went and could not void he went to the hospital on 4/5/2023 he came back to the facility .have new schedule for 4/25/2023 to see the urologist . When asked if the RP should be notified of the transportation issues and changes, the Social Worker stated, .Yes . During an interview on 4/25/2023 at 12:20 PM, when asked if the facility informed her of the changes in appointments, the RP stated .all I want is to be informed when there is a change, or he is not going to make his appointment .its common courtesy .

Based on policy review, medical record review, observations, and interview, the facility failed to accurately assess weights for 2 of 4 sampled residents (Resident #11 and #15) reviewed for enteral feedings (method of receiving nutrition through a tube directly into the stomach). The findings include: 1. Review of the facility's policy titled, Weight Monitoring, dated 2022, revealed .the facility will ensure that all residents maintain acceptable parameters of nutritional status .Weight can be a useful indicator of nutritional status .(loss or gain) .may indicate a nutritional problem . 2. Review of medical record showed Resident #11 was admitted on [DATE], with diagnoses of Hypertension, Dementia, Diabetes, Heart Failure, Chronic Kidney Disease, and Morbid Obesity. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 00, which indicated the resident was severely cognitively impaired. Continued review showed the resident weighed 216 pounds and received artificial nutrition through a percutaneous endoscopic gastrostomy (PEG) tube (a tube that allows a resident to receive nutrition directly through their stomach). Review of the Weight and Vital Summary report on the facility's point click care computer system dated 3/27/2023, revealed Resident #11 recorded weighed was 203.6 pounds. Review of the March 26 -April 2, 2023 Weekly Weight AID (Aide) report (the Weight Aides documentation sheet), revealed .[Named Resident #11] .203.6 .H B [heel boots] [weigh] 2 lbs [pounds] .3/27 .[3/27/2023] . Review of April 2023 Monthly Weight List (another Weight Aides documentation sheet) revealed .[Named Resident #11] .H B [weigh] 2lbs .195.2 .4/6 .[4/6/2023] . Review of the Weight and Vital Summary dated 4/11/2023, revealed Resident #11's recorded weight was 201.2 pounds. Observation in the resident's room on 4/26/2023 at 9:06 AM, revealed Weight Aide #1 and #2, weighed Resident #11 with her bed pad, gown, brief, and lift sling. The resident's weight observed was 201.8 pounds. Observation in the resident's room on 4/26/2023 at 9:15 AM, revealed Weight Aide #1 and #2, weighed Resident #11's heel boots and the heel boots weighed 5 pounds. Continued observation showed Weight Aide #1 and #2, weighed Resident #11's bed pad and the bed pad weighed 3.8 pounds. Observation in the resident's room on 4/27/2023 at 11:39 AM, revealed Weight Aide #1 and #2, weighed Resident #11 with a lift sling, gown, and brief. The resident's weight observed was 195.2 pounds. Resident 11's weight was inaccurate since the resident was weighed with heel boots, pads and sling. The weights documented revealed the resident had lost an estimated 20 pounds in 2 months. There was no documentation Resident #11 was on a planned weight loss program. 3. Review of the medical record, showed Resident #15 was admitted on [DATE], with diagnoses of Diabetes, Major Depression, Chronic Kidney Disease, Dementia, and Hypertension. Review of significant change MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 06, which indicated the resident was severely cognitively impaired. Continued review showed the resident weighed 182 pounds and received artificial nutrition through a PEG tube. Review of the March 2023 Monthly Weekly Weight List revealed .[Named Resident #15] .173.2 [pounds] .3-3 [3/3/2023] .abduction pillow .[weighed] 2.6 lbs . Review of the Weight and Vital Summary dated 3/7/2023, revealed Resident #15 recorded weight was 173.2. Review of the April 9-15, 2023 Weekly Weight AID (the weight aides documentation sheets) revealed .[Named Resident #15] .172 .H-B [heel boots] 2lbs [pounds] .4/11 [4/11/2023] . Review of the Weight and Vital Summary, dated 4/11/2023 revealed Resident #15 recorded weight was 172.0 pounds. Review of the April 23-29, 2023 Weekly Weight AID (Weight Aide documentation sheets), revealed .[Named Resident #15] .177.2 .H-B 2lbs .4/24 [4/24/3023] . Review of the Weight and Vital Summary dated 4/25/2023, revealed Resident #15 recorded weight was 177.2 pounds. During an interview on 4/27/2023 at 8:33 AM, when asked how they are taught to weigh the resident, Weight Aide #1 aid stated .we did not take of the pads, heel boots and brace off before we weighted the residents .we would put down whatever [weight] we get .we thought they [Register Dietitian [RD] and Assistant Director of Nursing [ADON] were deducting the boots and brace .when we have to do a reweight the [Named Register Dietitian [RD] goes with us .she told us to write down what the resident is weight with .we use the pads .we can turn them better .if they have anything on we document it on the weight sheet .we turn the weight sheets into the RD and [named Assistant Director of Nursing] . When asked how Weight Aide #1 she determined the heel boots weighed 2 pounds since there are 2 different types of boots, the weight aide stated .I knew they were different .we did not weight them we should have . During an interview on 4/27/2023 at 8:47 AM, when asked how they weigh the resident, Weight Aide #2 stated .we weight them with the items [heel boots, pads and braces] .whatever the scale says the weight is with the heel boot is what we document .we write to the side of the weight sheet is with the heel boot . When asked how she knew how much the heel boots weighed, Weight Aide #2 stated .I never weighted the heel boots before .I did not know how much they weighed .the weight was already on the sheet .the 2 pounds . The Weight Aide #2 was asked had they always weighed the residents with the pads and did they get a weight on the pads. Weight Aide #2 confirmed they use the pad during the weights .we did not get a weight on them [pads] .I did not know how much they weighed until yesterday . During an interview on 5/4/2023 at 8:17 AM, the Assistant Director of Nursing (ADON) was asked when putting in the weights into PCC [point click care the facilities computer system] from the Weight Aides (documentation sheets) if she subtracted the pad, braces, and the heel boots. The ADON stated .No .I did not know to subtract the items [boots, braces or pads] from the weights [documented weights on the Weight Aides documentation sheets] .I put in the weight documented on the [Weight Aides] sheets . The ADON was asked if the facility had an effective weight management program. The ADON stated .based on the facts no we do not . The staff failed to remove the pads, braces and heel boots before weighing Resident #15 in order to ensure an accurate weight was obtained.

Based on facility assessment tool, job description review, policy review, daily staffing records, medical record review, video footage review, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when 1 of 48 sampled residents (Resident #13) left the facility unsupervised and without staff knowledge and who had a Peripherally inserted central catheter (PICC - a tube inserted in a large vein above the right side of the heart, used to administer medication by licensed professionals). The findings include: 1. Review of the Facility Assessment Tool dated 1/2022 through 12/2022, revealed Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs .Licensed nurses providing direct care .8 .Nurse aides [Certified Nursing Assistant] .10 . Review of the Director of Nursing job signed description dated 6/1/2022, revealed, .The Primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, stated, and local standards, guidelines, and regulation that govern our facility, and as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the resident .Assign a sufficient number of Licensed practical .registered nurses for each tour of duty to ensure that quality care is maintained .Develop work assignments and schedule duty hours .assist nursing supervisory staff in completing and performing such tasks . Review of the facility's policy titled Elopement and Wandering Resident, dated 2/22/2022, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents, and receive care in accordance with their personal-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization( .and order for discharge or leave of absence) and/or any necessary supervision to do so .Adequate supervision will be provided to help prevent .elopements . 2. Review of the Daily Census for the first floor revealed on 5/5/2023 a census of 46 residents. On the 5/5/2023 census Resident #13 was not captured. Review of the staff posting on 5/5/2023, revealed Licensed Practical Nurse (LPN) #7 was a call-in no show for the 3:00 PM - 11:00 PM shift. Review of the DAILY GROUP ASSIGNMENT dated 5/5/2023, for the first floor 100 hall unit, revealed on the 11:00 PM -7:00 AM shift, LPN #5 was the only nurse scheduled to work with 3 Certified Nursing Assistant (CNAs). There was no Registered Nurse (RN) scheduled in the facility on the 11:00-7:00 AM shift. 3. Review of the facility video footage for 5/5/2023, revealed Resident #13 exited through the lobby door at 11:17 PM pushing a wheelchair with clothes and other belongings. Resident #13 was seen outside the facility walking down the sidewalk, into the dark, out of camera view. Receptionist #1 was sitting at the front desk when Resident #13 eloped from the facility. 4. Review of medical record revealed Resident #13 was admitted on [DATE], with a diagnoses of Endocarditis, Sickle Cell Trait, Chronic Hepatitis, and Cocaine Abuse. The Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of a 15 indicating she was cognitively intact. Resident #13's Care Plan dated 4/14/2023, revealed the resident required every 4 hour checks due to a history of substance abuse. Physician Orders dated 4/18/2023, for Resident #13 revealed the resident was ordered to be visualized every 4 hours related to a history of substance abuse with accidental overdose . 5. During an interview on 5/1/2023 at 3:22 PM, Unit Manager #1 was asked how many nurses would be scheduled on the first floor on the 11:00 PM - 7:00 PM shift. Unit Manager #1 stated 2 LPN's and 3 CNA's. The Unit Manager #1 was asked how the call in system works, who is on call. The Unit Manager stated .we [The Managers] are on call 24 hours .if they [Nursing Staff] run into any kind of problem . During an interview on 5/9/2023 at 9:32 AM, LPN #5 was asked if she saw Resident #13 leave the facility on the night of 5/5/2023. LPN #5 stated .No, I did not .I probably was working . LPN #5 was asked at what point did she know Resident #13 missing. LPN #5 stated .I had an idea .[Resident #13] might be trying to leave .that was about 11:15 PM .when I had a conversation with her .[Resident #13] went back to her room .I did not know she was not in the facility .we had a conversation about her leaving .she told me I didn't have to worry about her leaving or nothing like that . LPN #5 was asked at the change of shift did she notice Resident #13 was not in the facility. LPN #5 stated .No ma'am . LPN #5 was asked when she found out that Resident #13 had left the facility. LPN #5 stated .Somebody called me at home .I believe it was [Named Unit Manager #1] she told me [Resident #13] was gone . LPN #5 was asked if she checked on [Resident #13] any time during the night. LPN #5 stated .[I'm] a walkie talkie .I made a mental note .I was checking on [Resident #13] all night long . LPN #5 was asked when the last time was she documented on seeing Resident #13. LPN #5 stated .probably in my notes .we got to do checks .so throughout the night [Resident #13] is up and down all night .my timeline is not going to be where I can remember what took place with her .my night was so busy .I can't say I saw [Resident #13] that night .I was the only nurse that night .it is a lot of stress . LPN #5 was asked how many residents did she have on 5/5/2023. LPN #5 stated .that night .I had 51 [Resident #13 was not listed on the census on 5/5/2023] residents . LPN #5 was asked if the facility was short staffed with 51 residents and one nurse. LPN #5 stated .that was my first time .I stayed over .I had no lunch .I was tired .I honestly believed the patient [Resident #13] knows me .she trusted me .she got along with me .I seen her .talked to her .[Resident #13] told me she was not going nowhere .I made a mental note to keep an eye on her .[Resident #13] probably caught me when I was busy . LPN #5 was asked what time she got the new admission on 5/5/2023. LPN #5 stated .he was a hospice patient that came in around midnight . During an interview on 5/11/2023 at 11:46 AM, Unit Manager #2 was asked if was safe to have one nurse working on the 11:00 PM - 7:00 AM shift with 51 residents and 3 CNAs. Unit Manager #2 stated .No .I have to say no . Unit Manager #2 was asked if she was informed LPN #5 had a new admission at 12:00 AM. Unit Manager #2 stated .No .that is a lot .I was not informed as the Unit Manager . Unit Manager #2 was asked when she was made aware that LPN #5 was the only nurse working on the 11:00 - 7:00 AM shift on 5/5/2023 - 5/6/2023. Unit Manager #2 stated .the next day when we were discussing [Named Resident #13] .when we learned [Resident #13] had left the building . Unit Manager #2 was asked when she found out Resident #13 was missing from the facility. Unit Manager #2 stated .when I got the call on Saturday around 3:30 PM or 4:00 PM .[Name Unit Manager #1] called me .she said were you aware [Named Resident #13] was missing from the facility .left the building .I said no .I was not aware of that . Unit Manager #2 was asked if you have a resident who refused to sign the AMA form should that be documented in the resident chart. Unit Manager #2 stated .it should be documented in the medical records .yes . Refer to F689.

Based on facility assessment tool, job description review, policy review, daily staffing records, medical record review, video footage review, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when 1 of 48 sampled residents (Resident #13) left the facility unsupervised and without staff knowledge and who had a Peripherally inserted central catheter (PICC - a tube inserted in a large vein above the right side of the heart, used to administer medication by licensed professionals). The findings include: 1. Review of the Facility Assessment Tool dated 1/2022 through 12/2022, revealed Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs .Licensed nurses providing direct care .8 .Nurse aides [Certified Nursing Assistant] .10 . Review of the Director of Nursing job signed description dated 6/1/2022, revealed, .The Primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, stated, and local standards, guidelines, and regulation that govern our facility, and as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the resident .Assign a sufficient number of Licensed practical .registered nurses for each tour of duty to ensure that quality care is maintained .Develop work assignments and schedule duty hours .assist nursing supervisory staff in completing and performing such tasks . Review of the facility's policy titled Elopement and Wandering Resident, dated 2/22/2022, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents, and receive care in accordance with their personal-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization( .and order for discharge or leave of absence) and/or any necessary supervision to do so .Adequate supervision will be provided to help prevent .elopements . 2. Review of the Daily Census for the first floor revealed on 5/5/2023 a census of 46 residents. On the 5/5/2023 census Resident #13 was not captured. Review of the staff posting on 5/5/2023, revealed Licensed Practical Nurse (LPN) #7 was a call-in no show for the 3:00 PM - 11:00 PM shift. Review of the DAILY GROUP ASSIGNMENT dated 5/5/2023, for the first floor 100 hall unit, revealed on the 11:00 PM -7:00 AM shift, LPN #5 was the only nurse scheduled to work with 3 Certified Nursing Assistant (CNAs). There was no Registered Nurse (RN) scheduled in the facility on the 11:00-7:00 AM shift. 3. Review of the facility video footage for 5/5/2023, revealed Resident #13 exited through the lobby door at 11:17 PM pushing a wheelchair with clothes and other belongings. Resident #13 was seen outside the facility walking down the sidewalk, into the dark, out of camera view. Receptionist #1 was sitting at the front desk when Resident #13 eloped from the facility. 4. Review of medical record revealed Resident #13 was admitted on [DATE], with a diagnoses of Endocarditis, Sickle Cell Trait, Chronic Hepatitis, and Cocaine Abuse. The Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of a 15 indicating she was cognitively intact. Resident #13's Care Plan dated 4/14/2023, revealed the resident required every 4 hour checks due to a history of substance abuse. Physician Orders dated 4/18/2023, for Resident #13 revealed the resident was ordered to be visualized every 4 hours related to a history of substance abuse with accidental overdose . 5. During an interview on 5/1/2023 at 3:22 PM, Unit Manager #1 was asked how many nurses would be scheduled on the first floor on the 11:00 PM - 7:00 PM shift. Unit Manager #1 stated 2 LPN's and 3 CNA's. The Unit Manager #1 was asked how the call in system works, who is on call. The Unit Manager stated .we [The Managers] are on call 24 hours .if they [Nursing Staff] run into any kind of problem . During an interview on 5/9/2023 at 9:32 AM, LPN #5 was asked if she saw Resident #13 leave the facility on the night of 5/5/2023. LPN #5 stated .No, I did not .I probably was working . LPN #5 was asked at what point did she know Resident #13 missing. LPN #5 stated .I had an idea .[Resident #13] might be trying to leave .that was about 11:15 PM .when I had a conversation with her .[Resident #13] went back to her room .I did not know she was not in the facility .we had a conversation about her leaving .she told me I didn't have to worry about her leaving or nothing like that . LPN #5 was asked at the change of shift did she notice Resident #13 was not in the facility. LPN #5 stated .No ma'am . LPN #5 was asked when she found out that Resident #13 had left the facility. LPN #5 stated .Somebody called me at home .I believe it was [Named Unit Manager #1] she told me [Resident #13] was gone . LPN #5 was asked if she checked on [Resident #13] any time during the night. LPN #5 stated .[I'm] a walkie talkie .I made a mental note .I was checking on [Resident #13] all night long . LPN #5 was asked when the last time was she documented on seeing Resident #13. LPN #5 stated .probably in my notes .we got to do checks .so throughout the night [Resident #13] is up and down all night .my timeline is not going to be where I can remember what took place with her .my night was so busy .I can't say I saw [Resident #13] that night .I was the only nurse that night .it is a lot of stress . LPN #5 was asked how many residents did she have on 5/5/2023. LPN #5 stated .that night .I had 51 [Resident #13 was not listed on the census on 5/5/2023] residents . LPN #5 was asked if the facility was short staffed with 51 residents and one nurse. LPN #5 stated .that was my first time .I stayed over .I had no lunch .I was tired .I honestly believed the patient [Resident #13] knows me .she trusted me .she got along with me .I seen her .talked to her .[Resident #13] told me she was not going nowhere .I made a mental note to keep an eye on her .[Resident #13] probably caught me when I was busy . LPN #5 was asked what time she got the new admission on [DATE]. LPN #5 stated .he was a hospice patient that came in around midnight . During an interview on 5/11/2023 at 11:46 AM, Unit Manager #2 was asked if was safe to have one nurse working on the 11:00 PM - 7:00 AM shift with 51 residents and 3 CNAs. Unit Manager #2 stated .No .I have to say no . Unit Manager #2 was asked if she was informed LPN #5 had a new admission at 12:00 AM. Unit Manager #2 stated .No .that is a lot .I was not informed as the Unit Manager . Unit Manager #2 was asked when she was made aware that LPN #5 was the only nurse working on the 11:00 - 7:00 AM shift on 5/5/2023 - 5/6/2023. Unit Manager #2 stated .the next day when we were discussing [Named Resident #13] .when we learned [Resident #13] had left the building . Unit Manager #2 was asked when she found out Resident #13 was missing from the facility. Unit Manager #2 stated .when I got the call on Saturday around 3:30 PM or 4:00 PM .[Name Unit Manager #1] called me .she said were you aware [Named Resident #13] was missing from the facility .left the building .I said no .I was not aware of that . Unit Manager #2 was asked if you have a resident who refused to sign the AMA form should that be documented in the resident chart. Unit Manager #2 stated .it should be documented in the medical records .yes . Refer to F689.

