Every finding on record at Jasper County NH

Based on record review, interviews, and facility policy review, the facility failed to administer physician-ordered medications and treatments in accordance with professional standards of practice by failing to administer a physician-ordered oral diabetic medication and perform physician-ordered blood glucose monitoring as prescribed for one (1) of three (3) residents reviewed for medication administration. (Resident #1).Findings include:A review of the facility's policy titled, JCNH ([NAME] County Nursing Home) Medication Administration Policy, revised 7/30/25, revealed Policy: Medications are administered. as ordered by the physician and in accordance with professional standards of practice. A review of the facility investigation revealed the facility became aware of the concern on 6/23/26 after Resident #1's daughter reported the resident had not received her scheduled Metformin or blood glucose monitoring. The investigation included review of video surveillance, which confirmed Licensed Practica Nurse (LPN) #1 did not enter Resident #1's room during the scheduled medication pass on 06/22/2026 or 06/23/2026. LPN #1 admitted she did not administer the ordered Metformin or obtain the physician-ordered blood glucose readings on either date despite documenting both as completed in the Medication Administration Record (MAR). The investigation resulted in termination of LPN #1 for falsification of medical records.A record review of the Medication Administration Record (MAR) revealed documentation indicating blood glucose monitoring was completed at 11:00 AM and Metformin 500 mg was administered at 12:00 PM on 06/22/2026 and 06/23/2026. Both entries were electronically signed by LPN #1.On 7/8/26 at 9:30 AM, during an interview with the Administrator confirmed, the facility became aware of the concern on 6/23/26 after Resident #1's daughter reported the resident had not received her scheduled 12:00 PM Metformin on 6/22/26 and 6/23/26 and that her blood glucose had not been checked. The Administrator confirmed video surveillance showed LPN #1 did not enter the resident's room during the scheduled medication pass on either date. He revealed LPN #1 admitted she did not administer the resident's Metformin or obtain the ordered blood glucose readings on both days, despite documenting the services as completed. The Administrator confirmed the nurse was terminated, the incident was reported to the State Agency, Attorney General's Office, and Mississippi Board of Nursing, and the facility completed staff education and initiated ongoing medication administration audits.On 07/08/2026 at 11:35 AM, during an interview, LPN #1 acknowledged the documentation was inaccurate and confirmed Resident #1 did not receive the ordered medication (Metformin) or blood glucose monitoring as documented on 6/22/26 and 6/23/26.On 07/08/2026 at 11:50 AM, during an interview with the Director of Nursing (DON), she confirmed Resident #1 had physician's orders for daily Metformin and blood glucose monitoring with sliding scale insulin before meals and at bedtime. The DON stated licensed nurses are expected to obtain blood glucose readings and administer medications in accordance with physician orders prior to documenting administration. She confirmed the investigation determined that LPN #1 did not enter the resident's room during the scheduled medication pass, did not obtain the resident's blood glucose, did not administer the ordered Metformin, and falsely documented the services as completed, on 6/22/26 and 6/23/26. The DON acknowledged this practice was not consistent with facility policy or accepted standards of nursing practice.On 07/08/2026 at 12:48 PM, during an interview, Resident #1's daughter stated that on 06/23/2026 she observed LPN #1 did not enter the resident's room to perform the physician-ordered blood glucose monitoring or administer the scheduled noon dose of Metformin. She stated she reported her concerns to the Unit Supervisor, which initiated the facility's investigation.On 07/08/2026 at 1:48 PM, during an interview, the Nurse Practitioner stated she was notified by the facility after the incident was identified. She confirmed LPN #1 had not notified her that Resident #1's physician-ordered Metformin or blood glucose monitoring had not been completed on 06/22/2026 and 06/23/2026. She further confirmed she was not notified the resident refused the medication, was unavailable, or that the physician's orders could not be carried out.A record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Diastolic (Congestive) Heart Failure and Unspecified Dementia, Mild, without Behavioral Disturbance.A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment.A record review of Resident #1's Order Summary Report revealed active physician orders for Metformin HCL (hydrochloride) Oral Tablet 500 MG (milligram), Give (1) tablet by mouth one time a day, dated 6/15/26, and Novolog Injection Solution 100 Unit/ML (milliliter) (Insulin Aspart) Inject as per sliding scale.before meals and at bedtime.dated 12/30/25. Validation:The SA validated on 7/8/26, through interview and record review that all corrective actions had been implemented as of 7/2/26, and the facility was in compliance as of 7/2/26, prior to the SA's entrance on 7/8/26.

Based on record review and staff interviews, the facility failed to maintain complete and accurate clinical records by documenting physician-ordered medication administration and blood glucose monitoring as completed when the ordered services were not provided, for one (1) of three (3) residents reviewed for clinical record accuracy. (Resident #1) Findings include:A review of the facility investigation revealed the facility became aware of the concern on 6/23/26 after Resident #1's daughter reported the resident had not received her scheduled Metformin or blood glucose monitoring. The investigation included review of video surveillance, which confirmed Licensed Practical Nurse (LPN) #1 did not enter Resident #1's room during the scheduled medication pass on 06/22/2026 or 06/23/2026. LPN #1 admitted she did not administer the ordered Metformin or obtain the physician-ordered blood glucose readings on either date despite documenting both as completed in the Medication Administration Record (MAR). The investigation resulted in termination of LPN #1 for falsification of medical records.During an interview on 07/08/2026 at 9:30 AM, the Administrator, confirmed the facility became aware of the concern on 6/23/26 after Resident #1's daughter reported the resident had not received her scheduled 12:00 PM Metformin on 6/22/26 and 6/23/26 and that her blood glucose had not been checked. The Administrator confirmed video surveillance showed LPN #1 did not enter the resident's room during the scheduled medication pass on either date. He revealed LPN #1 acknowledged she did not administer the resident's Metformin or obtain the ordered blood glucose readings on both days, despite documenting the services as completed. The Administrator confirmed the nurse was terminated, the incident was reported to the State Agency, Attorney General's Office, and Mississippi Board of Nursing, and the facility completed staff education and initiated ongoing medication administration audits.During an interview on 07/08/2026 at 10:55 AM, LPN #2 stated a Registered Nurse (RN) informed her that Resident #1's daughter reported no staff had entered the resident's room to perform the physician-ordered blood glucose monitoring on 06/23/2026. LPN #2 stated she immediately notified the Director of Nursing (DON), and together they reviewed the facility's video surveillance. She confirmed the surveillance showed no nursing staff entered Resident #1's room between 10:00 AM and 1:00 PM on 06/22/2026 or 06/23/2026. LPN #2 stated LPN #1 initially reported she had entered the room, administered the resident's Metformin, and performed the blood glucose check. However, on 06/24/2026, LPN #1 admitted she had not administered the physician-ordered Metformin or performed the physician-ordered blood glucose monitoring (Accu-Chek) on either 06/22/2026 or 06/23/2026. LPN #2 confirmed the resident's physician was notified.During an interview on 07/08/2026 at 11:35 AM, LPN #1 acknowledged the documentation was inaccurate and confirmed Resident #1 did not receive the ordered medication (Metformin) or blood glucose monitoring as documented on 6/22/26 and 6/23/26.During an interview on 7/8/26 at 11:50 AM, with the Director of Nursing (DON), she confirmed Resident #1 had physician's orders for daily Metformin and blood glucose monitoring with sliding scale insulin before meals and at bedtime. The DON stated licensed nurses are expected to obtain blood glucose readings and administer medications in accordance with physician orders prior to documenting administration. She confirmed the investigation determined that LPN #1 did not enter the resident's room during the scheduled medication pass, did not obtain the resident's blood glucose, did not administer the ordered Metformin, and documented in the MAR that both services had been completed. The DON acknowledged the documentation was inaccurate and not consistent with facility policy or accepted standards of nursing practice.A record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Diastolic (Congestive) Heart Failure and Unspecified Dementia, Mild, without Behavioral Disturbance.A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment.A record review of Resident #1's Order Summary Report revealed active physician orders for Metformin HCL (hydrochloride) Oral Tablet 500 MG (milligram), Give (1) tablet by mouth one time a day, dated 6/15/26, and Novolog Injection Solution 100 Unit/ML (milliliter) (Insulin Aspart) Inject as per sliding scale.before meals and at bedtime.dated 12/30/25.A record review of the MAR revealed documentation indicating blood glucose monitoring was completed at 11:00 AM and Metformin 500 mg was administered at 12:00 PM on 06/22/2026 and 06/23/2026. Both entries were electronically signed by LPN #1.Validation:The SA validated on 7/8/26, through interview and record review that all corrective actions had been implemented as of 7/2/26, and the facility was in compliance as of 7/2/26, prior to the SA's entrance on 7/8/26.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medications when the resident received an antipsychotic medication without an appropriate diagnosis and without informed consent, which resulted in lethargy, weight loss, and poor meal intake for one (1) of five (5) residents reviewed for unnecessary medications. Resident #79.Findings include:A review of the facility's policy titled .Use of Psychotropic Medication(s), dated 9/17/25, revealed, .It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.During an observation on 10/6/25 at 12:15 PM, Resident #79 was observed asleep in her wheelchair in the common area.On 10/8/25 at 1:05 PM, Resident #70 was observed asleep in her wheelchair and remained asleep until 5:15 PM.On 10/8/25 at 4:17 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained that Resident #79 had good days and bad days, often refusing to eat on her bad days. She stated the resident had been refusing meals that day and was uncooperative, often falling asleep during mealtime. She stated that CNAs typically set up the meal tray and later return to check on the resident.On 10/8/25 at 3:00 PM, during an interview with the Nurse Practitioner (NP), she explained that Resident #79 had lost over fifty (50) pounds in the past year. She stated Resident #79 often refused meals and care. She stated the resident was prescribed Geodon for psychosis related to combative behaviors but acknowledged that the resident did not have a diagnosis of bipolar disorder or Schizophrenia. She added that she had intended for the medication to be prescribed as needed (PRN) rather than scheduled daily. She stated that weight loss and lethargy could be side effects of the medication.A record review of the Behavior Monitoring and Interventions Report Log from 9/8/25 through 10/8/25 revealed there were no documented behaviors for Resident #79.On 10/8/25 at 3:30 PM, during an interview with the Director of Nursing (DON), she stated that psychosis was listed in the resident's medical history but acknowledged that it was not an approved indication for Geodon use. She confirmed that while the resident had a history of behaviors, the behavior documentation for the past month did not reflect any recorded behaviors.On 10/8/25 at 5:10 PM, during an interview with Licensed Practical Nurse (LPN) #3, she stated that Resident #79 often slept through meals and that it was difficult to get her to eat due to combativeness. She stated that CNAs had reported the resident's sleepiness and that she had reported these observations to her supervisor. She added that Resident #79 sometimes refused medications or slept through medication passes.On 10/9/25 at 10:00 AM, during an interview with Registered Nurse (RN) #2, Medical Records Nurse, she explained that the facility was unable to provide a signed consent for antipsychotic medication for Resident #79. She stated that Geodon was started in June 2024, prior to the facility's implementation of the consent process for antipsychotic use. She further explained that the medication was prescribed for psychosis, which was not an approved indication for use. She confirmed that the facility did not retroactively seek consent from the resident's representative or family after the regulation regarding consents for psychotropic medications went into effect.On 10/9/25 at 10:30 AM, during an interview with the Administrator and the DON, they stated it was their expectation that residents would be free from unnecessary medications and that medications would be administered only for appropriate diagnoses.On 10/9/25 at 11:04 AM, Resident #79 was observed asleep in her wheelchair in the dining area.A record review of Resident #79's admission Record revealed the facility admitted the resident on 10/17/23 with current diagnoses including Dementia.A record review of the Order Summary Report revealed Resident #79 had a physician's order, dated 1/8/25 for Ziprasidone (Geodon) HCL Cap (Capsule) 20 MG (Milligrams) Give 1 capsule by mouth at bedtime related to Unsp (Unspecified) psychosis not due to a substance or known physiological cond (condition).A record review of Quarterly Minimum Data Set (MDS) with an Annual Assessment Reference Date (ARD) of 8/19/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired.A record review of the Amount Eaten from 9/11/25 through 10/8/25 revealed the staff documented that Resident #79 refused her meal 38 times during the month.A record review of the Vital: Weight log for Resident #79 revealed that she weighed 214.2 pounds on 10/1/24 and 159.2 pounds on 10/1/25, which was a total of 55 pounds and 25.7 percent total weight loss in twelve (12) months.A record review of the RD (Registered Dietician) Assessment Summary, dated 10/7/25 revealed Resident #79 the Reason for Assessment was SWLX30/90/180 (Significant Weight Loss times 30/90/180 days) and included Observations/statements from chart/staff/resident. Assessment due to weight loss.Needs cueing r/t (related to) falling asleep while eating.A record review of the Psych (Psychiatric) Progress Note dated 9/25/25 revealed Resident #79's medication included Geodon 20 mg and the Case Conceptualization revealed, Chart indicates poor appetite and ongoing wt (weight) loss.