Based on review of the facility employee files and interview the facility failed to ensure the registry verification of the Certified Nursing Assistant (CNA) and failed to monitor expired licensed for 3 of 42 (Certified Nursing Assistant #8, #9 #12) reviewed for Licensure. The findings include: Review of the facility's policy titled, Background Investigations, dated 2022, revealed .For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing .The Human Resources Director .is responsible for maintaining and ensuring the validity and current status of individual certification/licensure . Review of the EMPLOYEE FILE CHECK LIST, revealed .Employee Name .BACKGROUND CHECK .LICENSE OR CERTIFICATION ACTIVE . Review of the New Employee Orientation Checklist, revealed .Verify License .copy for personnel file . Review of the employee files CNA #8 licensed expired on [DATE] and was not updated until [DATE]. Review of the employee files CNA #9 licensed expired on [DATE] and was not updated until [DATE]. Review of the New hire list revealed CNA #12's was hired on [DATE]. Review of the TENNESSEE NURSE AIDE REGISTRY, dated [DATE], revealed CNA #12's licensed expired on [DATE]. Review of the SEPARATION NOTICE, dated [DATE], revealed CNA #10 was discharged . During an interview on [DATE] at 3:43 PM, the Director of Human Sources was asked if CNA #1 had a current license. The Director of Human Sources stated .I checked the Tennessee registry .it was expired .we pull it up our selves .then went back to her .she gave us the Arkansas license .and she was allowed to work . During a Telephone interview on [DATE] at 3:59 PM, the Regional Human Resource Director was asked should have staff members working in the facility without a current license. The Regional Human Resource Director stated .No, we should not . The Regional Human Resource Director was asked if a CNA licensed in Arkansas could work in Tennessee. The Regional Human Resource Director stated .Not to my knowledge .they must have a Tennessee License to work in Tennessee . During an interview on [DATE] at 8:35 AM the Unit Manager #1 was asked who is responsible for checking and keeping up with the licensure. The Unit Manager #1 stated .Human Resources keeps up with the license .when I did staffing I would keep up with it . I think [Named Human Resources] is responsible now .

Based on facility review, job description review, medical record review, observation, and interview, the facility Administration failed to provide supervision and oversight to prevent the potential for serious injury when 2 vulnerable residents overdosed in the facility. The facility's failure resulted in Immediate Jeopardy for Resident #2 and #12. Resident #2 has had multiple drug overdose in the facility starting in 2021. Resident #2 was found unresponsive on [DATE] when the nurse was called to the room, Cardiopulmonary resuscitation (CPR) was started and 911 called, the resident was transported to the local hospital, upon arrival to the hospital Resident #2 was given 6 mg (milligrams) of Narcan by the EMS (emergency medical services) for a opioid overdose. Resident #12 on [DATE] was found in his room unresponsive and was given 4 mg of Narcan and sent out to the hospital for an accidental overdose with oxycodone and Benadryl. He reported to the hospital he saved his pain medication. 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 and the Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-689, during the complaint investigation on [DATE] at 9:37 AM, and again on [DATE] at 10:44 in the Conference Room. The Administrator was notified of the Immediate Jeopardy (IJ) for F-835 during the complaint investigation on [DATE] at 12:37 PM, in the Conference Room. An acceptable AOC for F835 was received on [DATE] and validated onsite by surveyors on ,d+[DATE] - ,d+[DATE]. Noncompliance continues at a s/s level of D for F835. 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 Immediate Jeopardy existed from [DATE] and is ongoing. A partial extended survey was conducted from [DATE] through [DATE]. The findings include: Review of the facility's policy titled, Administrator of Facility, date 2022, 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 .An appropriately licensed Administrator, in good standing with the state in which the facility resides, will be appointed by the governing body to be responsible for the management and overall operation of the facility . Review of the facility's Administrator Job signed Description dated [DATE], revealed .is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our resident at all time .Develop and maintain written policies and procedures and professional standard of practice that govern the operation of the facility .Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed . Review of the facility's Director of Nursing signed Job description dated [DATE], revealed .plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical director, to ensure that the highest degree of quality care is maintained at all times .Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing service department .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure adequate supervision and monitoring of residents, to ensure a safe and secure environment for the residents, and to ensure incidents and accident were prevented, thoroughly investigated, and reported. Refer to F-689. Administration failed to provide oversight that established and implemented policies and procedures to ensure care plans were developed and reviewed with appropriate interventions implemented to ensure the safety of residents. Refer to F-656. Administration failed to provide oversight that established and implemented policies and procedures to ensure the facility provided an effective weight management program. Refer to F-692. During an interview on [DATE] at 4:08 PM, the Administrator confirmed she was ultimately responsible for the facility. The surveyors verified the Removal Plan through review of QAPI minutes and signature sheets, and staff interviews on all shifts: 1. All residents in house have been reviewed to determine, known histories of substance abuse - Completed [DATE]. Known histories of drug overdose- Completed [DATE]. The residents had an individualized risk assessment completed on [DATE]. A plan of care was developed to include overdose interventions and interventions for known substance abuse was completed [DATE]. The residents have Physician's Orders to administer as needed (PRN) Narcan was completed on [DATE]. The residents will be monitored every 4 hours visual checks by the charge nurse and place on the MAR (Medication Administration Record) - was completed [DATE]. Surveyor confirmed by interviews and record reviews. 2. All Licensed and Unlicensed Nursing staff and Social Services will be educated prior to working by the Director of Nursing, Administrator or ADON (Assistant Director of Nursing) on Substance Use Disorder Care Plan, Opioid Overdose Management Policy, CDC (Center for Disease Control) responding to a suspected opioid overdose, F-689, Accidents and Supervision Policy, Narcan Use Policy, Narcan Administration and Standing Orders. Surveyor confirmed by interviews. 3. Administration is responsible for the safety and well-being of all residents. Administration has been educated and given directions by the governing body and Medical Director of their duties and responsibilities with residents with a history of substance abuse and/or drug overdose. Completed [DATE]. Surveyor confirmed by interviews. 4. The Administration duties will be monitored by the Regional Director of Operations/Clinical Nurse Consultant with oversight by the Medical Director for residents with history of drug abuse and/or drug overdose. Surveyor confirmed by interviews. 5. Audits will be conducted 3 times a week times 4, then 2 times week times 2, then weekly there after by the facility Administrator, Director of Nursing, ADON, and Unit Managers to ensure. Residents with known histories of substance abuse and/or drug overdose will have an individualized risk assessment conducted on admission, quarterly and PRN (as needed). A plan of care will be developed to include overdose interventions, and interventions for known substance abuse. The resident will have a physician's orders to administer as needed Narcan and Q (every) 4 hours and PRN nurse visual checks by the charge nurse. Surveyor confirmed by interviews and record review. 6. The audits will be reviewed by the Medical Director and Regional Director of Operations/Clinical Nurse Consultant. The results of these audits will be reviewed by the QAPI (Quality Assurance and Performance Improvement) team for trends, patterns and determination for continued process improvement and continued auditing. The Administrator is responsible for ensuring this process is followed. Surveyor confirmed by interviews and record review. The facility's noncompliance of F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review, observation, camera footage, and interview, the facility failed to ensure accurate medical records for 1 of 3 residents (Resident #13) reviewed for elopement. The findings include: 1. Review of medical record revealed Resident #13 was admitted on [DATE], with a diagnoses of Endocarditis, Sickle Cell Trait, Chronic Hepatitis, and Cocaine Abuse. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Review of Physician's Orders dated 4/18/2023, revealed .Q [every] 4 hours nurse visual checks on resident related to history of substance abuse with accidental overdose . Review of the Medication Administration Record, dated 5/1/2023-5/31/2023, revealed on 5/5/2023 at 11:00 PM - 7:00 AM shift through 5/6/2023, Resident #13 was charted as being in the building at 2:00 AM by Licensed Practical Nurse (LPN) #5. At 6:00 AM there was no documentation of the residents whereabouts, the space was blank. Review of the Nurse Note dated 5/5/2023, and created on 5/8/2023 at 11:15 AM, revealed .Late Entry . [LPN #13] .Resident scheduled for discharge tomorrow 5/6/2023. I reminded resident that her last medication would be given at 10:00 AM. Resident [Resident #13]verbalized understanding and returned to her room. Resident is alert and oriented X [times] 4. Resident is able to make all of her needs known . Review of the Video Footage on 5/5/2023, revealed at 11:17 PM, Resident #13 exited the building with her belonging in her wheelchair, and walked out of sight of the cameras vision out into the darkness. Review of the 24-HOUR REPORT/CHANGE OF CONDITION REPORT, revealed on 5/5/2023, and 5/6/2023, there was no documentation of Resident #13 being discharged or that the resident had left the facility Against Medical Advice (AMA). Review of the AMA form dated 5/5/2023, revealed .This is to certify that I [Resident Refused] a resident at [Named Facility] am being discharged against the advice of my attending physician . The AMA form indicated Resident #13 refused to sign the form and had no witness signatures. During an interview on 5/9/2023 at 9:23 AM, the DON was asked if LPN #5 documented that Resident #13 discharged herself or signed the AMA form. The DON stated .I will have to see if she did or not . During an interview on 5/9/2023 at 1:13 PM, Unit Manager #1 was asked when she found out Resident #13 had left the facility with a PICC. Unit Manager #1 stated .Saturday [5/6/2023] .around 2:30 PM or 3:00 PM . Unit Manager #1 was asked should Resident #13 been explained about the AMA form and sign the AMA form. The Unit Manager stated .yes .it should have been completed . During an interview on 5/10/2023 at 10:27 AM and 5/11/2023 at 11:46 AM Unit Manager #2 was showed the 24-hour report sheet for 5/5/203 and 5/6/2023. Unit Manager #2 was asked if there was anything documented on 5/5/2023 or 5/6/2023, that Resident #13 was discharged , or had left AMA. Unit Manager stated .I do not .it should be documented on the 24-hour report sheet it is the same thing as someone going home . Unit Manager #2 was asked if you have a resident who refused to sign the AMA form should that be documented in the resident chart. Unit Manager #2 stated .it should be documented in the medical records .yes . During a telephone interview on a 5/14/2023 at 3:32 PM, LPN #5 was asked if she discharged Resident #13. LPN #5 stated .no ma'am . LPN #5 was asked if she called the DON around 12:00 AM on 5/6/2023 to tell her Resident #13 was discharged or Resident #13 signed out AMA. LPN #5 stated .No .Never .I did not tell her [DON] she [Resident #13] was gone .no ma'am . LPN #5 was asked if she called the DON around on 5/6/2023 at 12:00 AM to tell her Resident #13 was missing. LPN #5 stated .No .Never .I did not tell her [DON] she [Resident #13] was gone .no ma'am .she [Named DON] .[Named DON] tried to get me to say that [Resident #13 was discharged or left AMA] . LPN #5 was asked when she talked with the DON about Resident #13. LPN #5 stated .I spoke to [Named DON] at 5:00 PM on Saturday [5/6/2023] .she [DON] was just dump founded [in shock] .I told her it [Resident #13 was missing] can't be true .I thought I seen her [Resident #13] throughout the night .walking through the hall .not 100 % [percent] sure .I would not have clicked on 2:00 AM .if I felt in my heart she was not there .if I made a mistake it was an honest mistake .when I left I was happy I made it through the night . The facility was unable to provide any documentation that Resident #13 was discharged or refused to sign the AMA form. The Director of Nursing (DON) signed the back of the AMA stating .I completed the form based on nurse information .5/10/2023 .

Based on medical record review, observation, camera footage, and interview, the facility failed to ensure accurate medical records for 1 of 3 residents (Resident #13) reviewed for elopement. The findings include: 1. Review of medical record revealed Resident #13 was admitted on [DATE], with a diagnoses of Endocarditis, Sickle Cell Trait, Chronic Hepatitis, and Cocaine Abuse. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Review of Physician's Orders dated 4/18/2023, revealed .Q [every] 4 hours nurse visual checks on resident related to history of substance abuse with accidental overdose . Review of the Medication Administration Record, dated 5/1/2023-5/31/2023, revealed on 5/5/2023 at 11:00 PM - 7:00 AM shift through 5/6/2023, Resident #13 was charted as being in the building at 2:00 AM by Licensed Practical Nurse (LPN) #5. At 6:00 AM there was no documentation of the residents whereabouts, the space was blank. Review of the Nurse Note dated 5/5/2023, and created on 5/8/2023 at 11:15 AM, revealed .Late Entry . [LPN #13] .Resident scheduled for discharge tomorrow 5/6/2023. I reminded resident that her last medication would be given at 10:00 AM. Resident [Resident #13]verbalized understanding and returned to her room. Resident is alert and oriented X [times] 4. Resident is able to make all of her needs known . Review of the Video Footage on 5/5/2023, revealed at 11:17 PM, Resident #13 exited the building with her belonging in her wheelchair, and walked out of sight of the cameras vision out into the darkness. Review of the 24-HOUR REPORT/CHANGE OF CONDITION REPORT, revealed on 5/5/2023, and 5/6/2023, there was no documentation of Resident #13 being discharged or that the resident had left the facility Against Medical Advice (AMA). Review of the AMA form dated 5/5/2023, revealed .This is to certify that I [Resident Refused] a resident at [Named Facility] am being discharged against the advice of my attending physician . The AMA form indicated Resident #13 refused to sign the form and had no witness signatures. During an interview on 5/9/2023 at 9:23 AM, the DON was asked if LPN #5 documented that Resident #13 discharged herself or signed the AMA form. The DON stated .I will have to see if she did or not . During an interview on 5/9/2023 at 1:13 PM, Unit Manager #1 was asked when she found out Resident #13 had left the facility with a PICC. Unit Manager #1 stated .Saturday [5/6/2023] .around 2:30 PM or 3:00 PM . Unit Manager #1 was asked should Resident #13 been explained about the AMA form and sign the AMA form. The Unit Manager stated .yes .it should have been completed . During an interview on 5/10/2023 at 10:27 AM and 5/11/2023 at 11:46 AM Unit Manager #2 was showed the 24-hour report sheet for 5/5/203 and 5/6/2023. Unit Manager #2 was asked if there was anything documented on 5/5/2023 or 5/6/2023, that Resident #13 was discharged , or had left AMA. Unit Manager stated .I do not .it should be documented on the 24-hour report sheet it is the same thing as someone going home . Unit Manager #2 was asked if you have a resident who refused to sign the AMA form should that be documented in the resident chart. Unit Manager #2 stated .it should be documented in the medical records .yes . During a telephone interview on a 5/14/2023 at 3:32 PM, LPN #5 was asked if she discharged Resident #13. LPN #5 stated .no ma'am . LPN #5 was asked if she called the DON around 12:00 AM on 5/6/2023 to tell her Resident #13 was discharged or Resident #13 signed out AMA. LPN #5 stated .No .Never .I did not tell her [DON] she [Resident #13] was gone .no ma'am . LPN #5 was asked if she called the DON around on 5/6/2023 at 12:00 AM to tell her Resident #13 was missing. LPN #5 stated .No .Never .I did not tell her [DON] she [Resident #13] was gone .no ma'am .she [Named DON] .[Named DON] tried to get me to say that [Resident #13 was discharged or left AMA] . LPN #5 was asked when she talked with the DON about Resident #13. LPN #5 stated .I spoke to [Named DON] at 5:00 PM on Saturday [5/6/2023] .she [DON] was just dump founded [in shock] .I told her it [Resident #13 was missing] can't be true .I thought I seen her [Resident #13] throughout the night .walking through the hall .not 100 % [percent] sure .I would not have clicked on 2:00 AM .if I felt in my heart she was not there .if I made a mistake it was an honest mistake .when I left I was happy I made it through the night . The facility was unable to provide any documentation that Resident #13 was discharged or refused to sign the AMA form. The Director of Nursing (DON) signed the back of the AMA stating .I completed the form based on nurse information .5/10/2023 .

Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when isolation signage was not posted on 4 of 4 resident rooms (Resident #4, #6, #7, and #8's rooms), and when 5 of 8 facility staff (Activity Assistant, Certified Nursing Assistant (CNA) #1, #2, #3, and #4) failed to use appropriate Personal Protective Equipment (PPE) per facility guidelines. The findings include: 1. Review of the undated facility's policy titled, Infection Prevention and Control Program revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Review of the facility policy titled, Isolation-Categories of Transmission Based Precautions revised 1/2012 revealed, .Droplet Precautions .In addition to Standard Precautions, implement Droplet Precautions for an individual suspected to be infected with microorganisms transmitted by droplets .that can be generated by the individual coughing, sneezing, or talking .Signs - The facility will implement a system to alert staff and visitors to the type of precautions the resident requires . Review of the facility policy titled, Novel Coronavirus Prevention and Response revised 2/15/2021 revealed, .This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus .it is spread person-to-person, mainly between people who are within 6 feet of one another through respiratory droplets produced when an infected person coughs or sneezes .Interventions to prevent the spread of respiratory germs within the facility .Droplet precautions with eye protection .Educate staff on proper use of personal protective equipment and application of standard .droplet .precautions, including eye protection .Promote easy and correct use of personal protective equipment .by .Posting sings on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE .Make PPE, including facemask, eye protection, gowns, and gloves, available immediately outside of the resident's room .Procedure when COVID-19 is suspected or confirmed .Wear gloves, gown, goggles/face shields, and masks upon entering room and when caring for the resident . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Chronic Inflammatory Demyelinating Polyneuritis, Major Depressive Disorder, Chronic Kidney Disease, Diabetes, Cerebral Infarction, Hepatitis B, and Peripheral Vascular Disease. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact, and required staff assistance for most activities of daily living (ADLs). Review of the December 2022 Medication Administration Record (MAR) revealed Resident #4 tested positive for Covid-19 on 12/28/2022 and 12/29/2022. Review of the comprehensive Care Plan initiated on 12/29/2022, and revised on 1/10/2023, revealed Resident #4 had an active diagnosis of Covid-19 and was on contact/droplet isolation. Review of the January 2023 MAR revealed Resident #4 tested positive for Covid-19 on 1/6/20233, 1/7/2023, 1/9/2023, and 1/10/2023. Observation outside the resident's room on 1/10/2023 at 12:10 PM, revealed there was not an isolation cart present, and there was no signage which identified Resident #4 was in droplet isolation posted on the door or wall. The Activity Assistant entered Resident #4's room wearing a KN95 mask and donned gloves inside the room. The Activity Assistant did not don a face shield, goggles, or a gown prior to entering Resident #4's room. Observation outside of the resident's room on 1/10/2023 at 12:11 PM, revealed CNA #3 and CNA #4 entered Resident #4's room wearing a KN95 mask and donned gloves inside the room. CNA #3 and CNA #4 did not don face shields, goggles, or gowns prior to entering Resident #4's room. Observation and interview outside the resident's room on 1/10/2023 at 12:16 PM, revealed the Activity Assistant exited Resident #4's room. The Activity Assistant was asked what PPE was required in the resident's room. The Activity Assistant stated, Gloves and dress out gown .Covid [Covid positive resident rooms]. The Activities Assistant was asked if he should have worn a face shield in the room. The Activity Assistant stated, .I know we always have to protect the eyes. The Activity Assistant confirmed he did not wear a gown or face shield when he entered Resident #4's room. During an interview on 1/10/2021 at 12:21 PM, CNA #3 was asked what PPE staff were required to wear when they entered a Covid positive resident's room. CNA #3 stated, The gown, gloves .face shield, N95 or KN95 . CNA #3 confirmed that a KN95 mask was the only PPE she wore inside Resident #4's room. During an interview on 1/10/2021 at 12:46 PM, CNA #4 confirmed she worked for a staffing agency, and this was her first time to work in the facility. CNA #4 was asked what PPE staff were required to wear when they entered a Covid positive resident's room. CNA #4 stated, Gown, gloves, face mask, and face shield. CNA #4 confirmed that she was not aware Resident #4 was Covid-19 positive, and that a KN95 mask and gloves were the only PPE she wore in Resident #4's room. Observation outside the resident's room on 1/10/2023 at 1:55 PM, revealed the door to Resident #4's room was closed, there was no isolation cart next to the door, and no signage posted to indicate he was in droplet isolation. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Adult Failure to Thrive, Dementia, Anxiety Disorder, Hypertension, Thyroid Cancer, and Alzheimer's Disease. Review of the annual MDS dated [DATE], revealed Resident #6 was rarely or never understood, had moderately impaired cognitive skills for daily decision making, and required extensive staff assistance for most ADLs. Review of the January 2023 MAR revealed Resident #6 tested positive for Covid-19 on 1/5/2023. Review of the comprehensive Care Plan initiated on 1/3/2023, with a revision date of 1/10/2023, revealed, .active dx [diagnosis] of COVID-19 .Resident to be on contact/droplet isolation . Observation outside the resident's room on 1/10/2023 at 11:54 AM, revealed Resident #6's door was closed, there was no signage posted to indicate the resident was in droplet isolation posted on the door or wall outside of the room, and there was an isolation cart located across the hall from Resident #6's room. Observation outside the resident's room on 1/10/2023 at 1:56 PM, revealed Resident #6's door was closed and there was no signage posted to indicate the resident was in droplet isolation posted on the door or wall. 4. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Dementia, and Benign Prostatic Hyperplasia. Review of the significant change MDS dated [DATE], revealed Resident #7 had a BIMS score of 04, which indicated severe cognitive impairment, and required staff assistance for most ADLS. Review of the January 2023 MAR revealed Resident #7 tested positive for Covid-19 on 1/5/2023, 1/9/2023, and 1/10/2023. Review of the comprehensive Care Plan initiated 12/29/2022, with a revision date of 1/10/2023, revealed, .active dx [diagnosis] of COVID-19 .Resident to be on contact/droplet isolation . Observation outside the resident's room on 1/10/2023 at 12:33 PM, revealed the door was open, there was no signage posted to indicate Resident #7 was in droplet isolation, and there was not an isolation cart beside the resident's room. CNA #2 entered Resident #7's room with a meal tray, placed the meal tray on Resident #7's over bed table and set up the meal tray. CNA #2 wore a KN95 mask and a face shield. CNA #2 did not don gloves or a gown prior to entering Resident #7's room. Observation and interview outside the resident's room beginning on 1/10/2023 at 12:35 PM, revealed CNA #1 entered Resident #7's room wearing a KN95 mask. CNA #1 did not don a gown, gloves, goggles, or a face shield prior to entering Resident #7's room. CNA #1 went to Resident #7's bedside and pulled the curtain around the bed. The door to the room remained open. CNA #1 exited the room at 12:37 PM. CNA #1 was asked what PPE staff should wear in a Covid positive resident's room. CNA #1 stated, .the gown, put our gloves on, and the shield [face]. CNA #1 was asked what PPE she wore when she entered Resident #7's room. CNA #1 stated, I only had my mask on. During an interview on 1/10/2023 at 12:40, CNA #2 was asked if she wore a gown and gloves when she entered Resident #7's room. CNA #2 stated, I was just giving a tray, I wasn't touching nobody .that's the way I do it . Observation outside the resident's room on 1/10/2023 at 1:59 PM, revealed there was no signage posted to indicate Resident #7 was in droplet isolation. 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Nontraumatic Intracerebral Hemorrhage, Neuropathy, Hemiplegia and Hemiparesis following Cerebral Infarction, Hypertension, Alcohol Abuse, Depression, and Anxiety Disorder. Review of the quarterly MDS dated [DATE] revealed Resident #8 had a BIMS score of 8, which indicated he was moderately cognitively impaired, and required staff supervision to extensive assistance for ADLS. Review of the January 2023 MAR revealed Resident #8 tested positive for Covid-19 on 1/5/2023. Review of the comprehensive Care Plan initiated 1/5/2023, with a revision date of 1/10/2023, revealed, .active dx [diagnosis] of COVID-19 .Resident to be on contact/droplet isolation . Observation outside the resident's room on 1/10/2023 at 12:32 PM and 2:05 PM, revealed the door to Resident #8's room was open and there was no signage posted to indicate Resident #8 was in droplet isolation. During an interview on 1/10/2023 at 1:20 PM, the Infection Preventionist confirmed that staff were supposed to wear the N95 or KN95 mask, gowns, gloves, and face shields when they entered Covid-positive residents' rooms. The Infection Preventionist was asked if signage should be posted outside the residents' rooms to indicate what type of isolation they were in. The Infection Preventionist stated, We have the doors closed saying you're entering the quarantine area .it should say see nurse before entering or the isolation cart right beside the door . The Infection Preventionist confirmed Resident #4, #6, #7, and #8 were on the second floor and were not in a quarantine unit. The Infection Preventionist stated, Soon as the outbreak occurred, we had everybody located in a quarantine area .upstairs didn't have enough room to move [to a quarantine area] .isolate in their room as each person became positive everybody was made aware . During an interview on 2/27/2023 at 3:47 PM, the Director of Nursing (DON) confirmed that staff should wear gowns, gloves, N95 or KN95 masks, and goggles or face shields when they entered a Covid-positive resident's room. The DON was asked how staff would know which residents were Covid-positive. The DON stated, There should be signage on the door [of the resident's room].

Based on policy review, employee personnel file review, the working schedule, employee timecard, medical record review, observation and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse and Neglect Prevention, with a revision date of 5/9/2019 revealed, .To establish guidelines that prevents, identifies and report resident abuse and neglect .All residents have the right to be free from abuse .misappropriation of resident property .Residents must not be subjected to abuse by anyone including but not limited to .facility staff .Misappropriation of resident property .means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Should an incident or suspected incident of Resident abuse .be reported or observed, the administrator or .designee will designate a member of management to investigate the alleged incident .The investigation should include .Interview all witnesses to the incident and document all witness statements .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate .if appropriate .Witness reports will be reduced to writing. Witnesses will be requested to sign and date such reports. A copy of reports will be maintained with the investigation file . Review of the undated facility document titled, BILL OF RESIDENT'S RIGHTS revealed, Each person residing in a Tennessee nursing center is accorded extensive rights guaranteed under federal and state law .As a nursing center Resident, you have the right to be informed prior to or upon admission .both orally and in writing in a language you understand. Of these rights and regulations .You also have the right exercise your rights as a Resident of the center .You have the right to be free from verbal, sexual, physical or mental abuse .This Center has developed and implemented written policies and procedures that prohibit mistreatment, neglect or abuse .You may voice complaints with respect to .abuse, neglect, and/or misappropriation of property .The Center will undertake prompt efforts to resolve any grievances you may have . 2. Review of Certified Nursing Assistant (CNA) #6's personnel file revealed her date of hire as 10/13/2022. Continued review revealed an active CNA certification and a background check, which included the Abuse Registry, dated 10/12/2022. CNA #6 was educated on the Elder Justice Act and the Facility Abuse Policy on 10/14/2022. 3. Review of the Working Schedule dated 1/5/2023, revealed CNA #6 was not scheduled to work that day. 4. Review of CNA #6's timecard dated 1/5/2023, revealed she clocked in at 10:55 PM and clocked out at 12:00 AM on 1/6/2023. 5. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Sepsis, Diabetes, Acquired Absence of Right Leg below Knee, Heart Failure, Anxiety Disorder, Rheumatoid Arthritis, and Hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status score of 15, which indicated she was cognitively intact, and required extensive staff assistance for most activities of daily living. Review of the facility investigation included an incident report dated 1/6/2023, a written statement from Licensed Practical Nurse (LPN #3) dated 1/6/2023, a typewritten statement by the Director of Nursing (DON) dated 1/6/2023, a local police department report number and officer name and number dated 1/6/2023, a Midnight Census dated 1/5/2023 with names of residents interviewed, the Abuse Prohibition policy, and a California Association of Long Term Care Medicine article, dated 2/15/2022, titled New CMS [Centers for Medicare and Medicaid] Regulations on Abuse-Do You See What We See. With the exception of LPN #3 and the DON, there were no staff witness statements. Review of LPN #3's witness statement dated 1/6/2023, revealed she received a call between approximately 11:30 PM [on 1/5/2023] and 12:30 AM [on 1/6/2023] from a man who told her his name and asked for someone in charge. He told LPN #3 that a CNA who worked there, CNA #6, was stealing residents' money, residents' identification, and had taken money out of residents' accounts. LPN #3 put the call on speaker so Registered Nurse (RN) #1 could witness the call. The caller told LPN #3 that he had proof of the theft, LPN #3 gave him her cell phone number, and the caller sent pictures of a resident's [Resident #1] bank card and identification. LPN #3 reported the call to the DON immediately and forwarded the picture to her. The DON instructed LPN #3 and RN #1 to walk CNA #6 out of the facility. LPN #3 and RN #1 were not able to find CNA #6 and were told by other staff that she had already left. Review of the DON's typed statement dated 1/6/2023 revealed, On 1/5/23 [2023] I spoke with resident [named Resident #1]. She stated that a short lady came into her room and provided care for her. She states that now she is unable to find her driver's license, debit card and 70 dollars. I asked resident where she kept them and she replied in her pillow-case. I informed resident that I would look for her items. I was sure I would find them in laundry. On 01/06/23 I received a call from [named LPN #3] stating that a man was on the phone saying we have an employee that is stealing from the resident's [residents] .states he has proof and will send it to us. He texted the nurse pictures of [named Resident #3] social security card, [named Resident #2] driver's license and [named Resident #1] driver's license and debit card .he identified the employee as [named CNA #6]. I said to the nurse [named CNA #6] should not be on the schedule and she was not on the schedule .nurse .stated I'm sure I saw her come into the building. [Named LPN #3 and RN #1] went upstairs to send the c.n.a home and they were unable to find the c.n.a . Observation and interview on 1/10/2023 at 2:01 PM, revealed Resident #1 sat on the right side of her bed, was fully clothed, and appeared neat and clean. Resident #1 confirmed some of her personal items had been taken and stated, .my money .keep in this little purse and put in the pillow case .noticed my pillow wasn't the way it was supposed to be .and my money was gone . Resident #1 could not recall who she was or describe the staff member who she believed had taken her money. Resident confirmed that it had been about 2 weeks since the incident occurred. Resident #1 stated, .got my driver's license .supposed to have been her boyfriend, made a copy of my debit card and driver's license, that was proof it was missing, I told them .don't know the date .transferred my money to savings and didn't renew my debit card . Resident #1 confirmed there was no money missing from her bank account, but $70 cash was taken, and the facility was replacing the money. During a telephone interview on 2/27/2023 at 1:12 PM, LPN #3 confirmed she answered a call at the facility between 11:30 PM on 1/5/2023 and 12:30 AM on 1/6/2023, where the caller informed her that CNA #6 was stealing residents' information. LPN #3 stated, I was on 3 to 11, signaled to [named RN #1] .to come listen .[named RN #1] started writing stuff down .I said let me give you my number [personal cell number] .got off the phone called [named DON], told her the names, what happened .he said he was going to send me pictures. She said when he sends it to you, send it to me .go up there and find the girl [CNA #6] and tell her she needs to leave the building .she works 11 to 7 but she came in about 10:30, we just spoke .[when we] get up there, we're asking for her, all the CNAs had been acting weird .like they're hiding her .one of the CNAs said she's not here she left .I said if she's in the building she needs to leave per [named the DON] .walked back to the elevator and it wouldn't work .walked down the back way on the stairs. While on the stairs the young man sends me the pictures .sent them to [named the DON] .deleted them from my phone . LPN #3 confirmed that she did not remember which CNA told her that CNA #6 had already left the facility. During a telephone interview on 2/27/2023 at 3:47 PM, the DON confirmed that Resident #1 reported to her on 1/5/2023 that a young lady had come in her room and that her driver's license and debit card were now missing. The DON stated, I think she said some money was missing as well, 73 dollars or something, said it was in her pillowcase .I went to laundry, but they hadn't gotten to the personals yet, we were just waiting until they got to the personals, we was just sure it was going to come up in that laundry. The DON was asked when did laundry staff tell her they would get to the residents' personals. The DON stated, After the next day [in 2 days]. The DON was asked were you just going to wait until that time to launch an investigation into the allegation. The DON stated, Well, I was just so certain that we would come up with it in that laundry .especially since she had it all stuffed down in a pillowcase. During a telephone interview on 2/28/2023 at 11:41 AM, RN #1 confirmed she witnessed most of the telephone call where the caller alleged CNA #6 had stolen residents' information. RN #1 stated, .Was at the nurses' station, my co-worker [named LPN #3] .received a call, male at the other end .[named LPN #3] said wait a minute .waved me to come over there and put him on speaker .[he stated] this lady done got me in trouble with the law so I want to tell you some things she was doing .got copies of credit cards and residents' identification .he gave us her name .he said I got proof so I told [named LPN#3] to give him her number .he sent it on her phone, it was her [Resident #1] bank card, driver's license, several more residents, had their social [security card] .we called [named the DON] and told her .she said she [CNA #6] shouldn't be there tonight .not on the schedule .[named the DON] said if you see her in the building make her leave . RN #1 stated, We went through the building and when staff seen us, they said she had already left. When we went up the elevator, she went down the stairs . RN #1 confirmed that she was not asked to write a statement about the incident, and she was not interviewed by Administration about the incident. During a telephone interview on 3/1/2023 at 12:53 PM, the DON confirmed that she did not interview RN #1 or have her write a statement regarding the misappropriation allegation. The DON was asked if she requested that any other staff members who worked on 1/5/2023 write a statement regarding the misappropriation allegation incident. The DON stated, .No, I didn't .should have . The DON was asked if she requested laundry to look for Resident #1's lost items immediately instead of waiting the couple of days before they got through all of the personal items. The DON stated, I think I said as quick as you can. During a telephone interview on 3/1/2023 at 2:35 PM, the Administrator was asked should someone who witnessed an allegation be asked to write a statement regarding the allegation. The Administrator stated, Yes, if they witness it. The Administrator was asked if she considered this a thorough investigation. The Administrator stated, She [DON] started the investigation, it may not have been the best investigation, but she started it .