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices, as evidenced by failure to wear gloves during the administration of eye drops and by placing medication containers on contaminated surfaces without cleaning or using a barrier for two (2) of three (3) residents observed for medication administration (Residents #14 and #96). Findings include:A review of the facility's .Medication Administration Policy, dated 7/30/25, revealed, . Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Resident #14A record review of the admission Record revealed the facility admitted Resident #14 on 11/14/22 with current diagnoses including Unspecified Glaucoma.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/25 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.A record review of the Order Summary Report revealed Resident #14 had a Physician's Order for Combigan Opthalmic Solution 0.2-0.5%, dated 11/14/2022.On 10/7/25 at 8:18 AM, during an observation, Licensed Practical Nurse (LPN) #2 was observed administering medications to Resident #14 during the morning medication pass. LPN #2 administered one (1) drop of eye drops to each of the resident's eyes without wearing gloves. She then placed the plastic medication bag on the resident's bed, retrieved it, and returned it to the medication cart without sanitizing the container.On 10/7/25 at 8:21 AM, during an interview, LPN #2 stated that gloves should have been worn during eye drop administration to prevent the spread of infection through bodily fluids or potential eye infections such as conjunctivitis (pink eye). She further stated medication containers should not be placed on the resident's bed or returned to the cart without sanitizing. She stated that a barrier, such as a paper towel, should be used between items and contaminated surfaces to prevent infection transmission.Resident #96A record review of the admission Record revealed the facility admitted Resident #96 on 3/11/24 with current diagnoses including Pulmonary Fibrosis.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/25 revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired.A record review of the Order Summary Report revealed Resident #96 had a physician's order, dated 8/27/24, for Artificial Tears eye drops. On 10/7/25 at 8:37 AM, during an observation, LPN #1 administered eye drops to Resident #96 without wearing gloves.On 10/7/25 at 8:45 AM, during an interview, LPN #1 stated she should have worn gloves while administering eye dops to Resident #96.On 10/7/25 at 10:15 AM, during an interview with the Director of Nursing (DON), she stated that any items placed on a resident's bed or bedside table must have a clean barrier and should be sanitized before being returned to the medication cart. She further stated that gloves should always be worn for procedures involving the eyes to prevent the spread of infection.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to an insulin medication for Resident #2 and an anticoagulant medication for Resident #14 for two (2) of (21) sampled residents.Findings include: A review of the facility's policy, Assessment Frequency/Timeliness dated 10/1/23, revealed, The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI (Resident Assessment Instrument) Manual . Resident #2A record review of Drugs.com website revealed the drug classification for Trulicity is GLP-1 receptor agonists.A review of the admission Record revealed the facility admitted Resident #2 on 6/19/24 with current diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy. A record review of the Quarterly MDS with an ARD of 8/04/2025 revealed Section N, N0300. Insulin was marked as Resident #2 had received two (2) insulin injections in the seven (7) day look-back period.A record review of the Order Summary Report with Active Orders As Of 7/01/2025 revealed Resident #2 had a Physician's Order, dated 9/18/24, for Trulicity Subcutaneous Solution Pen-Injector 3mg(milli-gram)/0.5 ml (milli-liters) (Dulaglutide) Inject 3 mg subcutaneously one time a day every Wednesday related to Type 2 Diabetes Mellitus Without Complications. Further review revealed there were no Physician's Order for an insulin medication. A record review of Resident #2's MAR for July and August 2025, revealed Trulicity was documented as administered. There was no documentation indicating that insulin was administered.Resident #14A record of the admission Record revealed Resident #14 was admitted by the facility on 11/14/2022 with diagnoses including Hypertensive Heart Disease with heart failure. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/25 for Resident #14 revealed Section N, N0415. High-Risk Drug Classes: Use and Indication was marked as Yes, indicating Resident #14 had taken an anticoagulant medication during the seven (7) day look-back period. A record review of the Order Summary Report with Active Orders as of 7/28/2025 revealed there were no Physician's Orders for an anticoagulant medication.A record review of the Medication Administration Record (MAR) for the month of July 2025 revealed there were no anticoagulant medications administered to Resident #14.On 10/7/25 at 12:41 PM, during an interview with the Registered Nurse/Minimum Data Set (RN/MDS) Coordinator, she confirmed that Resident #14 did not have a Physician's order for an anti-coagulant medication and was not administered an anticoagulant during the look-back period, although the MDS reflected anticoagulant use. The RN/MDS further confirmed Resident #2 was prescribed an insulin medication but was on Trulicity injections. She reported that the MDS was coded incorrectly for both residents.On 10/7/25 at 4:30 PM, during an interview with Director of Nurses (DON), she stated that MDS assessments must be completed accurately and acknowledged the errors for Resident #2 and Resident #14.

Based on interview, record review and facility policy review, the facility failed to maintain an accurate resident clinical record related to a physician's order for a resident hospital transfer for one (1) of (21) sampled residents. Resident #7Findings include: A review of the facility's Physician's Orders Policy, revised 8/29/17 revealed .Reminders.The nurse noting the order is responsible for.Transcribing the orders to the appropriate place. A record review of the facility's admission Record revealed the facility admitted Resident #7 on 4/23/2019 with current diagnoses including Type 2 Diabetes Mellitus A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed Resident #7 was transferred from the facility due to a unplanned discharge to a Short-Term General hospital on 7/25/2025. A record review of Progress Notes revealed Resident #7 had a Transfer to Hospital Summary note, dated 7/25/2025, which indicated she had been sent to an acute hospital for further evaluation. A review of the clinical record for Resident #7 revealed there was no physician order documented related to the 7/25/25 transfer to the hospital. On 10/08/2025 at 11:56 AM, during an interview with the Assistant Director of Nursing (ADON), she acknowledged there was no Physician's order in the medical record related to Resident #7's transfer to an acute hospital on 7/25/25. She stated it was the responsibility of the nurse that receives the order to transcribe it and follow it through. On 10/08/2025 at 1:21 PM, during an interview with the Director of Nursing (DON), she confirmed there was no physician's order in the clinical record for Resident #7 when she was transferred to the hospital on 7/25/25. The DON stated that when a verbal order is received from the physician the nurse must put that information in the computer immediately or as quickly as possible.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide shaving for residents who were dependent on staff for Activities of Daily Living (ADLs) for two (2) of (21) sampled residents, Residents #6 and #11.Findings include:A review of the facility's Shaving Policy, (undated) revealed, It is the policy of this facility that male residents will be shaved as follows: - Encouraged to be shaved daily and as needed .Resident #6A record review of the admission Record revealed the facility admitted Resident #6 on 2/13/23 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/25 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired. Section GG revealed Resident #6 had limitations in range of motion in both lower extremities and was dependent on staff for bathing and personal hygiene.A record review of the facility's Bath Schedule - Group C revealed Resident #6 received a pan bath daily on the night shift.On 10/6/25 at 10:44 AM, during an observation and interview, Resident #6 was lying in bed with long facial hair. He stated that staff were responsible for shaving him, but he had not been shaved in a long time and wished to be shaved.On 10/7/25 at 12:32 PM, during an observation, Resident #6 was observed sitting in his wheelchair with long facial hair.On 10/7/25 at 3:00 PM, during an interview with Certified Nurse Aide (CNA) #2, she stated that Resident #6 received a bed bath daily on the evening shift (7:00 PM-7:00 AM) and required total assistance for all ADLs except feeding. She stated the resident was cooperative and never refused care, including baths. CNA #2 stated that shaving was part of the bath or shower routine and should occur daily or at least every other day. She confirmed Resident #6 had long facial hair that appeared not to have been shaved in several days, possibly a week. She reported that Resident #6 preferred to be clean-shaven and that she had last shaved him approximately two (2) weeks ago when his facial hair was also long.On 10/7/25 at 3:30 PM, during an interview with Licensed Practical Nurse (LPN) #4, she stated that Resident #6 was cooperative and dependent on staff for all ADLs except feeding. She confirmed the resident received a bed bath nightly, which included shaving. She stated the resident had long facial hair and that she had not been informed of any refusals. Resident #11A record review of the admission Record revealed the facility admitted Resident #11 on 12/13/18 with diagnoses including Alzheimer's Disease.A record review of the Quarterly MDS with an ARD of 8/13/25 revealed a BIMS score of 3, which indicated the resident's cognition was severely impaired. Section GG revealed Resident #11 had limitations in range of motion in both lower extremities and was dependent on staff for bathing and personal hygiene.A record review of the facility's Bath Schedule - Group A revealed Resident #11 received a pan bath daily on the day shift.On 10/6/25 at 12:11 PM, during an observation, Resident #11 was sitting in her wheelchair with multiple long hairs several inches in length noted on her chin.On 10/6/25 at 12:15 PM, during an interview and observation with CNA #3, she confirmed Resident #11 had long chin hair and that shaving should be completed during showers. She stated the resident received her showers on the evening shift.On 10/7/25 at 12:31 PM, during an observation, Resident #11 was sitting in the dining room with long chin hair visible.On 10/7/25 at 12:35 PM, during an interview and observation with CNA #4, she stated that she worked restorative care and also assisted on the floor as needed. She confirmed that ADL care included bathing, brushing teeth, dressing, and shaving as needed on shower days. She stated Resident #11 had long chin hair that appeared to have been there for some time.On 10/7/25 at 2:20 PM, during an interview and observation with CNA #5, she stated that Resident #11 was totally dependent for all ADLs and was scheduled for showers on the evening shift, which included shaving. She stated the resident was usually cooperative with care, though occasionally confused. She confirmed the resident had long chin hairs that appeared to have not been recently shaved.On 10/7/25 at 3:25 PM, during an interview with LPN #4, she stated that Resident #11 received showers on the evening shift and that she had not been informed of any refusals of care. She stated the resident was confused but easily redirected and cooperative.On 10/8/25 at 8:35 AM, during an observation, Resident #11 was lying in bed and continued to have long chin hair.On 10/8/25 at 9:00 AM, during an observation and interview with the Director of Nursing (DON), Resident #6 was sitting in the dining room eating breakfast. The DON stated that both men and women were expected to be shaved as part of bathing or shower care. She stated that, as a woman, she would not want to have long chin hair and expected staff to shave or pluck such hairs as needed. She confirmed that Resident #6 had long facial hair and stated she would follow up on Resident #11.On 10/9/25 at 1:01 PM, during a follow-up interview with the DON, she confirmed Resident #11 had numerous chin hair and stated she expected staff to provide shaving for all residents as needed to meet each resident's individual needs and ensure quality care.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement resident-specific care plan interventions when staff did not provide personal hygiene (shaving) as identified in the care plans (Residents #6 and #11), and failed to develop a care plan addressing triggers and interventions for a resident with Post-Traumatic Stress Disorder (PTSD) (Resident #2) for three (3) of (21) sampled residents.Findings include:A review of the facility's Care Plan Assessment (CAA) Care Planning Policy (undated), revealed, It is the policy of this facility that the CAA/Care Planning Process will be done as follows: Includes.Each triggered CAA will be assessed to facilitate a plan of care based on problems identified through the assessment process.Resident #2On [DATE] at 11:55 AM, during an interview with Resident#2 she confirmed she had the diagnosis of PTSD and reported it is related to her husband died due to a stab wound to his leg. He bled out and said he waited to tell her that he loved her, and he died. She no longer likes knives and does not watch knife shows. She thinks staff are aware of the PTSD. A record review of the admission Record revealed the facility admitted Resident #2 on [DATE] with current diagnoses including Post-Traumatic Stress Disorder, Unspecified.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section I indicated she had an active diagnosis of Post-Traumatic Stress Disorder.A record review of the Psych Eval, dated [DATE], revealed Past Medical History Active Medical Problems included Post-Traumatic Stress Disorder. The Case Conceptualization section indicated, . demonstrates how she wrapped her arms around her younger siblings to protect them from hearing her abusive father's [NAME] . Hesitates and almost tears up before expounding upon these scenarios saying she doesn't want to be sent to a psychiatric hospital, then exhibits the same display of hesitation near tearfulness when she talks . My husband passed away, and I found him by myself, and they said it was PTSD .A record review of Resident#2's clinical record revealed there was no care plan developed with interventions that included trauma or triggers. Resident #6A record review of the Care Plan Report revealed Resident #6 had a Focus of Resident requires total ADL assistance . with Interventions/Tasks including Assist as needed with ADL'S . A record review of the admission Record revealed the facility admitted Resident #6 on [DATE] with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired. Section GG revealed Resident #6 had limitations in range of motion in both lower extremities and was dependent on staff for bathing and personal hygiene.During an observation and interview on [DATE] at 10:44 AM, Resident #6 was noted to have long facial hair. He explained the staff were supposed to shave him, but he had not been shaved in a long time. He expressed that he wished to be shaved. During an observation on [DATE] at 12:32 PM, Resident #6 continued to have long facial hair. During an interview on [DATE] at 3:00 PM, Certified Nurse Aide (CNA) #2, confirmed Resident #6 had long facial hair that appeared not to have been shaved in several days, possibly a week. She reported that Resident #6 preferred to be clean-shaven and that she had last shaved him approximately two (2) weeks ago when his facial hair was also long.Resident #11A record review of the Care Plan Report revealed Resident #11 had a Focus of Resident requires ADL assistance with Interventions/Tasks of Assist As Needed With ADL'S .A record review of the admission Record revealed the facility admitted Resident #11 on [DATE] with diagnoses including Alzheimer's Disease.A record review of the Quarterly MDS with an ARD of [DATE] revealed a BIMS score of 3, which indicated the resident's cognition was severely impaired. Section GG revealed Resident #11 had limitations in range of motion in both lower extremities and was dependent on staff for bathing and personal hygiene.During an observation on [DATE] at 12:11 PM, Resident #11 had numerous long stray hairs that were several inches long on her chin. During an interview and observation on [DATE] at 12:15 PM, CNA #3 confirmed Resident #11 had long chin hair and that shaving should be completed during showers. During an observation on [DATE] at 12:31 PM, Resident #11 had long chin hair visible.During an observation on [DATE] at 8:35 AM, Resident #11 was lying in bed and continued to have long chin hair.During an interview on [DATE] at 12:00 PM, Registered Nurse (RN)#1 explained that the purpose of the care plan was to guide staff in providing individualized care for each resident. She stated that she expected all staff to follow the care plans as written to ensure residents received the highest quality of care. She reviewed Resident #2's care plan and confirmed that no care plan had been developed for Post-Traumatic Stress Disorder (PTSD) and that no triggers were identified for prevention of recurrence. She stated that since the diagnosis was present on admission, a care plan might have been in the medical record but confirmed that if it was not included in the comprehensive care plan, staff would not be aware of the triggers or how to prevent recurrence.During an interview on [DATE] at 1:01 PM, the Administrator and the Director of Nursing (DON) stated that they expected staff to follow each resident's care plan and provide quality care to support residents in achieving their highest practicable level of well-being. They stated that care plans should be developed based on each resident's comprehensive assessment and confirmed that Resident #2 should have had a care plan addressing Post-Traumatic Stress Disorder (PTSD), and that Residents #6 and #11 should have been shaved in accordance with their care plans for activities of daily living (ADL) care.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and dignity during medication administration when licensed nursing staff administered prescribed eye drops to a resident in the dining room while other residents were present, for one (1) of three (3) residents reviewed for medication administration, Resident #96.Findings include:A review of the facility's .Medication Administration Policy, dated 7/30/25, revealed, .Policy Explanation and Compliance Guidelines.7. Provide privacy.On 10/7/25 at 8:37 AM, during an observation, LPN #1 administered medications to Resident #96 while the resident was in the dining room. At the time of the observation, nine (9) other residents were also present in the dining room.On 10/7/25 at 8:45 AM, during an interview, LPN #1 stated she normally administered medications in the dining room for residents who were present there during the morning medication pass. She reported that Resident #96 had not expressed a problem with receiving medications in the dining room but acknowledged that privacy could be an issue when medications were given in the presence of other residents.On 10/7/25 at 10:15 AM, during an interview, the Director of Nursing (DON) stated medications should not be administered in the dining room in front of other residents. She stated her expectation was that all medications be administered in a private setting to ensure resident dignity and privacy.A record review of the admission Record revealed the facility admitted Resident #96 on 3/11/24 with current diagnoses including Pulmonary Fibrosis.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/25 revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired.A record review of the Order Summary Report revealed Resident #96 had a physician's order, dated 8/27/24, for Artificial Tears eye drops.

Based on interviews and record review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of (21) sampled residents. Resident #2.Findings include:A review of a written statement provided and signed by the Administrator revealed, (Proper Name) Nursing Home does not have a policy on Post-Traumatic Stress Disorder.A record review of the admission Record revealed the facility admitted Resident #2 on [DATE] with current diagnoses including Post-Traumatic Stress Disorder, Unspecified.A record review of the Order Summary Report revealed orders for .May consult (Proper Name) Health Services for Psych (Psychiatric).as needed, dated [DATE], and May have Psych consult as needed, dated [DATE].A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section I indicated she had an active diagnosis of Post-Traumatic Stress Disorder.A record review of the Certified Nurse Aide (CNA) Kardex for the Behavior Monitoring and Interventions Report for [DATE] revealed staff were to indicate behaviors observed, interventions attempted, and outcomes. There were no resident-specific triggers identified in the document related to PTSD.A record review of the Psych Eval, dated [DATE], revealed Past Medical History Active Medical Problems included Post-Traumatic Stress Disorder. The Case Conceptualization section indicated, . demonstrates how she wrapped her arms around her younger siblings to protect them from hearing her abusive father's [NAME] . Hesitates and almost tears up before expounding upon these scenarios saying she doesn't want to be sent to a psychiatric hospital, then exhibits the same display of hesitation near tearfulness when she talks . My husband passed away, and I found him by myself, and they said it was PTSD .A record review of Resident #2's medical record revealed there was no documentation indicating that the resident had been evaluated to identify PTSD triggers or that any resident-specific interventions had been developed or implemented.On [DATE] at 11:55 AM, during an interview, Resident #2 confirmed she had been diagnosed with PTSD and stated it was related to the death of her husband, who had died from a stab wound to his leg. She explained she no longer likes knives and does not watch television shows involving knives. She stated she believed the staff were aware of her PTSD diagnosis. On [DATE] at 2:20 PM, during an interview with Certified Nurse Aide (CNA) #6, she stated that Resident #2 had never mentioned PTSD or exhibited complaints about triggers. She reported the resident occasionally became anxious and complained about various issues. She reviewed the Kardex and stated that the resident was monitored every shift for behaviors, but neither the resident nor staff had ever identified PTSD-related triggers.On [DATE] at 3:10 PM, during an interview with Licensed Practical Nurse (LPN) #4, she stated she was not aware of Resident #2 having PTSD, and the resident had never discussed it or any triggers. She confirmed that Resident #2 spoke frequently about anxiety and had medications for anxiety management. After reviewing the resident's admitting diagnoses, LPN #4 confirmed that PTSD was listed among them.On [DATE] at 11:01 AM, during an interview with the Director of Nursing (DON), she stated she was not aware of any trauma-informed or PTSD-specific assessments being completed for residents. She explained she had been employed at the facility since August and was not aware of any existing assessments. The DON stated she would verify whether Resident #2 had received a psychiatric evaluation addressing PTSD. She reported she had consulted with the Assistant Director of Nursing (ADON), who informed her that Resident #2 was admitted with the PTSD diagnosis but that neither she nor the ADON knew the associated triggers. The DON confirmed that there was no documentation identifying PTSD-related triggers and acknowledged that without such information, staff would be unable to recognize or avoid potential triggers. The DON provided a copy of Resident #2's initial Psych Eval Note, dated [DATE]-four (4) months after admission-which listed PTSD under past medical history and included trauma-related content, but no identified triggers or interventions. The DON confirmed that while the resident was seen by a Mental Health Nurse Practitioner quarterly and a psychotherapist weekly, the facility had not conducted an assessment to identify triggers or develop corresponding interventions. She stated the facility did not have a PTSD policy.

Based on observation, staff interview, and facility policy review, the facility failed to ensure nurse staffing information was posted in a location daily that was visible to residents and the public for two (2) of four (4) survey days.Findings include:A review of the facility's Posting Daily Staffing Information Policy (undated) revealed, It is the policy of this facility that Nurse Staffing information will be posted as follows.The information will be posted daily.This form will be posted in the foyer of the building.On 10/6/25 at 11:05 AM, during an observation of the common areas, including the facility's foyer, and surrounding the nursing stations on Unit 200, Unit 300, and Unit 400, there was no posted nurse staffing information visible.On 10/7/25 at 2:09 PM, during an observation of the common areas, including the facility's foyer, and surrounding the nursing stations on Unit 200, Unit 300, and Unit 400, there was no posted nurse staffing information visible.On 10/7/25 at 3:25 PM, during an interview with the Assistant Director of Nursing (ADON), she explained that the daily nurse staffing information was completed daily but was posted inside a locked room near the time clock with a sign on the door that read Staff Only. She further stated that the staffing information was also kept in a binder behind the nursing station counter. The ADON confirmed that no staffing information was posted in the common areas surrounding any of the three nursing stations.On 10/7/25 at 3:40 PM, during an interview with the Director of Nursing (DON), she confirmed that there was no nurse staffing information posted in the common areas near Units 200, 300, or 400. She explained that while the nurse staffing information was completed, it was kept in binders behind the nursing station counter. The DON stated that posting nurse staffing information is important to demonstrate that the facility has adequate staff to meet residents' needs and provide appropriate care.