Based on policy review, medical record review, and interview, the facility failed to ensure investigations, neurological (neuro) checks, and assessments were completed for 3 of 3 sampled residents (Resident #55, #70, and #149) reviewed for falls and accident hazards. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 10/2010, revealed .The purposes of this procedure are to provide guidelines for assessing a resident after a fall .Residents must be assessed in a timely manner for potential causes of falls .After a Fall .If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries .Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record .An incident report must be completed for resident falls. The incident report form should be completed . Review of the facility's undated policy titled, Accidents And Incidents- Investigating and Recording, revealed .All accidents/incidents occurring in the facility and/or on the premises, must be investigated .The charge nurse (for resident indicated in accident) will assess the resident for injuries, document resident status, initiate and complete the investigation . Review of the medical record, revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], and Diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of the fall investigation dated 7/14/2022, revealed .At 6:45 am, Resident was observed lying on the floor .beside the bed. Resident stated that he had no memory of how he fell out of bed. Resident was unable to explain what happened d/t [due to] cognitive deficit. Resident was very confused The facility failed to do monitoring or follow up after the fall for Resident #55 and was unable to provide documentation that neuro checks were completed for 48 hours following the fall. During an interview on 8/10/2022 at 5:33 PM, Licensed Practical Nurse (LPN) #1 was asked what should be documented after a fall. LPN #1 stated, .incident report and a progress note should be done .the nurse should assess them, notify the doctor, notify RP [Responsible Party] .unwitnessed fall, do vital [signs], assess them and neuro checks q [every] 15 [minutes] x [for] 4 [hours], 30 minutes x [for] 4, for 72 hours .monitor for 3 days after the fall in the Progress Notes .neuro checks done on all unwitnessed falls . Review of the medical record, revealed resident #70 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hypertension, and Contracture of Left Forearm. Review of the quarterly MDS dated [DATE], revealed Resident #70 had short- and long-term memory problems and required total assistance from staff for ADLs. Review of the Incident Report dated 8/8/2022, revealed .Called to room .at approximately 8:40 PM. Observed resident noted a small skin tear to right outer forearm . Review of the Progress Note dated 8/11/2022, revealed .Upon further investigation, on Saturday 8/6/22 [2022] .resident obtained scratch/skin tear from strap on shower gurney . There was no Incident Report for the incident that occurred on 8/6/2022. During an interview on 8/11/2022 at 10:13 AM, the Assistant Director of Nursing (ADON) confirmed that the incident occurred on 8/6/2022, but an Incident Report was not completed timely. Review of the medical record, revealed Resident #149 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hypertension, Heart Failure, and Dementia. Review of quarterly MDS dated [DATE], revealed Resident #149 had a BIMS of 5, indicating severely impaired cognition, and required extensive assistance from staff for all ADLs. Review of the fall investigation dated 4/29/2022, revealed .resident on floor no injury .resident confused .impaired memory .this fall was on 4/27/2022 . The facility failed to do monitoring or follow up after the fall for Resident #149 and was unable to provide documentation that neuro checks were completed for 48 hours following the fall. Review of Resident #149's fall occurrence dated 5/20/2022, revealed .Resident was sitting on the side of the bed and fell to the floor face forward Resident stated she slid to the floor .confused, gait imbalance, impaired memory . The facility failed to do monitoring or follow up after the fall for Resident #149 and was unable to provide documentation that neuro checks were completed for 48 hours following the fall. During an interview on 8/10/2022 at 3:11 PM, the Director of Nursing (DON) confirmed neuro-checks should be completed for 72 hours. The DON was asked if a fall should be documented at the time of the occurrence. The DON stated, .the fall occurrence should be documented immediately and the follow up for post fall monitoring on resident's condition should be completed for 48 hours .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 3 of 5 sampled residents (Resident #5, #55, and #110) reviewed for unnecessary medications failed to receive antihypertensives (medication to lower blood pressure), cardiac (heart), and renal (kidney) medications, Insulin (medication to lower blood sugar), anticoagulants (medication to thin the blood), and anticonvulsants (treats seizures) as ordered and when 1 of 7 nurses (Licensed Practical Nurse (LPN) #2) failed to administer an antihypertensive medication as ordered for 1 of 10 sampled residents (Resident #37) observed during medication administration. The findings include: Review of the facility's policy titled, Administering Medications, dated 2012, revealed .Medications must be administered in accordance with the orders, including any required time frame .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR [Medication Administration Record] space provided for that drug and dose . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 8/11/2022, revealed the following orders active as of 5/31/2022: a. [MEDICATION(S)] (a heart medication) 25 milligrams (MG) give 1 tablet by mouth 2 times a day for hypertension hold for systolic blood pressure (SBP) less than (<) 110 or heart rate (HR) < 55 b. [MEDICATION(S)] (a heart medication) give 60 MG by mouth 1 time a day c. Nitro-Dur ([MEDICATION(S)], a heart medication) Patch 24 Hour Apply 0.1 mg trans dermally for [CONDITION(S)] d. [NAME] (renal medication for patients receiving [CONDITION(S)]) give 3 tablet by mouth with meals e. [MEDICATION(S)] (HCl) (an antihypertensive) 50 MG give 1 tablet by mouth every 8 hours f. Insulin Detemir Solution 100 units per milliliter (U/ML) Inject 8 units at bedtime g. [MEDICATION(S)] R (regular human insulin) Solution 100 U/ML Inject as per sliding scale: if 0 - 150 = 0 Glucose <60 Follow [CONDITION(S)] protocol 151 - 200 = 2 Units 201 - 250 = 4 Units 251 - 300 = 6 Units 301 - 350 = 8 Units 351 - 400 = 10 Units Over 401 = 12 Units recheck in 4 hours and if still > (greater than) 401 notify provider, subcutaneously before meals and at bedtime for Diabetes. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. Insulin Detemir on 6/22/2022 and 6/23/2022. b. [MEDICATION(S)] on 6/3/2022, 6/6/2022, 6/7/2022, 6/17/2022, 6/22/2022, and 6/23/2022. c. [MEDICATION(S)] on 6/3/2022, 6/6/2022, 6/7/2022, and 6/17/2022 at 10:00 AM, and on 6/22/2022 and 6/23/2022 at 10:00 AM and 6:00 PM. d. Nitro-Dur Patch 24 Hour on 6/3/2022, 6/6/2022, 6/7/2022, and 6/17/2022 at 10:00 AM, and on 6/22/2022 and 6/23/2022 at 10:00 AM and 10:00 PM. e. [MEDICATION(S)] on 6/3/2022, 6/7/2022, and 6/17/2022 at 2:00 PM, on 6/20/2022 at 6:00 AM, on 6/22/2022 and 6/23/2022 at 6:00 AM, 2:00 PM, and 10:00 PM, on 6/25/2022 at 6:00 AM, and on 6/27/2022 at 2:00 PM. f. [MEDICATION(S)] on 6/3/2022 at 12:30 PM, 6/6/2022 at 7:30 AM, 6/7/2022 and 6/17/2022 at 7:30 AM and 12:30 PM, and on 6/22/2022 and 6/23/2022 at 7:30 AM, 12:30 PM, and 5:30 PM. g. [MEDICATION(S)] R insulin on 6/3/2022, 6/6/2022, 6/7/2022, and 6/17/2022 at 11:30 AM, on 6/20/2022 at 6:30 AM, on 6/22/2022 and 6/23/2022 at 6:30 AM, 11:30 AM, 4:30 PM, and 8:00 PM, and on 6/25/2022 at 6:30 AM. No blood sugar checks were documented on these dates and times. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. Insulin Detemir on 7/10/2022 and 7/25/2022. b. [MEDICATION(S)] on 7/1/2022. c. [MEDICATION(S)] on 7/1/2022 at 10:00 AM and 7/10/2022 at 6:00 PM. d. Nitro-Dur Patch 24 Hour on 7/1/2022 at 10:00 AM, and on 7/10/2022 and 7/12/2022 at 10:00 PM. e. [MEDICATION(S)] on 7/1/2022 at 2:00 PM, 7/3/2022 and 7/4/2022 at 6:00 AM, 7/10/2022 at 10:00 PM, and on 7/12/2022 at 6:00 AM. f. [MEDICATION(S)] on 7/1/2022 at 7:30 AM and 12:30 PM, and on 7/10/2022 at 5:30 PM. g. [MEDICATION(S)] R insulin on 7/1/2022 at 11:30 AM, 7/3/2022 and 7/4/2022 at 6:30 AM, 7/8/2022 and 7/9/2022 at 11:30 AM, 7/10/2022 at 4:30 PM and 8:00 PM, 7/12/2022 at 6:30 AM and 4:30 PM, and on 7/25/2022 at 4:30 PM and 8:00 PM. No blood sugar checks were documented on these dates and times. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] on 8/6/2022 at 6:00 AM b. [MEDICATION(S)] R insulin on 8/6/2022 at 6:30 AM. No blood sugar checks were documented on this date and time. Review of the medical record, revealed Resident #55 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 8/10/2022, revealed orders for the following: a. [MEDICATION(S)] (a blood thinner) 5 mg give 1 tablet by mouth 2 times daily with a start date of 10/7/2021. b. [MEDICATION(S)] (an antihypertensive) 25 mg 1 tablet by mouth 1 time daily with a start date of 5/19/2021. c. [MEDICATION(S)] (an antihypertensive) 25 mg 1 tablet daily with a start date of 5/19/2021. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] on 6/4/2022 at 10:00 AM, on 6/13/2022 at 10:00 AM and 6:00 PM, on 6/22/2022 at 10:00 AM and 6:00 PM, and on 6/23/2022 at 10:00 AM. b. [MEDICATION(S)] and [MEDICATION(S)] on 6/4/2022, 6/13/2022, 6/22/2022, and 6/23/2022. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] on 7/8/2022 at 10:00 AM and 7/10/2022 at 10:00 AM b. [MEDICATION(S)] and [MEDICATION(S)] on 7/8/2022 and 7/10/2022. Review of medical record, revealed Resident #110 was admitted to facility on 12/07/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 8/11/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (an anti-[CONDITION(S)] medication) 250 mg give 1 two times daily with a start date of 12/07/2021. b. [MEDICATION(S)] (a blood thinner) 5mg give 1 two times daily with a start date of 3/24/2022. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/10/2022 at 5:04 PM, the Director of Nursing (DON) confirmed the missed doses on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, We missed that. During an interview on 8/10/2022 at 5:33 PM, Licensed Practical Nurse (LPN) #1 was asked should there be documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .should definitely be something documented. Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report dated 8/11/2022, revealed orders for [MEDICATION(S)] HCl Tablet 100 MG three times a day for Hypertension and to hold the [MEDICATION(S)] if the SBP was less than 110, or HR was less than 60, and [MEDICATION(S)] (a blood pressure medication) 40 MG 1 tablet daily for blood pressure. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 8/10/2022, revealed .[MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth one time a day for blood pressure held due to vital sign 133/74 HR.74 [there was no order to hold the [MEDICATION(S)] based on parameters] . Observation in the 200 hallway at The Porch Medication Cart on 8/10/2022 at 2:25 PM, revealed LPN #2 was preparing to give Resident #37's medications. LPN #2 entered Resident #37's room, obtained his vital signs, returned to the medication cart and stated, I am holding his [MEDICATION(S)] and [MEDICATION(S)] because his pulse is below 60, below the parameter. LPN #2 was asked what Resident's blood pressure and heart rate were. LPN #2 stated, Blood pressure 133 over 74 and heart rate 53. There was no order to hold the [MEDICATION(S)] related to a heart rate less than 60. During an interview on 8/10/2022 at 5:18 PM, the DON was asked under what circumstances should blood pressure medications be held. The DON stated, If a parameter is there that says to hold .have to have an order to hold. The DON was asked what if 2 blood pressure medications are ordered, one blood pressure medications had parameters and one blood pressure medication did not. The DON stated, She can give the one with no parameters.

Based on policy review, medical record review, and interview, the facility failed to provide education for Advance Directives to residents or residents' responsible parties for 4 of 32 sampled residents (Resident #98, #101, #154, and #565) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled Advance Directives, dated 2014, revealed .Prior to or upon admission of a resident to our facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the rights to accept or refuse medical or surgical treatment, and the right to formulate advance directives .If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision .Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline . Review of the medical record, revealed Resident #98 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #98 had moderate cognitive impairment. Review of Resident #98's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #101 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #101 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #101's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #154 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #154 had moderate cognitive impairment with a BIMS score of 9. Review of Resident #154's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #565 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #565 had severe cognitive impairment. Review of Resident #565's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 8/9/2022 at 4:48 PM, the Director of Nursing (DON) confirmed all residents should be educated and offered advance directives on admission.

Based on the facility's timeline review, policy review, medical record review, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 4 residents (Resident #1) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #1, a moderately impaired vulnerable resident wearing an ankle wander guard monitor (a monitoring device to alert staff when a resident attempts to exit a door in the facility) was left unsupervised at a medical appointment and the resident left the appointment without authorization or necessary supervision. The facility was unaware of the resident's location for 8 hours and 39 minutes. Resident #1 was located approximately 7.1 miles from the facility, sitting outside a convenience store, drinking alcohol, and smoking a cigarette when the facility staff arrived at the store. 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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/16/2022 at 6:31 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 2/10/2022 through 2/11/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 2/14/2022 through 2/18/2022. The facility was cited past noncompliance and is not required to submit a Plan of Correction. The findings include: Review of the facility's titled, Policy and Procedure .Abuse Prohibition, dated 2015, revealed .Neglect' means failure to provide goods and services necessary to avoid physical harm . 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 admission Elopement Risk Evaluation dated 5/7/2021, revealed Resident #1 was assessed at a high risk for elopement and a wander guard monitor was placed on his left ankle. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 10 on the Brief Interview of Mental Status (BIMS), which indicated the resident was moderately impaired for decision making. Review of the Care Plan dated 11/16/2021, revealed Resident #1 was at risk for elopement, wore a wander guard, and was to remain safe during nursing home placement. Review of the facility's timeline dated 2/10/2022, revealed Resident #1 had an appointment with a Social Security Disability Psychiatric Doctor on 2/10/2022 at 9:45 AM. On 2 /4/2022, Resident#1's sister requested the Social Worker arrange transportation to the appointment and the sister would then meet Resident #1 at the appointment. On 2/10/2022 Resident #1 left the facility at 9:02 AM in the transport van with the transport driver. The transport driver was informed that Resident #1's sister would be at the appointment and to transfer responsibility of the resident to the sister upon arrival. The transportation driver escorted Resident #1 to the appointment on 2/10/2022 and left Resident #1 in the waiting room without checking to see if the sister was at the appointment. The transportation driver returned to the physician's office at 2:25 PM and found the building to be dark, the doors locked, and Resident #1 was not present outside the building. The facility was notified. The facility made attempts to notify the sister with no answer. Emergency 911 was called by the facility to report Resident #1 missing. Facility staff left the facility to search for Resident #1. At 4:15 PM, a facility staff member reported Resident #1 was at a Community Center, approximately 2.2 miles from the facility but had left the Community Center walking, approximately 20 minutes before staff arrived. At 4:48 PM, Resident #1's sister called and informed the facility that she did not go to the appointment. She had received a call from Resident #1 from a stranger's phone and he stated he was at an intersection that was approximately 4.1 miles from the facility and planned to go to the (Named) store where he used to work located approximately 7.1 miles from the facility. Staff arrived at the (Named) store at 5:41 PM and found Resident #1 drinking vodka from a bottle and smoking a cigarette. The facility staff escorted Resident #1 back to the facility at 6:04 PM. The facility failed to ensure Resident #1 was free from neglect and failed to provide supervision for him, a vulnerable moderately impaired resident, wearing an ankle wander guard monitor. Resident #1 was unsupervised for approximately 8 hours and 39 minutes. During an interview on 2/14/2022 at 5:15 PM, Resident #1 stated, .I went to an appointment .the Social Worker made arrangements for them to take me .my sister told me she was not coming, she had to work [the resident did not tell the facility this] .I went outside to look for my ride, and the driver was not there, he was gone .I sat and talked to the homeless people, and they gave me cigarettes. I got tired of waiting .I went back into the office they told me to wait outside. I went outside and sat on the steps .I walked to a friend's house that lived in the area, he was not there so I came back [to the appointment location] and went and asked again where my ride was .they told me to go outside so the driver could see me. I waited until I started to get cold and hungry. I walked back to my friend's house, he was home, and he took me to East [part of the city where he lived]. I called my sister and told her to come and get me and that's when she told me the [facility] had been calling her looking for me .then I went to the place I used to work [Named Store] they were glad to see me, they said they thought I was dead. My friends gave me some vodka and cigarettes .I was outside drinking .nurses caught me when I was turning the bottle up drinking my friends gave me 2 small bottles [of alcohol] and I put it in my pocket .I drank them on the way back. I told them I didn't want to come back .I'm trying to get out of here .I don't belong here .I was hungry and sleepy .just having a good time . During an interview on 2/15/2022 at 6:12 PM, the Administrator stated .when he left the facility to go to the appointment he was wearing a wander guard monitor .he should have been supervised .he is our responsibility . During a telephone interview 2/16/2022 at 11:27 AM, the transport driver stated, .picked him [Resident #1] up around 9:00 AM .I noticed he had an ankle monitor on, I wondered about it .I walked upstairs with him to the office [physician's office] .I don't know if his sister was there or not; I just walked him to the door and left .when I came back around 2:45 PM to pick him up the whole building was dark, the doors were locked, didn't see him .I called [Named Social Worker] and told her he wasn't there .I had a feeling I knew I shouldn't have left him . During an interview on 2/16/2022 at 12:02 PM the Social Worker (SW) confirmed she did not follow up to ensure Resident #1's sister would be attending the appointment with the resident. The SW stated, he wears the wander bracelet for his safety .he verbalizes going home and wanting to leave .he's not safe because of his drinking and drug history .he should've had an escort . During an interview on 2/18/2022 at 2:58 PM, the DON stated, .because of his drinking and drug history and verbalizing he wants to go home .don't know if we can trust him .he should have been supervised . The facility's corrective action plan included the following: 1. On 2/10/2022, an investigation of the incident was initiated. The surveyors reviewed the facility's investigation, interviewed the DON, Administrator, and facility staff. 2. On 2/10/2022, an AdHoc (as needed)/Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Medical Director, Administrator, DON, and Director of Social Services participating in the meeting. The meeting was held to notify and discuss the incident and receive input from the Medical Director. During this meeting, a new policy was developed and implemented that no residents are to go to appointments without a facility staff member escort. The surveyors reviewed the AdHoc sign in sheet and interviewed the Medical Director, Administrator, DON, Social Worker, and facility staff. The surveyors reviewed the new policy for transport. 3. On 2/10/2022, in-service education regarding the new policy was completed with the Social Worker. The surveyors interviewed the Social Worker and reviewed the in-service sign in sheets. 4. Beginning on 2/10/2022, Resident #1 was educated daily following the incident by the Psychiatrist, Nurse Practitioner (NP), DON, and Social Services that he does not need to attempt to leave on his own because the facility needs to be aware of where he is for his own safety. The surveyors interviewed the NP, DON, Social Services, and Resident #1 about the education provided. The surveyors reviewed the medical record for documentation of the education. 5. On 2/11/2022, the DON, Administrator, and Registered Nurse (RN) #1 initiated education for all staff regarding the new policy for resident transport. All staff will be educated prior to working their next shift. The education is ongoing. The surveyors interviewed facility staff on all shifts and reviewed the in-service sign in sheets. 6. On 2/11/2022, all Elopement Risk Evaluations were reviewed for accuracy. Two residents were no longer an elopement risk and wander guards were removed. The orders were checked on all residents (Elopement Risk Evaluation) with a score of 10 or higher and requiring wander guards to ensure nursing is alerted on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Wander guards were noted to be in place and functioning. The wander guard binder was audited to ensure all residents at high risk for elopement had the residents' pictures and face sheets present. The surveyors reviewed the audit form, the medical records, and reviewed the wander guard binders. 7. On 2/11/2022, all appointments made in the last 30 days were audited to ensure the facility did not fail to provide adequate supervision to prevent an incident of elopement of a moderately impaired vulnerable resident wearing a wander guard bracelet with a history of alcohol and cocaine abuse. The outcome of the audit was that no appointments were noted. The surveyors reviewed the audit form and interviewed the facility staff. 8. Beginning 2/10/2022, all new employees will be in-serviced during orientation on the transportation escort policy going forward. The surveyors interviewed the DON regarding new employee education. 9. On 2/10/2022, education was provided for family members regarding the new transportation escort policy as appointments are scheduled. The surveyors interviewed the DON, the Administrator, and the Social Worker regarding family education. 10. The Administrator will review appointment sheets weekly to ensure facility is providing an escort and to ensure that the facility is providing adequate supervision to prevent an incident of elopement of a vulnerable resident from an appointment. Review of appointment sheets will be done weekly for 4 weeks, bi-weekly for 30 days, monthly for 1 month, then quarterly. Findings will be reported to QA monthly for 3 months then quarterly. The surveyors reviewed the audit tool for appointments and interviewed the Administrator regarding the monitoring.