Based on interviews, record review, and facility policy review, the facility failed to prevent a significant medication error when Licensed Practical Nurse (LPN) #1 administered blood pressure medications to a resident that were prescribed for his roommate, resulting in Resident #1 being admitted to the intensive care unit (ICU) of a local acute care hospital due to an adverse reaction for one (1) of four (4) residents reviewed. Resident #1 Findings Included: Record review of the facility's policy titled Medication Set-Up and Administration, dated 5/31/23 revealed, .Policy .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .8. Identify residents by photo in the EMAR (electronic medication administration record) . Record review of the facility's Incident Note revealed, 12/15/2024 22:56 (10:56 PM) Incident Note .@1930 (7:30 PM) arrived to station 4 and notified of cart nurse (LPN #1) medication error. Logged into point click care to observe medications given in error. Obtain resident's allergies and medication list. While gathering data, delegated to cart nurse to obtain vitals. Resident awake, alert, and oriented. Vitals 99/55bp (blood pressure), 80p (pulse), O2 95% (oxygen saturation) . (At) 1945 MD notified of medication error and resident's condition. Order given to monitor resident bp for three hours; every 15 minutes the first hours, then thirty minutes the last two hours. Notified cart nurse of order. Cart nurse notified that resident bp decreased to 81/28. Resident awake, alert, oriented, and voice no c/o (complaints of) discomfort at time. Explained to resident that he will be placed in Trendelenburg position to help reduce bp from decreasing significantly. Placed in Trendelenburg with feet propped on pillow. (At) 1948 (7:48 PM) DON notified of med error. 1950 (7:50 PM) RR (Resident Representative) notified of medication error and order to be monitor for three hours. RR wanted to explanation as to how medication error occurred. Explained that Charge Nurse (CN) was unaware of the exact details of the error, apologized for error, and if any changes CN will notify of changes. 2200 (10:00 PM) Cart nurse notified that resident was c/o difficult of breathing in Trendelenburg position and that she has to raise his head for comfort. Vitals was obtained with bp resulting in 63/19 and Md was notified immediately. Order obtained to send to (local hospital). 2205 (10:05PM) Emergency service was called. 2208 (10:08 PM) RR .notified that resident was being sent to ER (emergency room ). RR stated, I am not happy and will be meeting with y'all tomorrow. (At) 2222 (10:22 PM) Emergency service arrived. vitals obtained with bp resulting to 60/40. EMT (Emergency Medical Technician) stated that he had to get bp stable before moving resident. IV (Intravenous) line started in right forearm by EMT. IV bolus given by EMT. Vitals obtain with bp 90/70. Resident then moved to stretcher. Resident awake, alert, and oriented. Resident asked for cell phone to be transferred with him. Placed on lap. Resident left facility with Emergency Service at 2242 (10:42 PM). Record review of the Physician Orders for Resident #1 revealed physician's order, 12/15/2024 to SEND TO (Acute hospital) DUE TO ADVERSE REACTION one time only for Prophylaxis (Prevention) . Record review of the written Witness Statement, signed by LPN #1 and dated 12/15/24 revealed LPN #1 had given the wrong medications to Resident #1 accidentally and immediately realized it wasn't his medications. The statement included measures taken by LPN #1 following the error, which included notification of LPN #2, the Charge Nurse, the resident's physician, RR and the Director of Nursing (DON). Record review of the acute hospital's Final Report, dated 12/26/24, revealed Resident #1 was admitted to the acute care facility following transfer from (the facility) for accidental medication ingestion. Patient was given the wrong medications by nursing staff at the facility .Medications included Lisinopril 40 mg (forty milligrams), Lipitor 20 mg, Carvedilol 25 mg, hydroxyzine 25 mg, and Seroquel 50 mg. Upon arrival to ER (emergency room ) patient was noted to be bradycardic and hypotensive requiring IV fluids and Levophed for blood pressure control .Patient is being admitted to ICU (Internsive Care Unit) . During an interview with Resident #1 on 1/2/2025 at 1:30 PM, he recalled receiving the wrong medications on 12/15/2024 and was told it was his roommate's medications. He described the experience as a rough time because he had to stay in the hospital and expressed hope that it would never happen again. During an interview on 1/2/2025 at 2:00 PM, the RR confirmed being notified by the facility on 12/15/2024 of the medication error and the Resident #1's subsequent transfer to the hospital due to low blood pressure as a result. The RR also confirmed Resident #1 was transferred and admitted to the ICU of an acute hospital. During an interview on 1/02/24 at 2:35 PM, the DON revealed she stated that during her investigation as to the cause of medication error involving Resident #1 on the evening of 12/15/24, she determined that LPN #1 had not followed current standards of practice or facility policy for medication administration because she had pre-poured, or pre-pulled medications when she prepared the medications for both residents simultaneously and took both cups of medications into the room for the residents. She reported that failure of LPN #1 to prepare, administer and document each resident's medications for one resident at a time, LPN #1 had confused the medications and administered the medications prescribed for Resident #4 to Resident #1. She confirmed that following administration of the wrong medications to Resident #1, LPN #1 had notified the Charge Nurse, LPN #2, the resident's physician, the resident's RR, and the DON. She confirmed that the physician issued instructions to monitor Resident #1's blood pressure and notify him if the resident's blood pressure decreased because two of the medications were antihypertensive agents. The DON explained that when the resident's blood pressure decreased, the nursing staff notified the resident's physician and received orders for transfer to an acute care hospital for treatment of hypotension. The DON stated that the facility implemented corrective actions immediately by providing In-Service training for all nurses beginning 11/16/24 which included Resident Drug Administration Rights, identification of the right resident prior to administration of medications, and avoidance of pre-pouring medications and preparation of medications for more than one resident at a time. She stated that the facility had also implemented a one hundred percent (100%) mandatory competency check-off for all nurses for medication administration. She stated that the incident had been investigated and reported to all agencies per federal and state guidelines with LPN #1 placed on suspension pending conclusion of the investigation. She confirmed LPN #1 was terminated upon conclusion of the investigation due to her failure to follow facility policy. She stated that the incident and investigation results were presented to the Quality Assurance (QA) committee during the committee meeting on 12/18/24, which was attended by the facility Infection Preventionist and the Medical Director and reported Resident #1 returned to the facility on [DATE]. During an interview on 1/02/24 at 3:00 PM, the Administrator confirmed that nurses were expected to follow the facility policy and current standards of practice for medication administration. He stated that the facility investigation concluded that the cause of the incident was that LPN #1 had prepared medications for more than one resident at a time and taken both residents medications into the room at the same time and became distracted and administered the wrong medications to Resident #1. He confirmed that that the incident and investigation results were presented to the QAPI committee during the committee meeting on 12/18/24, which was attended by the facility Infection Preventionist and the Medical Director, during which the facility policy was reviewed with no revisions made. A record review of the Admission Record revealed the facility admitted Resident #1 on 8/1/24 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Hypertension. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired. Based on the implementation of the facility's corrective actions on 12/18/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 12/19/2024. Validation: The SA (State Agency) validated on 1/2/2025, through interview and record review that all corrective actions had been implemented as of 12/18/24, and the facility was in compliance as of 12/19/24, prior to the SA's entrance on 1/2/2025.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure services provided met current professional standards when Licensed Practical Nurse (LPN) #1 prepared two (2) residents medications simultaneously and administered the wrong medications to Resident #1, resulting in the resident being admitted to the intensive care unit (ICU) of a local acute care hospital due to an adverse reaction for one (1) of four (4) sampled residents. Resident #1 Findings Included: A review of the facility policy titled Medication Set-Up and Administration, revised 5/31/2023, revealed, Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .8. Identify residents by photo in the electronic medication administration record (EMAR). Record review of the facility's Incident Note revealed, 12/15/2024 22:56 (10:56 PM) Incident Note .@1930 (7:30 PM) arrived to station 4 and notified of cart nurse (LPN #1) medication error. Logged into point click care to observe medications given in error. Obtain resident's allergies and medication list. While gathering data, delegated to cart nurse to obtain vitals. Resident awake, alert, and oriented. Vitals 99/55bp (blood pressure), 80p (pulse), O2 95% (oxygen saturation) . (At) 1945 MD notified of medication error and resident's condition. Order given to monitor resident bp for three hours; every 15 minutes the first hours, then thirty minutes the last two hours. Notified cart nurse of order. Cart nurse notified that resident bp decreased to 81/28. Resident awake, alert, oriented, and voice no c/o (complaints of) discomfort at time. Explained to resident that he will be placed in Trendelenburg position to help reduce bp from decreasing significantly. Placed in Trendelenburg with feet propped on pillow. (At) 1948 (7:48 PM) DON notified of med error. 1950 (7:50 PM) RR (Resident Representative) notified of medication error and order to be monitor for three hours. RR wanted to explanation as to how medication error occurred. Explained that Charge Nurse (CN) was unaware of the exact details of the error, apologized for error, and if any changes CN will notify of changes. 2200 (10:00 PM) Cart nurse notified that resident was c/o difficult of breathing in Trendelenburg position and that she has to raise his head for comfort. Vitals was obtained with bp resulting in 63/19 and Md was notified immediately. Order obtained to send to (local hospital). 2205 Emergency service was called. 2208 RR .notified that resident was being sent to ER (emergency room ). RR stated, I am not happy and will be meeting with y'all tomorrow. (At) 2222 (10:22 PM) Emergency service arrived. vitals obtained with bp resulting to 60/40. EMT (Emergency Medical Technician) stated that he had to get bp stable before moving resident. IV (Intravenous) line started in right forearm by EMT. IV bolus given by EMT. Vitals obtain with bp 90/70. Resident then moved to stretcher. Resident awake, alert, and oriented. Resident asked for cell phone to be transferred with him. Placed on lap. Resident left facility with Emergency Service at 2242 (10:42 PM). Record review of the Physician Orders for Resident #1 revealed physician's order, 12/15/2024 to SEND TO (Acute hospital) DUE TO ADVERSE REACTION one time only for Prophylaxis (Prevention) . Record review of the written Witness Statement, signed by LPN #1 and dated 12/15/24 revealed LPN #1 had given the wrong medications to Resident #1 accidentally and immediately realized it wasn't his medications. The statement included measures taken by LPN #1 following the error, which included notification of the LPN #2, the Charge Nurse, the resident's physician, Resident Representative (RR), and the Director of Nursing (DON). Record review of the acute hospital's Final Report, dated 12/26/24, revealed Resident #1 was admitted to the acute care facility following transfer from (the facility) for accidental medication ingestion. Patient was given the wrong medications by nursing staff at the facility .Medications included Lisinopril 40 mg (milligrams), Lipitor 20 mg, Carvedilol 25 mg, Hydroxyzine 25 mg, and Seroquel 50 mg. Upon arrival to ER (emergency room ) patient was noted to be bradycardic and hypotensive requiring IV fluids and Levophed for blood pressure control .Patient is being admitted to ICU . On 1/02/24 at 1:30 PM, an interview Resident #1 stated that he recalled receiving the wrong medications on 12/15/24 and said he was told he received medications that were prescribed for his roommate. He stated, I have had a time. It was rough. I had to go and stay in the hospital. I hope that never happens again. On 1/02/24 at 2:00 PM, an interview with the RR for Resident #1 revealed the facility nursing staff had notified him on the evening of 12/15/24 that Resident #1 had accidentally been administered the wrong medications and then later that Resident #1 was being transferred to an acute care hospital due to his blood pressure being too low after having been given two antihypertensive medications in error. He stated that he reported to the hospital and the resident was admitted to the ICU. On 1/02/24 at 2:35 PM, an interview the Director of Nurses (DON) stated that current standards of practice for medication administration included resident rights for medication administration. This would include the right medication and dose. She confirmed that nurses were expected to adhere to the current standards of practice and to make sure they were administering the right medications to the right resident. She stated that during her investigation as to the cause of medication error involving Resident #1 on the evening of 12/15/24, she determined that LPN #1 had not followed current standards of practice or facility policy for medication administration because she had pre-poured medications when she prepared the medications for both residents at the same time and took the medications into the room at the same time. She reported that failure of LPN #1 to prepare, administer and document each resident's medications for one resident at a time, that LPN #1 had confused the medications and administered the medications prescribed for Resident #4 to Resident #1. She confirmed that following administration of the wrong medications to Resident #1, LPN #1 had notified the Charge Nurse, LPN #2, the resident's physician, the resident's RR and the DON. She confirmed that the physician issued instructions to monitor Resident #1's blood pressure and notify him if the resident's blood pressure decreased because two of the medications were antihypertensive agents. The DON explained that when the resident's blood pressure decreased, the nursing staff notified the resident's physician and received orders for transfer to acute care hospital for treatment of hypotension. The DON stated that the facility had provided In-Service training for all nurses beginning 12/16/24 which included Resident Drug Administration Rights, identification of the right resident prior to administration of medications and avoidance of pre-pouring medications and preparation of medications for more than one resident at a time. She stated that the facility had also implemented a one hundred percent (100%) mandatory competency check-off for all nurses for medication administration. She stated that the incident had been investigated and reported to all agencies per federal and state guidelines with LPN #1 placed on suspension pending conclusion of the investigation. She stated that the employment of LPN #1 had been terminated upon conclusion of the investigation due to her failure to follow facility policy. She stated that the incident and investigation results were presented to the Quality Assurance (QAPI) committee during the committee meeting on 12/18/24, which was attended by the facility Infection Preventionist and the Medical Director. She confirmed that Resident #1 returned to the facility on [DATE]. On 1/02/24 at 3:00 PM, an interview with the Administrator confirmed that nurses were expected to follow the facility policy and current standards of practice for medication administration. He stated that the facility investigation concluded that the cause of the incident was that LPN #1 had prepared medications for more than one resident at a time and taken both residents medications into the room at the same time and become distracted/confused and administered the wrong medications to Resident #1. He confirmed that that the incident and investigation results were presented to the QAPI committee during the committee meeting on 12/18/24, which was attended by the facility Infection Preventionist and the Medical Director, during which the facility policy was reviewed with no revisions made. A record review of the Admission Record revealed the facility admitted Resident #1 on 8/1/24 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Hypertension. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired. Based on the implementation of the facility's corrective actions on 12/18/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 12/19/2024. Validation: The State Agency (SA) validated on 1/2/2025, through interview and record review that all corrective actions had been implemented as of 12/18/24, and the facility was in compliance as of 12/19/24, prior to the SA's entrance on 1/2/2025.