Based on the policy review, facility's timeline review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable, moderately impaired resident wearing a wander guard bracelet (a monitoring device to alert staff when the resident attempts to exit a door in the facility) for 1 of 4 sampled residents (Resident #1) reviewed for elopement. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 was transported to a medical office and left at the medical office without supervision. Resident #1 left the medical appointment unsupervised, without the facility's knowledge, and was found approximately 8 hours and 39 minutes after leaving 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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/16/2021 at 6:31 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 2/10/2022 through 2/11/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 2/14/2022 through 2/18/2022. The facility was cited as past noncompliance and is not required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Elopement, Risk Prevention, and Management of Missing Residents, revealed, .facility strives to promote resident safety .elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Traumatic Hemorrhage of Cerebrum, Cardiomegaly, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Cocaine Abuse and Seizures. Review of the admission Elopement Risk Evaluation dated 5/7/2021, revealed an elopement risk score of 13, which indicated a high risk for elopement, and a wander guard monitor was placed on his left ankle. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had moderate impairment for daily decision making. Resident #1 was independent with supervision for Activities of Daily Living (ADL). Review of the Care Plan dated 11/16/2021, revealed Resident #1 was at risk for elopement and had difficulty making daily decisions due to a [CONDITION(S)] and a Traumatic Brain Injury. The intervention to address this concern was to implement a wander guard monitor. Review of Physician's Progress notes dated 1/5/2022 and 2/8/2022, revealed Resident #1 had a past medical history of Cerebral Hemorrhage and Intracranial Bleed, Seizures, Diabetes, Hypertension, [CONDITION(S)], was alert, was oriented times two to person and place, and had paranoia attributes. Review of the monthly summaries dated 1/8/2022 and 2/8/2022, revealed Resident #1 participated in the Elopement Management Program. Review of the facility's timeline dated 2/10/2022, revealed Resident #1 left the facility at 9:02 AM in a transportation van for an appointment. The transportation driver escorted Resident #1 into the appointment office and left the resident unattended. The transportation driver returned to the office at 2:45 PM, the building was dark, the door to the office was locked, and Resident #1 was not present. The facility was notified. Staff left the facility to search for Resident #1. At 4:15 PM, a facility staff member reported Resident #1 was at a Community Center, approximately 2.2 miles from the facility but had walked away from the center about 20 minutes before staff arrived. At 4:48 PM, Resident #1's sister called the facility and stated she had received a call from Resident #1. He was using a stranger's phone. He said he was at an intersection that was approximately 4.1 miles from the facility and was going to a (Named) Store where he had previously worked, that was located approximately 7.1 miles from the facility. The facility staff arrived at the (Named) store at 5:41 PM. Resident #1 was drinking vodka from a bottle and smoking a cigarette. The facility staff escorted Resident #1 back to the facility at 6:04 PM. The outside temperature was noted to be 61 degrees at that time. Resident #1 was wearing capri length pants, a t-shirt, and a button up shirt with mid length sleeves, socks, and tennis shoes. The facility failed to ensure a secure and safe environment for Resident #1 when the facility was unaware the resident was missing from the appointment until 5 hours and 43 minutes later, when the transport van driver notified the facility. The facility was unaware of Resident #1's location for approximately 8 hours and 39 minutes. Resident #1 was located 7.1 miles from the facility, at a convenience store drinking alcohol and smoking a cigarette. During an interview on 2/14/2022 at 5:15 PM, Resident #1 stated, .I went to an appointment .the Social Worker made arrangements for them to take me .my sister told me she was not coming, she had to work [the resident did not tell the facility this] .the appointment only lasted 10 minutes, I went outside to look for my ride, and the driver was not there, he was gone .I sat and talked to the homeless people, and they gave me cigarettes. I got tired of waiting . I went back into the office they told me to wait outside. I went outside and sat on the steps .I walked to a friend's house that lived in the area, he was not there so I came back [to the appointment location] and went and asked again where my ride was .they told me to go outside so the driver could see me. I waited until I started to get cold and hungry. I walked back to my friend's house, he was home, and he took me to East [part of the city where he lived]. I called my sister and told her to come and get me and that's when she told me the [facility] had been calling her looking for me. I was at [named streets in the city]. I got a house in that area .I fed my dogs .then I went to the place I used to work, [named store] they were glad to see me, they said they thought I was dead. My friends gave me some vodka and cigarettes .I was outside drinking .when the police, I mean nurses pulled up .my girlfriend came up there too .she wanted us to go to the house .she said she had some liquor and cigarettes and some food .My friend at the store gave me some food to eat .didn't do any drugs .nurses caught me when I was turning the bottle up drinking my friends gave me 2 small bottles [of alcohol] and I put it in my pocket .I drank them on the way back. I told them I didn't want to come back .I'm trying to get out of here .I don't belong here .I was hungry and sleepy .just having a good time . During the interview, Resident #1 was looking at the windows in the Conference Room. Resident #1 stated, .do you think those windows would open .if they open, then you could get out of them . Observation downstairs at the vending machine on 2/15/2022 at 12:30 PM, revealed Resident #1 standing near the vending machines that were located near an exit door. A wander guard bracelet was noted on his left ankle. Resident #1 stated, .I'll go out that door, jump over that fence and go home . During an interview on 2/15/2022 at 3:36 PM, Registered Nurse (RN) #1 stated, .I heard he [Resident #1] was missing when the driver went to get him .everyone [driving around] looking for him .the resident's sister was called .she said he was walking to the [Named] convenience store .another nurse and I went to the [Named] store .when we arrived to the store he was sitting on a milk crate outside talking to some other people .drinking a bottle of liquor .he said 'I'm not ready to go' I told him we'd been looking for him all afternoon .he had liquor, he drank the rest of it .he had a small bottle of liquor in his pocket he drank it on the way back to the facility .I don't know if he had done any drugs I didn't ask . During an interview on 2/15/2022 at 3:54 PM, Licensed Practical Nurse (LPN) #1 stated, .I was informed transport had called and said the resident wasn't at the office when he went back to pick him up .[Named Social Worker] and I went to the building where the appointment was . the door was locked to the office .rode around grocery store parking lot .then came back to the facility .I got in my car and started looking in a different area .tried to call his sister, she called and gave me the address of his former home .the sister had not heard anything from him .I went to the address the sister had given me and looked around .didn't see him .I was notified that he had called his sister and said he was at a bus stop .the Police were here and Administrator said he's my responsibility we'll go get him. I got in the car and the Administrator called and said he was at the [Named] store and the staff at the store was going to hold him there until we got there. When we got there, he was sitting on a milk crate in the front of the store. He was drinking alcohol when he seen us, he turned the bottle up. He had 2 cigarettes behind each ear and he was smoking a cigarette and said, ' .oh lord it's the police .' he had a fifth of vodka in his hand and he drank it all .asked him how did you get out here .he said I caught the bus .he didn't say from where .just said he had friends .he's always had a wander guard on .always asks when am I getting out of here . During an interview on 2/15/2022 at 5:10 PM, the Social Worker (SW) stated, .[Named Resident #1]'s sister had requested transportation to be set up for an appointment because she didn't want to take him in her car because she said he would jump out of the car and take off .he asked me several times if we had transportation set up for the appointment .when I got to work the morning of the appointment .he was already dressed and ready to go, pacing around .transport came and got him took him to the appointment .the transport driver called around 2:45 PM and notified me that the resident wasn't at the medical office when he returned pick him up .everyone started looking for him .in our cars looking at the library, the grocery store .hoping we'd see him walking around .it was scary .didn't consider him an elopement risk .verbalizes he wants to go home that's why the wander guard is still on . During an interview on 2/15/2022 at 6:12 PM, the Administrator stated, .when he [Resident #1] left the facility to go to the appointment he was wearing a wander guard .we did not know he had left the appointment until the transport driver went back to pick him up .we didn't know where he was going .he knew where he was going and how to get there but he is still our responsibility .for his safety he is going to keep the wander guard on . During an interview on 2/16/22 at 11:18 AM, the Nurse Practitioner (NP) stated, .notified he [Resident #1] had gone to an appointment and didn't return .when he got back he was intoxicated I ordered some prn [as needed] medications .he was looking to get out .meet with friends he didn't think it was a big deal .I have concerns because of the history of a brain bleed .he wouldn't be safe .he has a history of [CONDITION(S)] .that [alcohol] is what he was after .not capable of making good decisions that are safe for him . During a telephone interview on 2/16/2022 at 11:27 AM, the transport driver stated, .picked [Named Resident #1] up around 9:00 AM .took him to the appointment address .I noticed he had an ankle monitor on, I wondered about it .on the way to the appointment he talked about where he was from, said his sister was going to meet him at the appointment, talked about his history of alcohol and what he was going to eat for lunch. I walked upstairs with him to the office and left .when I came back around 2:45 PM to pick him up, the whole building was dark, the doors were locked, didn't see him. I called [Named Social Worker] and told her he wasn't there .she asked me to look for him, so I drove to south [area of the city] looking around because that's where he said he was from around 5:00-6:00 PM that evening I found out he had been located . During an interview on 2/16/2022 at 12:02 PM, the Social Worker stated, .he's [Resident #1] not safe because of his drinking and drug history and his primary concern was drinking .he wasn't fearful .he should've had an escort . During an interview on 2/16/2022 at 5:05 PM, LPN #2 stated, .notified me that a resident is missing .went to the Community Center, a lady that works at the Community Center said he was there earlier .she showed me the video. He walked in the Community Center looked around and walked back out, walked toward [Named Street] .I called the facility and told them he had been at the Community Center .I looked around the area near the Community Center .police were looking .sister was on the phone .I called the [Named] store and talked to a staff member .they asked me if I was talking about the person with an ankle bracelet, I said yes that's him, they said he was he was walking down the street .I asked him [staff member] to get him back to the store . I talked to him [Resident #1] on the phone he said, 'how did you find me' guess he ate, got some alcohol. I told him to stay there .he had the wander guard on like it would do anything over there at the appointment . Observation in the resident's room on 2/16/2022 at 5:35 PM, revealed Resident #1 was lying in bed with a wander guard bracelet noted on his left ankle. Resident #1 stated to the surveyor, .are you coming to get me out of here? The surveyor stated, .no .the Social Worker is working on it . Resident #1 stated, .she's [the Social Worker] not going to do anything .all I need is a ladder and a rope . During a telephone interview on 2/17/2022 at 10:35 AM, the Appointment Secretary stated, .he [Resident #1] arrived to the appointment about 9:15 AM .he went to the hall where patients wait .he left the office probably about 10:10 AM .around 11:45-12:00 I was straightening up the office and I looked up and he was standing at the desk .I told him he couldn't be here .told him to go outside and wait on his ride, he walked out .I left the office about 12:30 PM saw him sitting at a bus stop .I guess he went on a joy ride/walk . During a telephone interview on 2/17/2022 at 11:55 AM, the Medical Director stated, . notified Thursday night that he [Resident #1] went to an appointment and left the appointment .went to a liquor store .he was intoxicated .no he is not safe to go by himself .he was supposed to have family meet him . During a telephone interview on 2/17/2022 at 12:10 PM, a Governing Body member stated, .he [Resident #1] was intoxicated when he was brought back to the facility .it is an unfortunate incident . During an interview on 2/18/2022 at 2:58 PM, the DON stated, .residents with a wander guard should be supervised when going out to an appointment .alcohol affects decision making if they drink enough .because of his [Resident #1] drinking and drug history and verbalizing he wants to go home .he is an elopement risk .don't know if we can trust him . The facility's corrective action plan included the following: 1. On 2/10/2022, an investigation of the incident was initiated. The surveyors reviewed the facility's investigation, interviewed the DON, Administrator, and facility staff. 2. On 2/10/2022, an Adhoc (as needed)/Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Medical Director, Administrator, DON, and Director of Social Services participating in the meeting. The meeting was held to notify and discuss the incident and receive input from the Medical Director. During this meeting, a new policy was developed and implemented that no residents are to go to appointments without a facility staff member escort. The surveyors reviewed the AdHoc sign in sheet and interviewed the Medical Director, Administrator, DON, Social Worker, and facility staff. The surveyors reviewed the new policy for transport. 3. On 2/10/2022, in-service education regarding the new policy was completed with the Social Worker. The surveyors interviewed the Social Worker and reviewed the in-service sign in sheets. 4. Beginning on 2/10/2022, after this incident, Resident #1 was educated daily by the Psychiatrist, Nurse Practitioner (NP), DON, and Social Services that he does not need to attempt to leave on his own because the facility needs to be aware of where he is for his own safety. The surveyors interviewed the NP, DON, Social Services, and Resident #1 about the education provided. The surveyors reviewed the medical record for documentation of the education. 5. On 2/11/2022, the DON, Administrator, and Registered Nurse (RN) #1 initiated education to all staff regarding the new policy for resident transport. The education is ongoing. Staff will be in-serviced prior to their first shift to work. The surveyors interviewed facility staff on all shifts and reviewed the in-service sign in sheets. 6. On 2/11/2022, all Elopement Risk Evaluation scores were reviewed for accuracy. Two residents were no longer an elopement risk and wander guards were removed. Orders were checked to ensure nursing is alerted on Medication Administration Record (MAR) to check wander guards for placement and functioning on all residents (Elopement Risk Evaluation) with a score of 10 or higher and requiring wander guards. Wander guards were noted to be in place and functioning. The wander guard binder was audited to ensure all high risk for elopement residents' pictures and face sheets were present. The surveyors reviewed the audit form, the medical records, and reviewed the wander guard binders. 7. On 2/11/2022, all appointments made in the last 30 days were audited to ensure the facility did not fail to provide adequate supervision to prevent an incident of elopement of a moderately impaired vulnerable resident wearing a wander guard bracelet with a history of alcohol and cocaine abuse. The outcome of audit of the audit revealed no appointments were noted. The surveyors reviewed the audit form and interviewed the facility staff. 8. On 2/10/2022, all new employees will be in-serviced during orientation on the transportation escort policy going forward. The surveyors interviewed the DON regarding new employee education. 9. On 2/10/2022, education for family members was provided regarding the new transportation escort policy regarding scheduled appointments and is ongoing. The surveyors interviewed the DON, the Administrator, and the Social Worker regarding family education. 10. The Administrator will review appointment sheets weekly to ensure the facility is providing an escort and is providing adequate supervision to prevent an incident of elopement of a vulnerable resident from an appointment. Review of the appointment sheets will be done weekly for 4 weeks, bi-weekly for 30 days, monthly for 1 month, and then quarterly. Findings will be reported to Quality Assurance (QA) monthly for 3 months then quarterly. The surveyors reviewed the audit tool for appointments and interviewed the Administrator regarding the monitoring.