Based on observation, staff interview, record review and facility draft policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one (1) of three (3) residents reviewed as high risk for acquiring multi-drug-resistant organisms (MDROs) Resident #69 and had the potential to affect six (6) residents identified as high risk for MDROs. Findings Include: Record review of the facility policy Draft Enhanced Barrier Precautions Policy dated reviewed 9/28/24 revealed This policy aims to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDROs) within our facility by implementing Enhanced Barrier Precautions (EBP). This policy seeks to prevent the spread of MDRO's among residents and staff members by expanding the use of personal protective equipment (PPE) during high contact resident care activities for certain residents .Policy Explanation and Compliance Guidelines .4. Examples of indwelling medical devices for EBP should include but are not limited to .feeding tube . On 11/05/24 at 12:10 PM, during an observation, Licensed Practical Nurse (LPN #1) entered Resident # 69's room to administer medication via the residents Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 did not put on a gown while accessing the PEG tube and administering the medication. During an interview with LPN #1 on 11/05/24 at 12:25 PM, she admitted that she had forgotten to wear a gown and noted that there was no signage or other indicators to alert the staff that Resident #69 resident required EBP, nor was PPE readily accessible. She acknowledged the importance of EBP in preventing the transmission of MDROs, particularly during high-contact activities with residents who have PEG tubes, catheters, or central lines. During an interview with the Director of Nursing (DON) on 11/06/24 at 9:00 AM, she confirmed that the facility had developed a Performance Improvement Plan (PIP) for EBP training, initiated in September 2024. She indicated that the facility's policies were being revised to enhance compliance with EBP guidelines. On 11/06/24 at 9:25 AM, an interview with Registered Nurse (RN) #1 revealed that the facility follows standard precautions and uses transmission-based precautions for contact, droplet, and airborne pathogens. RN #1 confirmed that EBP protocols require the use of gowns and gloves during high-contact care activities involving residents with PEG tubes, catheters, and central lines. She noted that the facility currently had no policies in place to incorporate enhanced barrier precautions but was updating their infection control policies to include EBP guidelines. During an interview on 11/7/24 at 10:45 AM, the Licensed Nursing Home Administrator (LNHA) disclosed that the facility was currently under a PIP for EBP training, which began in September 2024. He indicated that facility policies were being revised to improve compliance with EBP guidelines. The revised policy aims to reduce the transmission of MDROs within the facility by implementing enhanced barrier precautions, specifically through expanded use of PPE during high-contact care activities. The LNHA expressed that his expectation for nursing staff was to follow universal precautions consistently, along with any additional protective measures necessary to prevent resident exposure to potential pathogens. A record review of the Admission Record revealed the facility admitted Resident #69 on 03/29/22 with diagnoses including Benign Neoplasm of the Brain.

Based on observation, record reviews, interviews, and facility policy review, the facility failed to treat residents in a dignified manner by posting clinical data in a resident room (Resident #85) and failing to knock before entering a resident's room (Resident #69) for two (2) of 21 sampled residents. Findings Include: A review of the facility's Dignity Policy, undated, revealed, .It is the policy of this facility to promote care for the residents .in a manner and environment that maintains or enhances each resident's dignity, with respect in full recognition of his or her individuality .Special Concerns .Respecting the resident's private space and property, knocking on doors and requesting permission to enter . Resident #69 On 11/5/23 at 12:10 PM, during an observation and interview with Licensed Practical Nurse (LPN) #2, Certified Nurse Aide (CNA) #2 entered Resident #69's room without knocking on the door, addressing the resident, or introducing herself and did not explain the purpose for her visit. CNA #2 placed the resident's meal tray on the bedside table, set it up for eating, and left the room. LPN #2 remarked that CNA #2's behavior did not align with proper protocol, noting that she should have knocked on the resident's door, waited for a response, entered the room, introduced herself, and explained the purpose for the visit. On 11/5/24 at 12:25 PM, in an interview with CNA #2, she admitted that she failed to knock on Resident #69's door before entering the room while the resident was receiving medication. She explained that her familiarity with the resident made her feel comfortable enough to skip this step, believing it would not offend the resident. However, she acknowledged her awareness of the facility's policy, which requires knocking, waiting for a response, and then entering the room with an introduction. CNA #2 confirmed that this protocol was included in her training program as well as during her orientation at the facility. On 11/6/24 at 9:00 AM, the Director of Nursing (DON) confirmed that CNA #2 should have knocked on Resident #6's door before entering the room. The DON emphasized that the facility's policy supports residents' rights to a home-like environment and personal dignity. She explained that knocking and acknowledging residents before entering their room is essential for maintaining privacy and dignity, as well as demonstrating common courtesy. A record review of the Admission Record revealed the facility admitted Resident #69 on 03/29/22 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction. A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/24 revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. Resident #85 During an observation on 11/04/24 at 11:17 AM, there was clinical documentation (Resident Baseline Care Plan) containing Resident #85's name and care details posted on a wall at the head of the bed. During an interview on 11/06/24 at 10:18 AM, Resident #85's family member explained that the documentation was meant to assist CNAs and staff in providing specific care for his grandfather, such as showing the direction and timing for turning the resident to prevent pressure sores. During an interview on 11/06/24 at 3:45 PM,LPN #2 stated that information on the resident's board was intended to make staff aware of specific care needs. LPN #2 acknowledged that the documents included the resident's name, which could be considered a dignity issue, and confirmed that this information was also available in the Electronic Medical Record (EMR). During an interview on 11/07/24 at 10:18 AM, the DON stated that the information on the resident's board was intended to guide staff who may be unfamiliar with the resident's care needs. She acknowledged that the same information was accessible in the EMR. A record review of the Admission Record revealed the facility admitted Resident #85 on 04/19/24 with diagnoses including Adult Failure to Thrive. A record review of the Quarterly MDS with an ARD of 10/14/24 revealed Resident #85 had a BIMS score of 3, which indicated his cognition was severely impaired.

Based on interviews, record review, and facility policy review, the facility failed to ensure grievances raised by resident council members were consistently resolved for six (6) of (12) months. Findings Include: A review of the facility's Grievance/Complaint Policy (undated) revealed It is the policy of this facility that a resident/responsible party/legal representative has the right to voice a grievance .All grievances should be directed/reported to Social Services . A review of the facility's Resident Council Policy (undated) revealed, It is the policy of this facility that residents have the right to form a Resident Council group to elect a governing body made up of fell ow residents who preside over the resident council, conduct regularly scheduled meetings .Purpose .to identify problems within the nursing home, to help resolve the problems that have been identified . A record review of the resident council minutes revealed from 5/22/24 through 10/16/24, residents had recurring complaints regarding issues such as staff noise on the unit, staff clearing meal trays before residents finished eating, and the malfunctioning lift on the facility bus, which prevented outings. The minutes documented unresolved concerns regarding these issues over six (6) consecutive months. On 11/05/24 at 9:30 AM, during the resident council meeting, members expressed dissatisfaction with the facility's failure to resolve grievances, leading to the resignation of the council's president and vice president. The council decided to reconvene the meeting on 11/06/24 to invite department heads to discuss these unresolved issues. On 11/06/24 at 1:00 PM, the resident council met with the Dietitian, Dietary Manager, Social Worker, Activity Director, Director of Nursing (DON), and Administrator. During this meeting, residents reiterated concerns about staff noise, including talking loudly, yelling down the hall, and playing music at night. They also complained that staff frequently removed meal trays before residents could finish eating, leading some residents to hide food in napkins to ensure they had time to eat. Additionally, the residents reported that the lift on the facility bus had been broken for an extended period, preventing outings. The resident council members included Resident #1, Resident #2, Resident #10, Resident #53, Resident #57, Resident #61, Resident #66, Resident #74, Resident #79, and Resident #87. During an interview on 11/06/24 at 2:30 PM, the Social Services Director confirmed that all department heads receive copies of the resident council minutes. She explained that it is the responsibility of each department head to address and resolve complaints documented in these minutes. During an interview on 11/07/24 at 11:45 AM, the Activity Director stated that residents had not been to local shops since she began working at the facility in December. She was unaware that the facility had a van for resident transportation and stated she would discuss this with the Administrator. During an interview on 11/07/24 at 11:50 AM, the Administrator confirmed that the bus had been out of commission for approximately six (6) months due to a malfunctioning lift and door. He indicated plans to take the bus to a repair shop and acknowledged that residents could be transported in smaller groups using a facility van, which accommodates two (2) wheelchairs at a time. During an interview on 11/07/24 at 12:12 PM, the DON stated that she expects staff to allow residents ample time to finish their meals. She reported that staff had previously been in-serviced regarding noise reduction and the timing of tray removal but acknowledged that the issues had resurfaced. She noted that she would instruct staff to wait at least thirty (30) minutes after serving meals before entering resident rooms to collect trays and indicated plans to make unannounced visits to monitor compliance.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to maintain and provide a clean, sanitary, and home-like environment for one (1) of twenty-six (26) resident rooms on Unit 2. This affected Resident #2. Findings Include: A review of the facility's Environmental Policy (undated) revealed, .It is the policy of this facility to provide a safe, clean, comfortable, and homelike environment .Special Information - A determination of 'comfortable and homelike' should include whenever possible, the resident's or a representative of the resident's opinion of the living environment .'Environment' refers to any environment in the facility that is frequented by residents, including resident rooms, bathrooms . On 11/05/24 at 11:06 AM, during an observation and interview with Resident #2, the resident reported that her bathroom was not cleaned appropriately. A thick white substance (dust) was observed on the ceramic tile in the resident's bathroom and on the back of her recliner. During an interview on 11/07/24 at 11:00 AM, the housekeeper confirmed that she had failed to clean the ceramic tile in Resident #2's bathroom and to wipe down the resident's recliner. The housekeeper stated that she occasionally forgets to clean some residents' furniture and ceramic tiles but would ensure this was done daily going forward. During an interview on 11/07/24 at 11:10 AM, the Housekeeping Supervisor confirmed the facility failed to clean the dust on the ceramic tile in Resident #2's bathroom and on the back of her recliner. The supervisor stated that he conducted in-service training with staff, emphasizing that the ceramic tile in resident bathrooms and the residents' furniture should be cleaned daily to promote a home-like environment. During an interview on 11/07/24 at 11:20 AM, the Administrator stated that he expects the housekeeping staff to dust the residents' bathrooms and furniture to keep the environment clean and sanitized. A record review of the Admission Record for Resident #2 revealed an admitted [DATE], with diagnoses including Type 2 Diabetes. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/9/24 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a seatbelt as a restraint for one (1) of 21 sampled residents. Resident #44. Findings Include: A review of the facility's Restraint Policy dated 09/18/14 revealed, .It is the policy of this facility that restraints will be used as follows: Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . On 11/04/24 at 12:07 PM, during an observation, Resident #44 was sitting in a wheelchair in the day room with a seatbelt attached across the waistline. When asked if she could remove the seatbelt, Resident #44 was unable to understand the request. At 1:20 PM on 11/05/24, during an interview with Certified Nurse Aide (CNA) #1, she reported that although Resident #44 understands some instructions, she is unable to remove the seatbelt independently, and staff have to remove it for her. She confirmed that the resident is dependent on staff for Activities of Daily Living (ADLs) and requires a full-body lift with transfers. On 11/06/24 at 9:30 AM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that Resident #44 was a fall risk due to her diagnoses, but had not experienced recent falls. She added that Resident #44 is forgetful and sometimes displays behaviors in the evening with increased anxiety, attempting to get out of the chair to go home. During an additional interview at 2:10 PM on 11/06/24, LPN #1, explained that Resident #44 cannot always remove the seatbelt on demand, depending on her mood. She stated that in the evenings, the resident sometimes tries to release the seatbelt herself when she becomes intent on going home, which indicates her behavior changes. LPN #1 confirmed that if Resident #44 cannot remove the seatbelt on command, it should be considered a restraint, as it restricts her from getting out of the wheelchair. At 2:15 PM on 11/06/24, during an observation with LPN #1, Resident #44 was unable to remove the seatbelt when prompted by the nurse. Resident #44 attempted multiple times, saying, I can't do it, you do it, indicating she could not remove it independently. LPN #1 confirmed that Resident #44 could not remove the seatbelt at that time. On 11/06/24 at 2:50 PM, during an interview with Registered Nurse (RN) #1, she confirmed that Resident #44 cannot remove the seatbelt on command consistently. She noted that although Resident #44 had experienced previous falls, no falls had occurred in the past six (6) months, and she should have been re-evaluated for seatbelt use. RN #1 confirmed that if the resident cannot remove the seatbelt on command, it acts as a restraint, as it restricts her movement and ability to exit the wheelchair. She acknowledged that the facility had not considered the seatbelt a restraint, nor had an assessment or consent been completed for its use. At 4:00 PM on 11/06/24, during an interview with the Director of Nursing (DON), she explained that Resident #44 had been using the seatbelt for an extended period. The DON confirmed that the resident has a low Brief Interview for Mental Status (BIMS) score and dementia, with variable memory. She also stated that while the resident occasionally removes the seatbelt for her sister or some staff members, she has not had falls in the past six (6) months but remains a fall risk. The DON admitted that staff only check the seatbelt once a week to ensure Resident #44 can remove it independently, and she had not been informed that the resident was unable to remove the seatbelt consistently. The DON confirmed that the seatbelt was not identified as a restraint and stated the facility aims to avoid restraints. At 4:40 PM on 11/06/24, during an interview with the Administrator, he reported awareness that Resident #44 could not remove the seatbelt on command consistently. He explained that the resident's ability to remove it varies depending on the day and who is asking. The Administrator emphasized that the facility tries to avoid restraints and expects staff to assess properly for restraints. A record review of the Order Summary Report revealed Resident #44 had a physician order, dated 8/1/24 to Ensure Resident Can Remove Self-Release Alarming Seatbelt On Que . A record review of the Admission Record revealed the facility admitted Resident #44 on 07/17/20 with diagnoses including Parkinson's Disease. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/24 revealed Resident #44 had a BIMS score of (4), indicating severely impaired cognition. Section GG indicated no range of motion limitations for upper or lower extremities, and the resident used a wheelchair. Section J showed no recent falls, and Section P indicated no trunk restraint was used in or out of bed. A record review of Resident #44's medical record revealed there were no assessments for a restraint or a consent for the seatbelt use.

Based on staff, Resident Representative (RR) interview and record review, the facility failed to provide written notification to the resident or RR of a transfer to an acute care hospital for one (1) of (21) residents sampled. (Resident #7) Findings Include: A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/24 indicated Resident #7 was discharged to an acute hospital and it was anticipated she would return to the facility. On 11/06/24 at 8:38 AM, during an interview with the Director of Nursing (DON), she acknowledged that the facility did not provide written documentation to Resident #7's Representative (RR) to inform them of the resident's transfer to the hospital or the reason for the transfer. The DON confirmed that the facility calls the resident's RR by phone to inform them that the resident has been sent to the hospital. On 11/06/24 at 8:45 AM, during an interview with the RR, she stated that facility staff spoke with her in person regarding the resident being sent to the hospital and the reason for the hospitalization . The RR confirmed she did not receive written documentation related to the hospitalization . On 11/06/24 at 9:02 AM, during an interview with the Administrator, he acknowledged that the facility failed to notify Resident #7's RR in writing regarding the reason for her hospitalization . A record review of the Admission Record revealed the facility admitted Resident #7 on 03/16/10 with diagnoses including Anoxic Brain Damage.

Based on interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident receiving psychotropic medications and diagnosed with a new mental health diagnosis for one (1) of one (1) resident reviewed for PASARR. (Resident #69) Findings Include: Record review of the Resident Assessment-Coordination with PASARR Program, undated, revealed Policy: This facility coordinates assessment with the preadmission screening and resident review (PASARR) under Medicaid to ensure that individual with a mental disorder, intellectual disability or related condition receives care and services in the most integrated setting appropriate to their needs .9.Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review . A record review of Resident #69's Pre-Admission Screening (PAS), dated 03/25/22 revealed the Level II Referral Criteria had negative responses to all questions regarding the need for a Level II evaluation, indicating there was no history of mental illness or the use of psychotropic medications. A record review of Resident #69's Physician Orders List revealed Resident #69 started Seroquel on 08/07/23 for increased psychotic behaviors and hallucinations. A record review of the Admission Record revealed the facility admitted Resident #69 on 03/29/22 with diagnoses including Unspecified Psychosis Not Due to a Substance or Known Physiological Condition and Unspecified Hallucinations, both with an onset date of 08/07/23. A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/24 revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section I noted diagnoses of Anxiety Disorder, Depression, and a Psychotic Disorder (other than Schizophrenia). Section N indicated the resident had taken antipsychotic, antianxiety, and antidepressant medications during the look-back period. On 11/06/24 at 4:15 PM, during an interview with the Director of Nursing (DON), she explained the staff member who completed Resident #69's initial PAS was no longer employed at the facility, and the completion date was prior to her tenure as the DON. After reviewing the resident's medical record, she confirmed that only the PAS screening from the resident's admission was available, which did not indicate the need for a Level II evaluation. The DON acknowledged that Resident #69 experienced a change in mental health status with a new diagnosis after her admission to the facility and was prescribed a psychotropic medication, including Seroquel. She was unaware that a new diagnosis or initiation of psychotropic medication would necessitate another screening to determine if a Level II evaluation was indicated. At 4:40 PM on 11/06/24, during an interview with the Administrator, he confirmed his awareness that a Level II PASARR is required if a resident undergoes a significant change, including a new diagnosis or medication. He stated he expects his staff to adhere to these regulations.