Based on policy review, Director of Nursing (DON) job description, record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 10 sampled residents (Resident #1) reviewed for wandering/elopement risk which resulted in Immediate Jeopardy when Resident #1, a vulnerable resident, eloped from the facility and was found by the police unsupervised across the street from the facility near a heavily traveled 4-lane street. The facility was unaware of the resident's location for 21 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 Administrator and the Director of Nursing were notified of the Immediate Jeopardy (IJ) on 12/21/2020 at 12:50 PM, in the Conference 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 12/12/2020-12/22/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/21/2020 at 5:15 PM. The corrective actions were validated onsite by the surveyors on 12/22/2020 - 12/23/2020 through policy review, medical record review, observation, and interviews. The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident, dated 2014, showed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering . Review of the facility's undated policy titled, Missing Residents, showed, .Residents will be evaluated to determine those who are at highest risk to wander from the facility .Those residents who are at high risk for wandering from the building will have Identifications on their person in the form of an I.D. (identification) bracelet .Staff interventions to prevent wandering from the facility are included in each resident's Care Plan. The effectiveness of these interventions will be reviewed at least quarterly by all members of the Interdisciplinary Care Plan team. Additional interventions the staff feels appropriate will be initiated timely to provide a safe environment for the resident .A security system such as a bracelet to trigger a door alarm may be determined interventions by the team . Review of the DON job description dated 12/23/2014, showed, .Assess resident care needs and assist in the development of individualized plans of resident care .Identify safety hazards and initiate corrective action .Be responsible for safety of residents under his/her supervision . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/Readmission Nursing Evaluation dated 8/19/2020, showed Resident #1 was at high risk for elopement. Additional comments showed, .increased change in mental status due to past UTI (urinary tract infection) . Review of Resident #1's Care Plan dated 9/14/2020, showed, .(Resident #1) is an elopement risk .r/t (related to) Disoriented to place, Impaired safety awareness, Resident wanders aimlessly .My safety will be maintained through the review date .I will not leave facility unattended through the review date . Review of a Quarterly Nursing Evaluation dated 11/19/2020, showed Resident #1 had intermittent confusion, poor safety/environment awareness, and scored 13 on the risk for elopement and required additional comments. Nursing documentation in the additional comments showed, .Easily redirected at this time. Is not exit seeking . Review of the quarterly Minimum Data Set assessment dated [DATE], showed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 9, which indicated Resident #1 had moderately impaired cognitive skills for decision making. Resident #1 was assessed to have no wandering behaviors. Resident #1's assessment of activities of daily living needs showed she required supervision from staff. She required a wheelchair for safe mobility. Review of a Nurses' Note dated 12/1/2020, showed, .resident (Resident #1) continues to constantly move about in her w/c (wheelchair) asking all staff all kinds of questions .how to get out . Review of a Nurses' Note dated 12/5/2020, showed, .at nurses' station at this time in w/c with mask on asking which door can she exit out . Review of the Skilled Documentation form dated 12/8/2020, showed, .resident (Resident #1) is a flight risk (at risk for elopement). Continues to seek exit to get out of facility. Facility staff and administration aware of resident's behavior .redirected resident many times, but unsuccessful . Review of a Nurses' Note dated 12/9/2020, showed, .resident (Resident #1) continues to try and find exits to leave facility . Review of the Nurses, Notes, assessments, and Care Plan showed no additional supervision was implemented to address Resident #1's exit seeking behavior. Review of an Incident Note dated 12/12/2020, showed, .At approximately 1559 (3:59 PM) resident (Resident #1) was noted at Nursing station .Power went out all staff began to do rounds .At approximately 1618 (4:18 PM) police officer arrived in facility asking if we had a resident by the name of (Named Resident #1) .Officer stated resident had been located in the church parking lot adjacent to the facility at (Named Church located across the street from the facility) asking for assistance to call her father to pick her up .Resident arrived back to the facility by police car at approximately 1620 (4:20 PM) in w/c . The facility staff were unaware Resident #1 was missing from the facility. Review of the head to toe assessment dated [DATE], after the elopement, showed Resident #1 did not have any injuries. Review of the facility's investigation of the elopement showed an investigation was completed. Multiple staff were interviewed and the Maintenance Director checked all of the exit doors in the facility with the power on and off, and the exit doors were locked and keypads were functioning. The facility did not have video cameras and the facility was unable to determine how Resident #1 actually exited the facility. During an interview on 12/17/2020 at 12:18 PM, the DON was asked when residents were assessed for wandering/exit seeking behaviors. The DON stated, .A wandering and exit seeking assessment is done on every new admission. She (Resident #1) had no behaviors of exit seeking . Observation on the side hallway beside the 1st floor Nurses' Station on 12/17/2020 at 1:14 PM, showed the door leading from the facility to the Wander Garden courtyard, was not locked. A wrought iron fence, with a code pad lock gate that was locked, surrounded the Wander Garden. There was no alarm or other means to alert staff when the door leading from the facility to the Wander Garden was opened. The Wander Garden could only be viewed through the exit door on the side hallway. The courtyard was an unsafe area with a paved narrow walking path surrounded by shrubs and trees. Observation in the resident's room on 12/17/2020 at 1:50 PM, showed Resident #1 was unaware of her current location, the time of day or the season, and did not recognize the staff. Observation in the hall on 2nd floor on 12/17/2020 at 2:15 PM, showed Resident #1 was propelling herself in a wheelchair to the 2nd floor dining room to play Bingo with other residents. She could not remember how to play the game of Bingo. During an interview on 12/17/2020 at 2:15 PM, the DON confirmed Resident #1 did not have a new/updated assessment completed after the elopement. The DON stated, .Never entered my mind to do an updated one .didn't do the assessment. During an interview on 12/18/2020 at 11:30 AM, at the Wander Garden doorway, the Maintenance Director confirmed the door leading from the facility to the Wander Garden was not locked. He stated, .Gate door is hooked to generator .No one knows the code but me .We have an alarm system for this door (door leading from the facility to the Wander Garden), but it is not activated . During an interview with the DON on 12/18/2020 at 2:34 PM in front of the Conference Room, the DON was asked when she knew Resident #1 was exit seeking. The DON stated, I was told on the 10th (12/10/2020) or 11th (12/11/2020). The DON was asked if any interventions were implemented for the exit seeking behaviors. The DON shook her head to answer no. During a telephone interview on 12/19/2020 at 1:37 PM, Licensed Practical Nurse (LPN) #1 stated, .She (Resident #1) did exit seek continuously. Always looking for a way to get out .Thought her sons were in the parking lot to pick her up. She would try to open any door .I spoke with Social Worker about maybe moving her upstairs .said she didn't have time .(Resident #1) would look out doors, push the doors, go to the Receptionist, she (Receptionist) would call me to get her from the front door .everyone knew her actions .the Social Worker and the DON knew her behaviors that week (week of 12/12/2020) and maybe prior . The facility did not move Resident #1 to the 2nd floor until the day of the elopement, after the elopement occurred. During an interview on 12/19/2020 at 3:13 PM, LPN #2 was asked when she Resident #1 last prior to the elopement. LPN #2 stated, It was 3:59 PM (12/12/2020) and the power went out .all the nurses said she (Resident #1) always tried to get out. She is confused. Talking about going home, going to work, her dad picking her up. She went back and forth in the hall to the receptionist up front. She did that a lot . During a telephone interview on 12/21/2020 at 12:32 PM, the Medical Director was asked what he would consider to be an elopement risk or elopement. He stated, .If they have gotten outside of the building .if they have gotten into a courtyard .going out of a building into a courtyard would be considered a risk because they are out of the building. That would be considered a safety risk as well . Observation at the 2nd floor Nurses' Station on 12/21/2020 at 1:20 PM, showed Resident #1 propelling herself in her wheelchair in the hallway to the elevator where she accessed the control panel button for the elevator to go to the first floor, and a staff member intervened and redirected Resident #1. During a telephone interview on 12/22/2020 at 9:20 AM, Resident #1's Responsible Party confirmed he was told Resident #1 was outside the building around 4:00 PM on 12/12/2020 and the staff were not aware. He stated the police located a family's member's telephone number in Resident #1's cellular telephone and called the family member. The family member was told Resident #1 was confused, was near a busy intersection close to a church, and looking for her father. Observation in the resident's room on 12/23/2020 at 11:25 AM, showed Resident #1 lying in bed, sleeping and a Wanderguard (ankle or wrist band tracking system that automatically locks and alarms the doors when the device is near the exit door) was on her ankle. Review of the Weather USA.com records, the recorded temperature on 12/12/2020 at 3:54 PM was 54 degrees Fahrenheit. The surveyors verified the Removal Plan by: 1. On 12/12/2020, the Charge Nurse assessed the resident from head to toe for any injuries. There were no signs/symptoms of injuries noted. The surveyor reviewed the assessment. 2. On 12/12/2020, the Maintenance Director checked all exit doors to ensure the locking mechanism was functioning as designed when there is a power outage. The surveyor observed all doors and interviewed the Maintenance Director. 3. On 12/12/2020, staff began providing one-on-one with Resident #1 at all times. The surveyor reviewed the documentation of the provision of one-on-one and interviewed staff, the DON and Administrator. 4. On 12/12/2020 at 5:31 PM, Resident #1 was relocated to the second floor to room [ROOM NUMBER]-1. The surveyors observed the resident residing on the second floor. 5. On 12/12/2020 at 5:28 PM, the electricity was restored. 6. On 12/14/2020, staff education was initiated for elopement drills and elopement in-services. This was continued until all staff were trained. The in-services were completed on 12/23/2020. The surveyors reviewed the in-service signature record for the in-services and interviewed staff on all shifts. 7. The facility will conduct elopement drills weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. The surveyors reviewed the signature record for the elopement drill. The surveyors interviewed the Maintenance Director and the Director of Education. 8. The Maintenance Director will complete door checks on all exit doors weekly and as needed to determine proper functioning of the doors. The surveyors reviewed the documentation and interviewed the Maintenance Director. 9. An Ad hoc meeting was held on 12/14/2020 with the Quality Assurance Performance Improvement (QAPI) team to determine the root cause of the resident's elopement and discussed other residents that were currently a high risk for elopement. The team reviewed the facility's Wandering, Unsafe Resident policy. The QAPI team included the Administrator, the DON, Director of Education, Unit Nurse Manager, Skilled Assessment Nurse, and the Social Worker. The surveyors reviewed the Ad hoc meeting minutes and interviewed each team member that attended the meeting. 10. On 12/21/2020, the Wandering, Unsafe Resident policy was updated to include wandering assessments to be completed quarterly and as needed. The surveyors reviewed the policy and interviewed the Administrator and DON. 11. On 12/19/2020-12/21/2020, an elopement risk assessment was completed on all residents. Residents who scored 10 or higher on the assessment will be identified as an elopement risk and an appropriate intervention will be immediately implemented, e.g. applying a Wanderguard bracelet, every 15 minute checks on the resident, provide one-on-one or discharge the resident from the facility to a more appropriate facility. Any resident who scored 10 or higher and does not have the ability to physically elope from the building will have an appropriate explanation in the additional comments section on the Elopement Risk Evaluation form. All residents who are at risk will have pictures and face sheets placed in the Wander binder at the front desk. The surveyors reviewed the Elopement Risk Evaluation forms, Wander binder, and interviewed the Director of Nursing. 12. On 12/19/2020, the Maintenance Director inspected the alarm system for the Wanderguard alarms and reconnected the Wanderguard door alarms to be heard at the nursing station. The surveyors observed the functioning of the door alarms, staff response to the alarms, and interviewed the Maintenance Director and the Administrator. 13. During a power outage, staff will go to each exit door to ensure all doors remain locked and cannot be opened to ensure no resident exits the building without staff knowledge. The surveyors interviewed the Administrator, the Director of Nursing, and staff from all shifts and all departments.

Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, page 746, facility policy, medical record review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 2 of 3 (Resident #1 and #2) sampled residents reviewed who were receiving Percutaneous Endoscopic Gastrostomy (PEG) Tube feedings. The failure to ensure staff provided appropriate care and services for the PEG tube feeding resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The Lippincott Manual of Nursing Practice, 10th Edition page 746 documented, .For continuous tube feeding .flush tubing, attach to volume control infuser according to manufacturer's instructions, attach distal end to feeding tube . 2. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17 documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed, .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a prescribed amount of time and then drain back out again) .LA (left arm) AV fistula Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (Licensed Practical Nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) the DON stated that they do a skills check-off upon hire and annually. Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter and she stated No. She further stated that she had taken care of him one other time in the past. Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: .Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition (a prognosis given by the physician when the outcome of a patient's illness is in doubt) . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure nursing staff provided professional care according to resident's care plan, facility policy, Physician order [REDACTED].#1 when the nursing staff connected a PEG tube feeding of Nepro Carb Steady and administered the feeding through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours. Resident #1 was sent to the hospital, had emergent surgery and remained in the hospital on mechanical ventilation at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].

Based on facility policy review, medical record review, facility incident report review, hospital record review, observation and interview, it was determined the facility failed to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tubes for 2 of 3 (Residents #1 and #2) sampled residents reviewed with PEG tubes. The failure to ensure that PEG tube feedings were administered through the PEG tube resulted in actual harm to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17, documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a while and then drain back out again) .LA (left arm) AV fistula. Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems. Has palpable thrill and audible bruit (an indication of a well functioning [MEDICAL TREATMENT] fistula) .Requires total care with all ADLs (activities of daily living) . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) prior to working at the facility, the DON stated that they do a skills check-off upon hire and annually. A written statement signed by RN #1 documented, .On the night of Oct (October) 31st at 845/pm I prepared to hang Nepro on (Resident #1). I checked his residual. The residual was zero. I did not know he had a peritoneal cath (catheter) & a peg tube. Resident was comfortable c no s/s (signs & symptoms) of distress. I did not provide any other services. Around 630/am I received a call from (named LPN #1) 11-7 (11:00 pm-7:00am) charge nurse. She informed me Resident (#1) had another tube higher up. I Jumped in my truck immediately & (and) came to the facility. B/P (blood pressure)153/94 (pulse)- 117 (pulse documented in medical record 119) (respirations), - 20 temp (temperature) 100.2 (degrees Fahrenheit). I called the Director (DON). Director informed me she was calling (named Medical Director). DON returned call back to facility & instructed to send out 911. 911 came to the facility immediately. Family notified. Report called to (named hospital) & spoke to a female nurse in the ER (emergency room ). Gave vital signs to nurse and informed her we were sending out due to Resident receiving tube feedings through his peritoneal cath - Informed nurse this is exactly why we are sending the Resident out. Family notified. Resident was being sent to hospital & reason for sending out. On exit Resident was easily aroused c (with) no s/s (signs and symptoms) of distress . Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She confirmed her written statement, and stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter, and she stated No. She further stated that she had taken care of him one other time in the past. A written statement signed by Licensed Practical Nurse (LPN) #1, dated 11/1/17, documented .During shift change off going nurse (RN #1) stated she couldn't find the end of the peg tube and she had replaced it. On going nurse (LPN #1) went to the resident (Resident #1) room to observe the new pegtube. Nepro was running through the line. At 5:45 am nurse (LPN #1) return to resident (Resident #1) room to give 6AM meds. CNA (Certified Nursing Assistant #1) was already inside resident room and ask for assistance in repositioning and turning; during this time CNA (CNA #1) changed resident gown and this is when nurse (LPN #1) notice that the resident was not receiving tube feeding in the right tubing. Resident (Resident #1) was receiving feeding through his peritoneal catheter. Nurse (LPN #1) immediately disconnect the feeding and informed RN supervisor (RN #2). The charge nurse (LPN #1) and RN supervisor (RN #2) assessed the resident. The unit manager (RN #1) which was the nurse who intact (attached) the feeding was notified and she return to the facility @ 6:15am. Unit Manager (RN #1) called the DON who contact the doctor. Charge nurse (LPN #1) was getting vitals signs which was as following B/P (blood pressure) 159/94, Pulse 119 Respiration 20, Blood Glucose 159. Unit Manager (RN #1) receive orders @ (at) 6:30 am to send resident (Resident #1) to the ER (emergency room ) for further evaluation. Nurse (LPN #1) and CNA (CNA #1) stayed with resident until paramedic arrived to transport . Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 confirmed her written statement. She stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds (medications) .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: a) Computerized Tomography (CT) Scan dated 11/1/17 at 2:50 PM - .Numerous nondistended fluid-filled loops of small bowel are noted with associated bowel wall thickening and adjacent fluids .A PEG tube is noted with balloon in the stomach. Fluid is present diffusely throughout the colon with associated air-filled levels .There is a 5.8 x 4.3 cm (centimeter) irregular gas fluid collection superior to the bladder. This is concerning for abscess .A small amount of free fluid is seen within the pelvis .IMPRESSION: .2. Small amount of free intraperitoneal air. Etiology uncertain, however this is concerning for bowel perforation .4. [MEDICATION NAME] (within a tube or tubular organ) fluid throughout nondistended small bowel with associated bowel wall thickening and adjacent free fluid. [MEDICATION NAME] fluid with air- fluid levels throughout a nondistended colon. These findings are concerning for [MEDICATION NAME]. Consider infectious, [MEDICAL CONDITION] ischemic (insufficient blood flow) etiologies. 5. Small amount of free fluid in the abdomen and pelvis . b) Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure that PEG tube feedings were administered appropriately through the PEG tube to Resident #1 who had Nepro Carb Steady administered through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours resulted in actual harm. He was sent to the hospital, had emergent surgery and remained in the hospital at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus of Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].

Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The failure to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tube resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The QAA Committee failed to ensure that care and services were provided appropriately to a resident with a PEG tube. The failure to provide appropriate care and services of a PEG tube feeding to a resident resulted in actual harm when Resident #1 received a feeding of Nepro Carb Steady through his peritoneal [MEDICAL TREATMENT] catheter for 9 hours. Resident #1 was sent to the hospital and had emergent surgery. Refer to F322. The deficient practice of F322 is a repeat deficient practice for failure to provide appropriate care and services to a resident with a PEG tube feeding. The facility was cited F322 on the recertification survey on 12/4/16. Interview with the Director of Nursing (DON) on 11/12/17 at 6:50 PM, in the conference room, the DON stated, Registered Nurse #1 was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN#1) wondered why they did that .took the flap off and put an adapter on it .

Based on policy review, medical record review, observation and interview, the facility failed to ensure all residents maintained acceptable parameters of nutritional status, failed to accurately assess, care plan and implement interventions to prevent severe and significant weight loss, failed to prevent a significant and severe weight loss for a resident receiving enteral nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube and failed to follow physician's orders [REDACTED].#123, 175, 21 and 32) sampled residents reviewed for nutrition of the 52 residents included in the stage 2 review. The failure to prevent significant and severe weight loss, resulted in actual harm for Resident #123 and 175. The findings included: 1. The facility's Weight Assessment and Intervention policy documented, .Weight Assessment .3. The Dietitian will review the unit Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. 4. The threshold for significant unplanned .weight loss will be based on the following criteria .a. 1 month .greater than 5% (percent) is severe. 3 months .greater than 7.5% is severe. 6 months .greater than 10% is severe. 5. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the a. Resident's target weight range (including rationale if different from ideal body weight). B. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example .Cognitive or functional decline .Chewing or swallowing abnormalities .Pain . Medication related adverse consequences .Environmental factors (such as noise or distractions related to dining) .Increased need for calories and/or protein .Poor digestion or absorption .Fluid and nutrient loss .and/or Inadequate availability of food or fluids .Care Planning 1. Care planning for weight loss .will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian and the resident or the resident's legal surrogate .2. Individualized care plans shall address .The identified causes of weight loss .Goals and benchmarks for improvement .Timeframes and parameters for monitoring and reassessment .Interventions .1. Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choices and preferences .Nutrition and hydration needs of the resident .Functional factors that may inhibit independent eating .Environmental factors that may inhibit appetite or desire to participate in meals .Chewing and swallowing abnormalities and the need for diet modifications .Medications that may interfere with appetite, chewing, swallowing, or digestion .The use of supplementation and/or feeding tubes .End of life decisions . 2. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 6/1/16 physician's orders [REDACTED]. Review of the monthly weight records revealed on 6/2/16 the resident weighed 91 pounds (lbs). Review of a telephone physician's orders [REDACTED]. Review of the June 2016 Medication Administration Record (MAR) revealed, a. MEDPASS 4 oz (ounces) BY MOUTH DAIL (Daily) . was not documented as given on 6/13/16, 6/14/16, and 6/16/16. b. .MULTIVITAMIN W/ (with) MINERALS TAKE ONE TABLET BY MOUTH ONCE DAILY (SUPPLEMENT) . was not documented as given on 6/16/16. c. .[MEDICATION NAME] 15 MG tab (tablet) .TAKE 1/2 TABLET BY MOUTH ONCE DAILY AT BEDTIME (APPETITE) . was not documented as given on 6/20/16. Review of the monthly weight records revealed on 7/2/16 the resident weighed 87 lbs, a 4.3 percent (%) weight loss in 1 month. Review of a COMS (computer based clinical software) note dated 7/7/16 revealed, .Interdisciplinary Team .She will refuse med pass . Review of the MEDICAL NUTRITIONAL THERAPY ASSESSMENT RECOMMENDATIONS form dated 7/21/16 revealed, .(Named Resident) cont (continue) (symbol for with) current POC (Plan of Care) (arrow down) 4.3% (percent) x (times) 30 d (days) refuses med pass .weekly weights . Review of the NUTRITION SERVICES PROGRESS NOTES dated 7/21/16 revealed, CBW (Current Body Weight) 87# (pounds). Wt (Weight) (arrow down) 4.3% x 30 d (days) .7/11/16 Continues to receive MVI (Multivitamin) (symbol for with) minerals, Liquid protein 30 ml (milliliters) BID (twice a day) & (and) Med Pass (nutritional supplement) 4 oz (ounces) QD (every day) Spoke (symbol for with) resident. No additional likes (dislikes). Does not want to (arrow up) med pass. Providing Regular diet .Will cont (symbol for with) supplements in place r/t (related to) weight (sign for changes). Will discuss with nsg (nursing) .weekly wts (weights) . Medical record review revealed there were no nutritional notes or assessments conducted by the RD after 7/21/16. There was no documentation weekly weights were discussed or obtained. Review of the July 2016 MAR revealed, a. .MEDPASS 4 oz BY MOUTH DAIL (Daily) . was not documented as given on 7/29/16. b. There was no documentation the LIQUID PROTEIN was administered. c. .[MEDICATION NAME] 15 MG tab .TAKE 1/2 TABLET BY MOUTH ONCE DAILY AT BEDTIME (APPETITE) . was not documented as given on 7/1/16, 7/23/16 and 7/24/16. d. .HS (Hour of Sleep) snack . was not documented as given on 7/5/16, 7/23/16, and 7/24/16. Review of the monthly weight records revealed on 8/2/16 the resident weighed 85 lb, a 6.59 % weight loss in 2 months. Review of the August 2016 MAR revealed, a. .MEDPASS 4 oz BY MOUTH QD (every day) . was not documented as given on 8/15/16. b. .LIQUID PROTEIN 30 ml (milliliters) BID (twice daily) . was not documented as given on 8/5/16, 8/15/16, 8/29/16, and 8/31/16 at 10 AM, and 8/12/16, 8/13/16, 8/15/16, 8/17/16, 8/18/16, 8/19/16, 8/21/16, 8/23/16, and 8/31/16 at 6PM. c. .MULTIVITAMIN W/ MINERALS TAKE ONE TABLET BY MOUTH ONCE DAILY (SUPPLEMENT) . was not documented as given on 8/28/16 and 8/31/16. d. .[MEDICATION NAME] 15 MG tab (TABLET) .TAKE 1/2 TABLET (7.5 mg) BY MOUTH ONCE DAILY AT BEDTIME (APPETITE) . was not documented as given on 8/11/16, 8/12/16, 8/15/16, 8/17/16, 8/18/16, 8/19/16, 8/21/16, and 8/23/16. Review of the monthly weight records revealed on 9/2/16 the resident weighed 84 lbs, a 7.69 % severe weight loss in 3 months. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #123 had moderately impaired cognition. The Comprehensive Nutritional Assessment note dated 9/30/16 and signed by the Dietary Technician (DT) documented, .Annual Review .Diet order Regular . Snacks/Supplements: Med Pass 2.0 4 oz QD .Vit (Vitamin) / Min (Mineral) Vit D2 Multivit w (with)/mineral Liq (Liquid) Protein .Feeds Self with limited assistance/Verbal Cues .% (percentage) Food Intake Fair (25-50%) .Date for Wt: 9/10/16 .Wt:84 IBW (Ideal Body Weight) 108-132 .BMI (Body Mass Index) 14.6 .ALB ([MEDICATION NAME]) 3.2 .(normal 3.5 and above) Evaluation & Summary .Res.(Resident) has no food dislike @ (at) this time HT (height) 64 (inches) .under weight .RD (Registered Dietitian) eval (evaluation) 7/21/16 added weekly wt . There was no documentation the facility addressed the resident's low [MEDICATION NAME] nutritional status. There was no documentation the facility was obtaining weekly weights as indicated in the nutritional assessment. Review of the September 2016 MAR revealed. a. .MEDPASS 4 oz BY MOUTH QD . was not documented as given on 9/8/16, 9/12/16, and 9/27/16. b. .LIQUID PROTEIN 30 ml BID . was not documented as given on 9/12/16 at 10 AM, 9/16/16, 9/23/16, 9/25/16, 9/26/16 and 9/30/16 at 6PM. c. .MULTIVITAMIN W/ MINERALS TAKE ONE TABLET BY MOUTH ONCE DAILY (SUPPLEMENT) . was not documented as given on 9/12/16. d. .HS snack . was not documented as given on 9/30/16. Review of the monthly weight records revealed on 10/3/16 the resident weighed 82 lbs, a 9.89% weight loss in 4 months. The care plan dated 10/7/16 and revised on 10/25/16 documented, .Problem .Weight loss .Dietician consult and follow up as needed .Supplements as ordered .administer medications as ordered . There was no documentation the facility administered the supplements and medications as ordered by the physician and in accordance with the care plan. The October 2016 MAR revealed the following: a. .MEDPASS 4 oz BY MOUTH QD . was not documented as given on 10/8/16, 10/9/16, 10/10/16, 10/29/16 and 10/30/16. b. .LIQUID PROTEIN 30 ml BID . was not documented as given on 10/9/16 at 10 AM and 6 PM, 10/17 at 6 PM, 10/28/16 at 10 AM and 6 PM, 10/29/16, 10/30/16 and 10/31/16 at 10 AM. c. .MULTIVITAMIN W/ MINERALS TAKE ONE TABLET BY MOUTH ONCE DAILY (SUPPLEMENT) . was not documented as given on 10/10/16, 10/29/16, 10/30/16, and 10/31/16. Review of the monthly weight records revealed on 11/9/16 the resident weighed 81 lb, a 10.99 % severe weight loss in 5 months. Review of the MEDICAL NUTRITIONAL THERAPY ASSESSMENT RECOMMENDATIONS form dated 11/10/16 revealed, .(Named Resident) add Medpass 2.0 4oz BID wt (arrow down) . Review of the Nursing PAR (Patient At Risk) Note dated 11/10/16 revealed, Resident has a weight loss -10.99% in 160 days. Resident stated (started) on Med pass twice a day and weekly weights . The facility documented to increase the med pass to twice a day, a supplement that the facility had previously documented as being refused by the resident. The November 2016 Medication Administration Record (MAR) revealed the following: a. .MEDPASS 4oz BY MOUTH QD . was not documented as given 11/4/16 and 11/8/16 b. .11-10-16 Med Pass 2.0 4 oz BID . was not documented as given on 11/11/16, 11/24/16, and 11/25/16 at 10 AM, and on 11/14/16, 11/19/16, and 11/27/16 at 6 PM. c. .LIQUID PROTEIN 30 ml BID . was not documented as given on 11/24/16 and 11/25/16 at 10 AM and 11/5/16, 11/14/16, 11/19/16 11/28/16 at 6 PM. d. .MULTIVITAMIN W/ MINERALS TAKE ONE TABLET BY MOUTH ONCE DAILY (SUPPLEMENT) . was not documented as given on 11/24/16 AND 11/25/16. e. .HS snack . was not documented. There was no documentation of any weekly weights from 7/21/16 to 12/3/16. The facility was asked multiple times for weekly weights and confirmed there were no weekly weights. Interview with the Director of Nursing (DON) on 12/2/16 at 3:15 PM, in the conference room, the DON was asked if she expected the nursing staff to follow physician orders. The DON stated, .Yes ma'am, I do . Observations in Resident #123's room on 12/4/16 at 12:45 PM, revealed Resident #123 was sitting in a wheelchair with the over bed table in front of her with her lunch tray sitting on it. The diet slip documented a regular diet with yogurt listed on the diet slip. The yogurt had a circle around it and documented OUT besides the yogurt. The lunch tray had all the items listed on the diet slip except yogurt. There was no yogurt on the tray and no substitution for the yogurt. Interview with the Administrator on 12/4/16 at 4:02 PM, in the conference room, the Administrator was asked if you would expect the resident to receive a substitution for the yogurt if it was not on the meal tray and the diet slip documented the facility was OUT of yogurt. The Administrator stated, Yes. Telephone interview with the Registered Dietician (RD) on 12/4/16 at 11:30 AM, the RD was asked why there was an intervention to increase the Medpass to twice a day if the resident was refusing to drink the Medpass. The RD stated, The only thing I can think is that I didn't see she was refusing it The RD was asked why there were no other interventions put in put in place related to her significant weight loss of 10.99% The RD stated, Not sure . The RD was asked about the weight loss of 91 lbs to 81 lbs in 6 months and if any other interventions should have been put in place. The RD stated, .didn't realize she was refusing it .I am not familiar with her . The RD was asked if she had seen the resident. The RD stated, I may have talked and asked about her in general, not sure .would have to go back and talk to her and check, not sure . The RD was asked if she had seen Resident #123 where would she document the visit. The RD stated, In my notes. No idea what I have on her but usually do document . Telephone interview with the Medical Director on 11/4/16 at 3:25 PM, the Medical Director was asked if he was aware of the Resident #123's significant weight loss. The Medical Director stated, I was aware it had come down . The Medical Director was asked if you would expect the facility staff to put different interventions in place especially when Resident #123 was refusing the Medpass. The Medical Director stated, Yes, you would try different approaches The intervention of increasing Medpass to twice a day was added to the resident plan of care when Resident #123 had previously refused the Medpass. The facility and the RD failed to identify, accurately reassess the resident's weight status and nutritional requirements and implement appropriate interventions to address the continued significant weight loss Resident #123 sustained. 3. Medical record review revealed Resident #175 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Fracture of Base of Skull, Laceration With Foreign Body of Left Hand. Overweight, Acute [MEDICAL CONDITION] with [MEDICAL CONDITION], Fracture of Nasal Bones, Hypertension, [MEDICAL CONDITION], Gastrostomy, Nontraumatic Subarachnoid Hemorrhage, [MEDICAL CONDITIONS], Cognitive Communication Deficit and [DIAGNOSES REDACTED]. A care plan dated 6/2/16 documented, .Problem .Potential for weight loss .Goal .Maintain stable weight thru NRP (next review period) .Approaches .Monitor weight weekly, Dietician consult and follow-up as needed .notify physician and family of significant weight loss . Record review revealed the resident was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. An admission order dated 6/16/16 revealed [MEDICATION NAME] 1.2, 2 cans per PEG 3 times a day. The post hospital readmission weight on 6/16/16 was 266 lbs. A physician's telephone order dated 6/21/16 documented, (change) [MEDICATION NAME] 1.2 Cal (Calories) to pump at 70 ml/hr (milliliters per hour) x 22 hr (hours)/day ., 1848 kilocalories (kcals). The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #175 had a weight of 260 lbs, indicating a 6 lb weight loss in a week. The Medication Administration Record (MAR) dated June 2016, revealed Resident #175 received [MEDICATION NAME] 1.2 Cal to pump at 70 ml/hr x 22 hr/day from 6/21/16 through 6/30/16. Record review revealed the following July 2016 weights: 7/1/16 - 257 lbs, a 3 lb loss in 1 week. 7/8/16 - 257 lbs, no change. 7/15/16 - 254 lbs, a 3 lb loss in 1 week. 7/22/16 - 250 lbs, a 4 lb loss in 1 week. A Registered Dietitian (RD) note dated 7/28/16 documented, .CBW (Current Body Weight) 250 # (pounds). Wt (decrease sign) 3.8% x 30 d (days) = (equals) 10 #. (decrease sign) 7.5% since admit = (decrease sign) 20.5 # .Tolerating [MEDICATION NAME] 1.2 Cal at 70 mL (milliliters) / (per) (hour sign) for 1848 Kcals (kilocalories) .Consider (increasing) [MEDICATION NAME] 1.2 Cal to 75 mL/hr x 22 hr for 1980 Kcals . The MAR dated July 2016, revealed Resident #175 received [MEDICATION NAME] 1.2 Cal to pump at 70 mL/hr x 22 hr/day from 7/1/16 through 7/31/16. A physician telephone order dated 7/28/16 documented, .(increase sign) [MEDICATION NAME] 1.2 to 75 ml/hr x 22 hrs . 1980 Kcals. This order increased the kilocalorie total by 132 Kcal per day. This increase was not reflected on the July or August MARs or documented as being administered as ordered on [DATE]. Resident #175 continued to receive 70 ml/hr for 22 hrs per day through 8/30/16. Record review revealed the following August weights: 8/1/16 - 246 lbs, 4 lb loss over 10 days. 8/7/16 - 242 lbs, 4 lb loss over 1 week. 8/15/16 - 238 lbs, 4 lb loss over 1 week. A 10.5% severe weight loss. 8/22/16 - 241 lbs, a 3 lb gain. 8/29/16 - 241 lbs, no change. The MAR dated August 2016, revealed Resident #175 received [MEDICATION NAME] 1.2 Cal via pump at 70 mL per hour for 22 hours per day from 8/1/16 through 8/30/16, a total of 1848 calories per day. There was no documentation Resident #175 received the 75 ml/hr x 22 hr/day, the 1980 Kcal/day as ordered on [DATE]. The resident continued to receive 70 ml/hr x 22 hrs/day which was 132 Kcal per day less for 33 days for a total of 4,356 Kcal. less than the order prescribed. A physician's telephone order dated 8/30/16 documented, .(change sign) TF (Tube Feeding) regimen [MEDICATION NAME] 1.2 at 80 ml/hr x 20 hr/d (day) . (1920 Kcals/day). Note: This change gave Resident #175 an increase of 72 Kcal/day from the previous incorrect amount she was receiving according to the MAR. The MAR dated August 2016, revealed Resident #175 received [MEDICATION NAME] 1.2 at 80 ml/hr on 8/31/16 for 1 day. The total number of daily hours for the feeding was not documented on the MAR. Record review revealed the resident's weight on 9/5/16 was 241 lbs. A physician order [REDACTED].[MEDICATION NAME] 1.2 CAL VIA PUMP 80 ml/HR (80 was hand written over the typed number of milliliters) X 18 HRS (18 was hand written over the typed number of hours) ., 1728 Kcal. The total kilocalories decreased by 192 Kcal per day from the August MAR documentation. Record review revealed the following September weights: 9/12/16 - 237 lbs, a 4 lb loss over 1 week. 9/19/16 - 236 lbs, an 11.2% significant and severe weight loss in 90 days. The quarterly MDS dated [DATE] revealed Resident #175 had a weight of 236 lbs. An RD note dated 9/22/16 documented, .CBW 236 # (pounds) .W (Weight) (decrease sign) 2.1% (percent) x (times) 30 d (day); -11.3% (loss) x (times) 90 d (days) .[MEDICATION NAME] 1.2 @ (at) 80 ml/hr x 18 hr/d .RD to f/u (follow-up) w (with)/TF (tube feeding) tolerance & wt (weight change sign) . Record review revealed the resident's weight on 9/26/16 was 234 lbs, 2 lb loss over 1 week. The MAR dated September, 2016 documented, .[MEDICATION NAME] 1.2 CAL VIA PUMP 80 ml/HR (80 was hand written over the typed number of mls) X 18 HRS (18 was hand written over the typed number of hours .(DO NOT CHANGE TIMES was handwritten under the entry) . This provided 1728 kilocalories per day. Record review revealed the following October weights: 10/3/16 - 231 lbs, 3 lb loss in 1 week. 10/10/16 - 228 lbs, 3 lb loss in 1 week. Lab values were reviewed and signed by the physician for 6/19/16, 7/8/16, 8/10/16 and 9/13/16 and included the following abnormal values: 6/19/16: PLT (Platelets) 569 High (Reference (Ref) range: 150-450) 7/8/16: HGB (Hemoglobin) 10.7 Low (Ref range: 12.0-16.0 grams per deciliter) 8/10/16: NA (Sodium) 148 High (Ref range: 135-145 millimole per liter) 9/13/16: CREAT (Creatinine) 0.5 Low (Ref range 0.6-1.0 milligrams per deciliter) Review of a physician's orders [REDACTED].[MEDICATION NAME] 1.2 @ (at) 80 ml/HR X 20 HRS (hours) .(The 20 hrs had a line drawn thru it and handwritten above was 18 hours) . The hand corrected 18 hours was not dated. Record review revealed the resident's weight on 10/17/16 was 224 lbs, a 4 lb loss in 1 week. A physician telephone order dated 10/18/16, not signed by the physician, written and signed by the RD, documented, .[MEDICATION NAME] 1.2 @ 90 ml/HR X 18 HR . Review of the RD note dated 10/18/16 documented, .CBW 228 # (pounds) .Due to wt loss signifant (significant) & losing ~ (approximately) 3 # per week, RD to increase TF rate to 90 ml/hr x 18 hrs of [MEDICATION NAME] 1.2 .will provide 1944 Kcals . Record review revealed the following October weights: 10/24/16 - 225 lbs. 10/31/16 - 226 lbs. A physician's orders [REDACTED]. Record review revealed the following November weights: 11/9/16 - 228 lbs. 11/15/16 - 225 lbs, a significant and severe weight loss of 15.4% in 5 months. Review of the RD note dated 11/15/16 documented, .[MEDICATION NAME] 1.2 @ (at) 90 ml/hr x 18 hrs .provides 1,944 Kcals .Estimated needs based on AlBW (Adjusted Ideal Body Weight): 1760-2115 Kcals (25-30 kcal/kg) .no new labs to assess . Review of the 12/1/16 physician telephone order revealed, to change tube feeding to Two Cal High Nitrogen (HN) - 4 cans daily, 1 can at 6 AM, 10 AM, 2 PM and 6 PM. Review of the RD note dated 12/1/16 revealed, .IBW (Ideal Body Weight) 130 # (pounds) .ADON (Assistant Director of Nursing) spoke with resident's family who agreed to wt loss plan . RD to change the resident's tube feeding to bolus, .Two Cal (Calorie) HN (High Nitrogen) @ 4 cans daily .regimen will provide 1900 KCal . Record review revealed Resident #175 received their calories/nutrition thru a facility administered feeding tube and had a 41 pound significant and severe weight loss from 266 lbs on 6/16/16 to 225 lbs on 11/15/16. There was no documentation the severe weight loss was care planned until 12/1/16, after the survey team entered on 11/28/16 and began to review weight loss. On 12/1/16 the care plan was revised to include the change in TF order and added planned weight loss. There were no other plans or interventions related to a planned weight loss or a safe plan to prevent significant and severe weight loss. Observations in Resident #175's room on 11/30/16 at 6:06 PM, Resident #175 was sitting in a geriatric chair and the resident's tube feeding was infusing via a feeding pump at 90 ml/hr. Observations in Resident #175's room on 12/2/16 at 3:46 PM, Resident #175 was asleep in bed. A feeding pump was at the bedside with no formula infusing at this time. Interview with the Director of Nursing (DON) on 12/3/16 beginning at 3:10 PM, in the conference room, the DON was asked if she was aware of Resident #175's weight loss and if she communicated with the RD on a regular basis regarding her weight loss. The DON stated, .I don't know if she (RD) has spoken with (Named Physician) . The DON stated, .(Named Resident #175) came in, and her head was full (of fluid). ½ of her brain, it looks like it is caved in now .I think she was on [MEDICATION NAME]. Let me get her chart. The DON left to go get Resident #175's medical record. The DON returned with the chart on 12/3/16 at 3:28 PM. The DON reviewed her chart to see if there was a diuretic ordered for her on admission. The DON stated, I don't see anything (diuretic ordered) .I know that each week, the dietitian was looking at making adjustments, regardless of what she (RD) switched her to, she (Resident #175's weight) kept going down. The DON was asked do you think the weight loss occurred because she (RD) was decreasing the amount of kilocalories (Named Resident #175) was receiving. The DON stated, No I don't, I really don't. I think it was because it was all she (Resident #175) was going through, and her body was just adjusting. I don't think it was because she (RD) was going down on her kilocalories . Interview with the ADON on 12/3/16 at 5:10 PM, at the 2nd floor nursing desk, She was asked if there are any PAR meeting notes that address Resident #175's weight loss. The ADON stated, .There are no notes, you would have to look at the RD's notes. The ADON was asked when the last PAR meeting was held. The ADON stated, .On November 22 we discussed a weight loss plan for her, and on November 24th . The ADON was asked how the subject of a weight loss plan came up after such a long time of her losing weight. The ADON stated, .We had a QA meeting, it was on Thursday, November 17th, and (Named Physician) discussed it. He said that her tube feeding was meeting her nutritional needs and to discuss with the family a planned weight loss. Telephone interview with the Nurse Practitioner (NP) on 12/3/16 at 5:55 PM, the NP was asked about (Named Resident #175) and was she aware of her weight loss. The NP stated, The RD usually tells us, and we cover that (weight loss) in QA (Quality Assurance) and in PAR (Patient At Risk) meetings . Telephone interview with the RD on 12/4/16 beginning at 11:16 AM, the RD was asked about (Named Resident #175's) weight loss. After reading the previous RD's nutrition notes to her, and prior to the current RD taking over this resident on Sept. 22nd, the RD was asked if she had been notified as of October 18th about Resident #175's weight loss at the time she wrote her note to increase the feeding due to significant wt. loss. She stated, No, but we did talk about a planned weight loss program, we were going to talk to (Named Physician) about a plan for her. The RD was then asked about that plan, who would write the plan and where would the plan be located. She stated, As far as I know it would have been a care plan. The RD was asked who would write the care plan for the weight loss. She stated, I'm not sure, I don't really know. She was asked who would monitor the controlled weight loss to ensure it was a safe reasonable weight loss. The RD stated, I would, and we would discuss it in the weekly meetings. The RD was asked if she would have managed this resident the same way as the previous RD. The RD stated, Probably not. The RD was asked what would an appropriate weight loss be each week related to Resident #175's weekly weight loss of approximately 3 pounds per week. The RD stated, It's not appropriate to lose 3 lbs in a week, anything more than a pound a week is too much . Telephone interview with the Medical Director (MDir.) on 12/4/16 at 3:19 PM, He was asked if he was aware of (Named Resident #175's) weight loss. The MDir. stated, We mentioned it sometime, but I don't know how much. On the flip side, she is a big woman, and she had a tragedy that was not unexpected, she is getting enough calories to meet her metabolic needs. She is not getting enough calories to maintain her weight, but she had a traumatic, devastating accident, and she has neurologic deficits. The MDir. was asked if it was acceptable for her to have lost 3-4 pounds a week from her readmission on 6/19/16 until October, when her weight stabilized. The MDir. stated, In her condition, it's ok, I have no idea what her caloric intake was before the accident, but her protein levels are ok, she has no [MEDICAL CONDITION], no swelling, she has no insufficiencies. It is normal for a person her size to lose 3-4-5 pounds early on. Like on TV (Named Weight Loss Program) advertises that as well. The MDir. was asked since the weight loss plan was agreed upon this week, who would initiate and write the plan in terms of a goal, and how much weight loss weekly would be acceptable. The MDir stated, The RD would look at that, she is the expert and she would look at her caloric needs. The MDir. was asked if he would have any input in developing the weight loss plan. The MDir. stated, Yes, I am there every week and the RD is there every week as well, yes, if it is a reasonable goal. She also has a very supportive family, and her mom is aware. The MDir. was asked if he and the RD have had any discussions regarding a weight loss plan for Resident #175 since the decision was made to put her on a weight loss program and stated, We have not. Interview with the DON on 12/4/16 beginning at 3:48 PM, in the conference room, the physician progress notes [REDACTED]. The DON confirmed there was no documentation on the progress notes that the physician or nurse practitioner was aware of the weight loss. The DON stated, (Named 2 physicians), 2 nurse practitioners are in the group. (Named Medical Director) gets a copy of the weight history monthly for a 6 month run .That wasn't the plan (Resident #175's weight loss plan) from June until now. She (Resident #175) stabilized (her weight) in October and November, and the mom said she wants to take (Named Resident #175) home. In order for that transition to take place and have a safe discharge, we have to now think about ok, what can we do to get (Named Resident #175) home. What is going to be safe. We have a very difficult time (managing her), so we have to get her where they can handle her. To be safe and to not cause other things .We discussed a supervised weight plan, and that was not to try and cover up from June to September (weight loss). The DON was asked if a weight loss care plan had been written and implemented. The DON stated, I do not believe there is one yet, let me check, the RD would handle that. The DON was asked if she would expect the RD to identify and address Resident #175's weight to either keep her weight stable or gain weight. The DON stated, Well yes, but I am not a dietitian and it would be wrong of me to say that she is not adjusting correctly. Both dietitians did the same thing (adjusted her feeding down). (Named Previous RD) did it and (Named Current RD) did the same thing, so they know something I don't know. The facility failed to adequately monitor for continued and sustained weight loss for a resident receiving nutrition through a PEG tube, and failed to provide recommended and ordered nutritional interventions from the RD and that resulted in an avoidable severe weight loss causing actual harm to Resident #175. 4. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].RENAL DIET W/(with) REGULAR TEXTURE .1000 cc (cubic centimeters) FLUID RESTRICTION . Observations on the 200 hall (porch area) on 12/2/16 on at 6:05 PM, revealed a dinner tray with a diet slip that documented, .RENAL - MECHANICAL SOFT FORTIFIED FOODS/1000 FLUID OZ (ounce) RESTRICTION . Orifice Food - 4 OZ . The tray had all food items listed on the diet slip. The menu items were confirmed by Certified Nursing Assistant (CNA) #1. Interview with the Administrator on 12/3/16 at 1:26 PM, in the conference room, the Administrator was shown the diet slip on Resident #21's food tray for 12/2/16 at dinner that documented, RENAL - MECHANICAL SOFT FORTIFIED FOODS/1000 FLUID OZ (ounce) RESTRICTION . Orifice Food - 4 OZ . The Administrator viewed the diet order on the chart and the RD notes, The Administrator was asked if Reside