The State Agency (SA) conducted a Complaint Investigation (CI) for CI MS # and CI MS # on 7/20/22 through 7/22/22 and substantiated CI MS # and CI MS # related to an elopement, when the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility. Resident #1 was last seen by facility staff at approximately 10:30 AM, on 7/16/22. Resident #1 was missing, unsupervised and away from the facility for approximately thirty (30) minutes. The facility Ward Clerk was notified at approximately 11:00 AM by a driver passing by on the street that Resident #1 was in her wheelchair 130 feet north of the facility's main entrance and was perpendicular to a highway at the edge of a paved driveway of a church next door to the facility. At approximately 11:01 AM, the Ward Clerk and Registered Nurse (RN)#1 located the resident and assisted her to return to the facility. Resident #1 re-entered the facility at 11:05 AM. RN#1 immediately assessed Resident #1 and documented no injuries. The resident reported she had exited out of the main door. She was not able to explain why she left the facility premises. Resident #1 had been admitted by the facility on 6/30/20 and had been assessed for wandering behaviors, but negative for elopement risk. RN#1 notified the Administrator, the Director of Nurses (DON), the Resident Representative (RR) for Resident #1 and the Nurse Practitioner (NP) who was the designee for the resident's primary physician. The NP issued orders for Resident #1 to have an Accutech Safe Wandering Device applied and monitored by the facility nursing staff. She was added to the facility list of residents at risk for elopement that was posted at all nurses stations. On 7/16/22, the facility staff, Administrator, DON and RN #1 performed a resident headcount and ensured all residents were present and accounted for and the Administrator checked all the exit doors to ensure they were closed, locked and locks were operating properly. Facility staff assessed all residents for elopement risk. The Administrator and DON updated the List of Residents at Risk of Elopement posted at each nurse's station. The Administrator investigated the incident. The DON conducted a mandatory in-service training related to Elopements and Missing Residents. The facility's failure to provide adequate supervision to prevent an elopement for Resident #1 allowed the resident to be away from the facility, unnoticed and unsupervised until a driver passing by the facility notified the facility. Resident #1 was propelling herself in her wheelchair. This situation place Resident #1 and other residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment or death. On 7/21/22, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which occurred on 7/16/22 and existed at 42 CFR(s): 483.25 (d)(1)(2)- Free of Accidents, Hazards/Supervision/Device (F689) - Scope/Severity J due to the facility's failure to provide adequate supervision to prevent an elopement for Resident #1. The SA notified the facility's Administrator of the Past Noncompliance IJ and SQC on 7/21/22 at 2:02 PM, and provided the Administrator with the IJ template. The SA notified the facility's Administrator of the Past Non-Compliance (PNC) Immediate Jeopardy (IJ) on 7/21/22 at 2:02 PM. Based on the facility's implementation of corrective actions on 7/16/22 through 7/18/22, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed as of 7/18/22, prior to the SA's entrance on 7/20/22. Based on interviews, record review, facility investigation review and facility policy review, the facility failed to provide adequate staff supervision to prevent the elopement of Resident #1, who had severe cognitive impairment, and was allowed out of the front door on 7/16/22 at 10:30 AM, by facility staff to sit outside without supervision. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised for approximately 30 minutes until a passerby observed and alerted the facility that Resident #1 was approximately 130 feet away from the facility main entrance on the side of the street. This concern was identified for one (1) of two (2) residents reviewed for wandering behavior and risk for elopement. Findings include: Record review of the facility policy titled Elopement Policy, undated, revealed .Facts to consider- Anytime the resident is successful in getting off the facility premises, this is considered to be elopement . Record review of the Facility Investigation prepared by the facility Administrator, dated 7/19/22, revealed the last staff observation of Resident #1 prior to the elopement was at 10:30 AM on 7/16/22. The facility received a telephone call from a driver passing by on the street in front of the facility at approximately 11:00 AM on 7/16/22, who notified the Ward Clerk that there was a female in a wheelchair on the street headed toward the highway. The Ward Clerk and RN#1 ran outside, immediately observed Resident #1 on the street, and assisted her back into the facility where she was immediately assessed by the RN with no injuries noted. The facility staff conducted a resident headcount and confirmed all residents on the daily census were present and accounted for. An elopement risk assessment was completed and dated 7/16/22 for Resident #1. This was reported along with the elopement incident to the designee and NP for the Resident #1's primary physician on 7/16/22 at 11:30 AM. New physician orders dated 7/16/22 were obtained for a wandering device (bracelet) to be applied to Resident #1 and a urinalysis (UA). The Resident Representative (RR) for Resident #1 was notified by RN#1 on 7/16/22 at 11:35 AM. The Administrator reported to the facility and checked all exit doors to ensure they were closed and locked and functioning properly on 7/16/22 at 1:15 PM. On 7/18/22, the Minimum Data Set (MDS) Nurse updated the Care Plan for Resident #1. The Quality Assessment and Performance Improvement (QAPI) committee held a meeting on 7/18/22 at 9:00 AM, attended by the NP as designee for the facility Medical Director who was on vacation, during which the facility policies related to elopement were reviewed. Observation on 7/20/22 at 1:00 PM, revealed the facility was situated on a tree lined street, 0.1 mile (one tenth of a mile) off a two lane highway. There was a local church on the corner of the highway and the street. The facility faced the street and was located behind the church. The north-east corner of the facility property, where the elopement occurred, had a front lawn that was shared with the hospital portion of the building. The front lawn was flat and free of holes and trip hazards. There was approximately 80 feet from the main entrance into the facility to the three (3) foot wide sidewalk which ran from the main entrance of the facility toward the parking lot adjacent the street (between the facility and the street) and turned at the parking lot and ran the length of the facility and then to the Main Entrance of the hospital. There was an approximately fifty (50) foot wide parking lot with two rows of parking, one faced the facility, and one row faced the street. From the Main Entrance of the facility to the east side driveway of the church (from the street), was approximately one hundred twenty feet. There was a well-maintained side yard on the northeast corner of the facility property with a hill which led up to the church. There was a flat area from the front of the facility to the side of the church and the church's east driveway where the ground was flat, smooth, even and the grass was short and ran all the way to the street [NAME] with no curb. The facility was connected directly to the county hospital on the south end. Observation on 7/20/22 at 1:10 PM, revealed there was one main entrance into the facility. The door was locked and the facility staff had to disengage the lock to allow entrance into the building. All other exterior doors had magnetic locking mechanism in place which prevented the doors from opening unless the fire alarm system was engaged in the event of a fire. The main entrance required staff to press a button from the front nurses station to open. On 7/20/22 at 1:30 PM, the SA attempted to contact the RR for Resident #1 without success. A message was left with a request for the RR to return a telephone call to the SA. The RR did not return a phone call to the SA. On 7/20/22 at 2:10 PM, interview and observation revealed Resident #1 was sitting up in her room in her wheelchair. She was wearing a wandering device (bracelet) on her left wrist. She was alert and able to communicate well verbally. Her mood was pleasant. She indicated to the SA she did not want to talk about the 7/16/22 elopement incident. She did not respond when asked why she had left the facility. On 7/20/22 at 3:00 PM, an interview with the facility Director of Nurses (DON) revealed she reported to the facility on [DATE] following notification by RN#1 of the elopement incident at approximately 11:35 AM. The DON confirmed RN#1 completed an incident report and performed an elopement risk assessment for Resident #1. She confirmed the staff had completed a resident headcount and all residents were accounted for and that the Administrator had personally checked all exit doors and locks to ensure they were closed, locked and locks were operating properly. The DON said she applied the safe wander bracelet to Resident #1 and confirmed proper functioning. She stated the Administrator updated the list of residents at risk for elopement at each nurses station with the name and photo of Resident #1 on 7/16/22 at approximately 1:30 PM, and had posted a notice to nursing staff with instructions that no resident was to exit the facility without direct staff supervision at approximately 2:40 PM. She stated she and the Administrator started mandatory in-service training on 7/16/22 at 2:45 PM, addressing the topics of elopement and missing residents, during which verbal instructions were issued to all staff for monitoring/assessment of all residents for elopement risk and that no resident was to exit the facility without direct staff supervision. The DON confirmed the care plan for Resident #1 was reviewed and updated by the MDS Nurse on 7/18/22 at 8:00 AM. She confirmed she had attended a QAPI committee meeting on 7/18/22 at 9:00 AM, that was attended by the NP, designee for the Medical Director (on vacation) during which the facility policy on elopement was reviewed with no changes made. Website review from (Formal name of website) revealed the weather in the area on 7/16/22 was warm and dry. The temperature was 86 to 90 degrees Fahrenheit between 9:56 AM and 11:09 AM during the timeframe when the resident was out of the facility unsupervised. The wind speed was three to five (3-5) miles per hour. On 7/20/22 at 3:30 PM, observation and an interview with Registered Nurse (RN) #1 revealed Resident #1 was last observed by facility staff at approximately 10:25 AM propelling herself in her wheelchair in the hallway. He stated that he was notified by the Ward Clerk who received a telephone call from a bystander and both immediately went outside where they saw Resident #1 on the side of the street at the driveway of the church next door, off the facility premises at approximately 11:00 AM. He stated they returned into the facility with the resident at approximately 11:05 AM, and he immediately assessed the resident and noted no injuries. He said the resident was not able to explain why she left the facility grounds on 7/16/22 or where she was going. The resident was dressed in pants, a short sleeved shirt and a pair of loafers at the time of the elopement. He said the facility staff performed a headcount of all facility residents and confirmed all were accounted for. He confirmed Resident #1 was assessed for risk of elopement on 7/16/22. He stated he notified Resident #1's NP at approximately 11:30 AM. He said new orders were received which included application of a safe wandering device, orders for routine monitoring of the device and a urinalysis. He stated he notified the Administrator and the DON and the RR for Resident #1 at approximately 11:35 AM. The SA and RN #1 toured the elopement scene and confirmed the site where the resident was located at the edge of the driveway on the east side of the church (same side of the street as the nursing home) approximately fifty (50) yards from the highway which was at the end of the street, perpendicular to the street the facility was on. He stated he had not witnessed or had staff report any exit seeking behavior by Resident #1 prior to the incident. He stated the resident's risk factors for elopement included her diagnosis of [CONDITION(S)] and wandering behavior. He added that following the incident the NP ordered a urinalysis which indicated a urinary tract infection which can result in change of behavior in the elderly. He confirmed Resident #1 was added to the list of residents at risk for elopement posted at the nurses stations on 7/16/22 at approximately 2:40 PM by the Administrator. RN #1 confirmed that the Administrator and the DON had reported to the facility following the incident on 7/16/22 at approximately 2:45 PM. A mandatory in-service training was provided by the DON and Administrator which included no residents were to be allowed outside the building without direct staff supervision. He stated the RR arrived at the facility following the incident and was involved in decisions regarding interventions. He said that generally he uses direct visual observation to monitor staff to ensure they were implementing care-planned interventions. He confirmed the name and photograph of Resident #1 was added to the list of residents at risk for elopement at the nurses stations by the Administrator. On 7/20/22 at 4:00 PM, an interview with the Administrator revealed he had been notified by staff at approximately 11:45 AM on 7/16/22 that Resident #1 had left the facility premises unattended. He said he reported to the facility on [DATE] at 1:15 PM and checked all doors to ensure proper locking and functioning. He said at approximately 1:30 PM on 7/16/22, he had updated the elopement risk list with Resident #1's name and photograph and distributed the updated list to each nurses station. He stated that at 1:44 PM on 7/16/22, he reported the elopement to the SA. He said Resident #1 was assessed for risk of elopement and a monitoring device had been ordered for and applied to Resident #1's left wrist by the DON. He stated that at approximately 2:40 PM on 7/16/22, he posted notices at the main nurses stations, adjacent to the main exit which stated no resident was to exit the facility without direct staff supervision. He said that at 2:45 PM on 7/16/22, he and the DON presented an in-service training to all staff present on elopement and missing residents, which included verbal instructions for nursing staff to monitor/audit/assess all residents for elopement risk. He