Based on policy review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized an ongoing concern with weight loss, [MEDICAL TREATMENT] care, and medication administration. The QA program failed to identify the root cause of the problems, develop appropriate plans and ensure systems and processes were in place and consistently followed by staff to address quality concerns. The QA committee failed to address concerns to ensure residents at risk for weight loss and [MEDICAL TREATMENT] care interventions were consistently implemented or followed. The facility failed to ensure the QA program was effective in preventing repeat deficiencies (F-280, F-282, F-371, F- 441, and F-514) from previous surveys. The facility failed to prevent significant and severe weight loss which resulted in actual harm for Resident #123 and 175. The findings included: 1. The facility's Quality Assessment and Assurance policy revealed, This facility will operate a Quality Assessment and Assurance Committee to identify quality issues, and develop and implement appropriate plans of action to correct identified quality deficiencies with in the facility .The Committee will develop plans of correction or action to correct identified quality deficiencies, including monitoring the effects of implemented changes and revising the action plans as needed . 2. The QA program failed to identify and develop interventions to prevent significant and severe weight loss resulting in actual harm to Resident #123 and 175. Refer to F325. 3. The QA program failed to ensure all residents' dignity was maintained and promoted. Refer to F241. 4. The QA program failed to ensure the facility was maintained to be sanitary, orderly, comfortable and odor free. Refer to F 253. 5. The QA program failed to ensure appropriate [MEDICAL TREATMENT] treatment and services were provided. Refer to F 309. 6. The QA program failed to provide an environment that was free from accident hazards. Refer to F 323. 7. The QA program failed to ensure medications were administered with a medication error rate less than 5 percent and was free from significant medication errors. Refer to F 332 and F 333. 8. The QA program failed to ensure a sanitary kitchen environment. Refer to F 371. 9. The QA program failed to ensure effective infection control. Refer to F 441. 10. The QA program failed to ensure medical records were complete and accurate. Refer to F 514. 11. The QA Committee failed to identify, monitor and revise plans to ensure the deficient practices and deficiencies (F280, F282, F371, F441 and F514) do not re-occur. Refer to F280, F282, F371, F441 and F514. 12. Interview with the Assistant Director of Nursing (ADON) on 12/4/16 at 4:55 PM, in the Administrator's office, the ADON was asked if she was chairperson over the QA committee. The ADON stated, Yes. The ADON was asked if weight loss was discussed in QA. The ADON stated, We discuss it in PAR (Patient at Risk.) The ADON was asked if there had been a problem identified with documentation of nutritional supplements. The ADON stated, .I don't know about that. The ADON was asked if there had been a problem identified with obtaining weekly and monthly weights in a timely manner. The ADON stated, .there were no specific dates over the weights. The ADON was asked if nutritional supplements not being administered had been identified. The ADON stated, I have seen a hole here or there .I have seen missing gaps in the Medication Administration Record. The ADON was asked if the problem had been addressed. The ADON stated, I had a meeting scheduled . The ADON was asked what should be done if a resident repeatedly refused a supplement. The ADON stated, We need to offer something else, we need to figure out what she will eat. The ADON was asked if it would be appropriate to increase the number of times per day the resident gets the supplement if she is refusing it. The ADON stated, No. The ADON was asked if nurses had been observed during a complete medication administration or just one resident. The ADON stated, .one resident. The ADON was asked if there had been a problem with medication administration. The ADON stated, No, but we need to review it. The ADON was asked if a problem with staff not following physician orders [REDACTED]. Interview with the Administrator (ADM) on 12/4/16 at 5:39 PM, in her office, the Administrator was asked if she was aware of a documentation issue with nutritional supplements before today. The ADM stated, No, we have an issue with documentation of supplements? The ADM was asked if she would expect weights to be obtained per policy. The ADM stated, Yes. The ADM was asked if a resident doesn't like the supplement they are receiving, would it be appropriate for them to increase the number of times per day that they give the supplement as an intervention. The ADM stated, I would think they would find something else to do. The ADM was asked if there was any documentation from the governing body where they have been involved with any of the issues regarding the facility. The ADM stated, No, I don't have any documentation of them being involved with anything. The ADM was asked if there had been a problem identified with reconciliation of physician orders. The ADM stated, No. The ADM was asked if there had been a problem identified with nurses following physician orders. The ADM stated, No.