said no other residents had been identified on 7/16/22 as elopement risk. He said the in-service training also included verbal instructions that no resident was to be allowed to exit the building without direct staff supervision. He said the care plan for Resident #1 was updated on 7/18/22 at 8:00 AM by the MDS Nurse. The Administrator reported that a QAPI committee meeting was held on 7/18/22 at 9:00 AM, during which the facility elopement policy was reviewed with no changes made to the policy. On 7/22/22 at 10:02 AM, an interview with the facility MDS Nurse revealed she was able to confirm that RN #1 had completed an elopement assessment of Resident #1, and new orders had been received on 7/16/22 for a wandering bracelet and monitoring. She stated she had updated the care plan for Resident #1 on 7/18/22 at 8:00 AM to include elopement risk as a 'Problem/Need' with appropriate interventions according to facility policy and resident need. She reported the resident had not had any elopement incidents since admission prior to 7/16/22. She stated Resident #1 had been assessed upon admission and every three months following for risk of elopement and did not assess as at risk. She stated she believed the resident's [CONDITION(S)] had a causal effect because the resident had not displayed exit seeking behaviors prior to the incident. She confirmed Resident #1's care plan been reviewed and revised as indicated to reflect changes as a result of the elopement incident. She confirmed there were no injuries related to the incident assessed. She confirmed changes in the resident's elopement risk was correctly identified and communicated with staff by mandatory in-service training, elopement risk lists at all nurses stations and verbal instructions by the Administrator and DON. Record review of laboratory results (urinalysis results) dated 7/17/22, Progress Notes dated 7/17/22, and Physician Orders for Resident #1 dated 7/17/22, pertinent to incident, revealed the resident had a positive result for urinary tract infection ([CONDITION(S)]). The Progress Notes review revealed the NP was notified of the urinalysis results on 7/17/22. The Physician Orders review revealed new orders dated 7/17/22 were documented for an antibiotic prescription ([MEDICATION(S)]) for [CONDITION(S)]. On 7/22/22 at 2:05 PM, a telephone interview with the NP revealed she confirmed the facility staff notified her on the afternoon of 7/16/22 of the elopement of Resident #1. She confirmed she was present at a QAPI committee meeting on 7/18/22 at 9:00 AM. She said she had issued orders for Resident #1 to have a safe wandering device applied as well as accompanying monitoring orders and a urinalysis (UA) to check for urinary tract infection. She said that upon receipt of the UA results she prescribed antibiotics for Resident #1 for a [CONDITION(S)]. The NP confirmed that a symptom of [CONDITION(S)] in the elderly was behavior changes and could have been a causal factor in the elopement incident. Record review of the Face Sheet for Resident #1 revealed Resident #1 had been admitted by the facility on 6/03/20. Resident #1 had diagnoses of Puerperal [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] following Cerebral Infarction Affecting Right Dominant Side, Urinary Tract Infection and Type 2 Diabetes Mellitus. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. She had 'Behavior' of 'Wandering' one (1) to three (3) days but was not assessed as an elopement risk. Further MDS review revealed Resident #1 required extensive one-person assistance for walking. Record review of the Care Plan for Resident #1 dated 7/16/22, revealed Problem/Need (Formal name of Resident #1) IS AT RISK FOR ELOPEMENT .GOAL .(Formal Name of Resident #1) WILL BE PROVIDED WITH A SAFE ELOPEMENT DETERRENT ENVIRONMENT .INTERVENTIONS .*2. APPLY WANDERING BRACELET . Record review of the Physicians Orders for Resident #1 revealed an order dated 7/16/22 for Check for Wander Bracelet Daily and Check for Wander Guard Battery Placement/Replacement Weekly Every Sunday. The facility implemented the following Corrective Action Plan prior to the SA's entrance on 7/20/22: Corrective Action Plan On July 16, 2022, at 10:30 AM Resident #1, exited the facility. Video evidence shows that resident exited the Station 3 door. At 11:01 AM, Ward Clerk, received a telephone call from a bystander stating that a lady in a wheelchair was on local street in front of facility heading north toward local highway. This represented an Immediate Jeopardy (IJ) and the Administrator was presented with an IJ template on July, 21, 2022 at 2:02 PM by the State Agency (SA). On July 16, 2022, at 10:30 AM Resident #1, exited the facility. Video evidence shows that resident exited the Station 3 door. At 11:01 AM, Ward Clerk, received a telephone call from a bystander stating that a lady in a wheelchair was on local street in front of facility heading north toward local highway. This represented an Immediate Jeopardy (IJ) and the Administrator was presented with an IJ template on July, 21, 2022 at 2:02 PM by the State Agency (SA). 1. On July 16, 2022, Registered Nurse #1 (RN#l), and Registered Nurse #2 (RN#2), completed a full body assessment on Resident # 1 at 11:20 AM. No injuries were noted upon assessment. 2. Family Nurse Practitioner (FNP) was notified at 11:30 AM on July 16, 2022, of resident elopement. Order was received to apply a wanderguard bracelet to Resident #1 and to collect a urine specimen for urinalysis, which was accomplished by RN #1. 3. On July 16, 2022, at 11:35, AM, RN# 1 notified Resident #1's responsible party of the elopement as well as the Director of Nursing (DON), and Administrator. 4. Vital signs were able to be obtained on July 16, 2022, at approximately 12:27 PM and were within normal range. 5. On July 16, 2022, at approximately 12:30 PM, each unit verified all residents were accounted for by facility staff present making rounds. 6. At approximately 12:45 PM, on July 16, 2022, all current elopement risk residents' wanderguard bracelets were checked for placement and proper function by the unit medication nurse. 7. On July, 16, 2022, the Administrator, arrived at the facility at approximately 1:00 PM and began the investigation. Employees with knowledge of the elopement were spoken with and asked to write statements. 8. On July 16, 2022, at approximately 1:15 PM, all exit doors, including locks and alarms were checked by the Administrator. 9. On July 16, 2022, at approximately 1:30 PM, a picture of Resident #1 was taken by the Administrator and added to the Wander Alert sheet kept at each nurses station. 10. On July 16, 2022, the Administrator sent an email at 1:44 PM notifying the SA of elopement. Attorney General's Office was notified of elopement per eForm at 2:01 PM. 11. On July 16, 2022, at approximately 2:30 PM, the Director of Nursing (DON), applied wanderguard bracelet to the right wrist of Resident #1, and verified function of the bracelet. Per facility protocol and Doctor orders: the placement of the wanderguard bracelet is checked by the nurse every shift. Battery is checked by nurse weekly. 12. On July 16, 2022 at approximately 2:40 PM, the Administrator posted a sign at the Station 3 (Main Entrance) nurses station informing staff that no resident can exit the Station 3 entrance doors without supervision. Staff present at the time the sign was posted were verbally informed of this decision. 13. Staff were inserviced on the facility elopement policy and that no resident can exit Station 3 entrance without supervision by the Administrator and DON at approximately 2:45 PM on July 16, 2022, which was required for every staff member prior to reporting to their assigned unit. No staff will be allowed to work until they have completed the inservice training. 14. On July 16, 2022 at approximately 2:50 PM, the Administrator directed the RN #1, Licensed Practical Nurse #1, etc. to review all residents for wandering/elopement behavior. No other residents were identified as an elopement risk at that time. 15. On Monday, July 18, 2022, Resident #1's care plan was reviewed and updated by the Minimum Data Set, (MOS) Coordinator at approximately 8:00 AM. 16. On Monday, July 18, 2022 at 9:00 AM members of the Quality Assurance and Performance Improvement (QAPI) committee met and discussed elopement of Resident #1 and potential modifications to the facility premises to prevent future elopements. The committee also reviewed the elopement policy and recommended no changes be made. The committee scheduled a drill to be conducted for Tuesday, July 19, 2022 and the facility will repeat elopement drills at least quarterly. Based on the steps the facility initiated and completed for this incident, the facility alleges that the immediate jeopardy was removed as of July 18, 2022, at 11:00 AM. VALIDATION The SA validated the facility's investigation of the incident and implementation of the Corrective Action Plan through observations, facility record review and interview. 1. SA validated through record review of the Progress Notes and Facility Investigation and interview with RN#1 that on July 16, 2022, Registered Nurse #1 (RN#l), and Registered Nurse #2 (RN#2), completed a full body assessment on Resident # 1 at 11:20 AM. No injuries were noted upon assessment. 2. SA validated through record review of the Progress Notes, Physician Orders, Facility Investigation and interview with the FNP that the Family Nurse Practitioner (FNP) was notified at 11:30 AM on July 16, 2022, of resident elopement. Order was received to apply a wanderguard bracelet to Resident #1 and to collect a urine specimen for urinalysis, which was accomplished by RN #1. 3. SA validated through record review of the Progress Notes, Physician Orders, Facility Investigation and interview with RN #1 and the Administrator that on July 16, 2022, at 11:35, AM, RN# 1 notified Resident #1's responsible party of the elopement as well as the Director of Nursing (DON), and Administrator. 4. SA validated through record review of the Progress Notes vital signs were able to be obtained on July 16, 2022, at approximately 12:27 PM and were within normal range. 5. SA validated through interview with the Administrator, RN #1, and LPN #1 that on July 16, 2022, at approximately 12:30 PM, each unit verified all residents were accounted for by facility staff present making rounds. 6. SA validated through interview with the DON and LPN #1 that at approximately 12:45 PM, on July 16, 2022, all current elopement risk residents' wanderguard bracelets were checked for placement and proper function by the unit medication nurse. 7. SA validated through record review of the 'Facility Investigation' and interviews with the Administrator and RN #1 that on July, 16, 2022, the Administrator, arrived at the facility at approximately 1:00 PM and began the investigation. Employees with knowledge of the elopement were spoken with and asked to write statements. 8. SA validated through interviews with the Administrator and RN #1 that on July 16, 2022, at approximately 1:15 PM, all exit doors, including locks and alarms were checked by the Administrator. 9. SA validated through observation of Wander Alert sheet at various nurses stations and interview with the Administrator that on July 16, 2022, at approximately 1:30 PM, a picture of Resident #1 was taken by the Administrator and added to the Wander Alert sheet kept at each nurses station. 10. SA validated through record review of correspondence with SA (eForm) that on July 16, 2022, the Administrator sent an email at 1:44 PM notifying the SA of elopement. Attorney General's Office was notified of elopement per eForm at 2:01 PM. 11. SA validated through interview with the DON and LPN #1 and record review of the Treatment Administration Record (TAR) 7/22 for Resident #1 on July 16, 2022, the Director of Nursing (DON), applied wanderguard bracelet to the right wrist of Resident #1, and verified function of the safe wandering bracelet. Per facility protocol and Doctor orders: the placement of the wandergaurd bracelet is checked by the nurse every shift. Battery is checked by nurse weekly. 12. SA validated through observation of the posted printed notification at the Station 3 nurses station and on July 16, 2022 at approximately 2:40 PM, the Administrator posted a sign at the Station 3 (Main Entrance) nurses station informing staff that no resident can exit the Station 3 entrance doors without supervision. Staff present at the time the sign was posted were verbally informed of this decision. 13. SA validated through record review of facility In-Service Training sheets with attached Sign-In sheets dated 7/16/22 and interviews with RN#1, DON, LPN#1, CNA#1 and CNA#2 that staff were inserviced on the facility elopement policy and that no resident can exit Station 3 entrance without supervision by the Administrator and DON beginning approximately 2:45 PM on July 16, 2022, which was required for every staff member prior to reporting to their assigned unit. No staff will be allowed to work until they have completed the inservice training. The DON interview revealed the facility continued the training until one hundred percent (100%) of staff had received the training. 14. SA validated through interview with RN #1, LPN #1, and the Administrator on July 16, 2022 at approximately 2:50 PM, the Administrator directed RN #1, Licensed Practical Nurse #1, etc. to review all residents for wandering/elopement behavior. No other residents were identified as an elopement risk at that time. 15. SA validated through record review of the care plan, dated 7/18/22 for Resident #1 and interview with the MDS Nurse that on Monday, July 18, 2022, Resident #1's care plan was reviewed and updated by the Minimum Data Set, (MDS) Coordinator at approximately 8:00 AM. 16. SA validated through record review of the committee meeting minutes with attached sign-in sheet dated 7/18/22 and interviews with the Administrator, the Maintenance Supervisor, the DON and the MDS Nurse that on Monday, July 18, 2022 at 9:00 AM members of the Quality Assurance and Performance Improvement (QAPI) committee met and discussed elopement of Resident #1 and potential modifications to the facility premises to prevent future elopements. The committee also reviewed the elopement policy and recommended no changes be made. The committee scheduled a drill to be conducted for Tuesday, July 19, 2022 and the facility will repeat elopement drills at least quarterly. Based on all the steps taken by the facility and have been successfully completed, the facility alleges the Immediate Jeopardy was removed as of 7/18/22 the facility alleges that the Immediate Jeopardy was removed as of July 18, 2022, at 11:00 AM and this represents a Past Non-compliance. The SA validated that all corrective action to remove the Immediate Jeopardy was completed as of 7/18/22, prior to entrance.