Every finding on record at Knollwood Manor

Based on policy review, record review, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when temperatures for the refrigerator, freezer and cooler, were not recorded daily. 38 residents received food trays from the kitchen. The findings include: 1. Review of the undated facility policy titled, Sanitation / Food Storage, revealed .The following rules of safe food storage have two purposes.to prevent contamination of foods.to prevent growth of bacteria that may already be in foods.Temperature control is an important part of food storage.Temperature of each freezer shall be recorded daily.Temperature of each refrigerator shall be checked and recorded each day. 2. Review of the Record of Refrigeration Temperatures, dated September 2025, revealed the facility failed to document the refrigerator temperature on the following dates: a. 9/5/2025 b. 9/18/2025 c. 9/19/2025 d. 9/20/2025 e. 9/22/2025 f. 9/23/2025 g. 9/24/2025 h. 9/25/2025 i. 9/26/2025 j. 9/27/2025 k. 9/28/2025 l. 9/29/2025 3. Review of the Record of Refrigeration Temperatures, dated September 2025, revealed the facility failed to document the freezer temperature on the following dates: a. 9/5/2025 b. 9/18/2025 c. 9/19/2025 d. 9/20/2025 e. 9/22/2025 f. 9/23/2025 g. 9/24/2025 h. 9/25/2025 i. 9/26/2025 j. 9/27/2025 k. 9/28/2025 l. 9/29/2025 4. Review of the Record of Refrigeration Temperatures, dated September 2025, revealed the facility failed to document the cooler temperature on the following dates: a. 9/4/2025 b. 9/5/2025 c. 9/18/2025 d. 9/19/2025 e. 9/20/2025 f. 9/22/2025 g. 9/23/2025 h. 9/24/2025 i. 9/25/2025 j. 9/26/2025 k. 9/27/2025 l. 9/28/2025 m. 9/29/2025 During an interview on 9/30/2025 at 2:15 PM, the Dietary Manager was asked if the temperature of the refrigerator, freezer, and cooler in the kitchen should be checked and recorded on the Record of Refrigeration Temperatures daily. The Dietary Manager stated, Yes .

Number of residents sampled:6Number of residents cited:6Based on policy review, medical record review, and interview, the facility failed to perform a complete and thorough investigation for injuries of unknown origin for 6 of 8 (Resident #8, #16, #20, #23, #25, and #35) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, ABUSE, revealed .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Incident reports shall be completed by charge nurses for all incidents to residents. These reports shall be completed for falls, bruising, skin tears .that occur or appear on each shift. Investigation of each incident shall be sufficient to determine just cause of the accident/incident with comments to prevent further injury noted on the incident report. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, and Insomnia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was not completed due to resident is rarely/never understood, which indicated Resident #8 was severely cognitively impaired. Review of the incident report dated 6/15/2025, revealed .notified by CNA [Certified Nursing Assistant] that resident [Resident #8] had superficial skin tear to R [right] forearm; unknown cause. treated per facility protocol . The facility was unable to provide an investigation with the incident report. 3. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Osteoarthritis, Osteoporosis, Depression and Anemia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #16 was severely cognitively impaired. Review of the incident report dated 8/10/2025, revealed .Resident [Resident #16] was found to have a 6 [inch] hematoma to left forearm when lunch tray taken into Room. Resident sitting up in a recliner . The facility was unable to provide an investigation with the incident report. 4. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and Transient Cerebral Ischemic Attacks. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #20 was severely cognitively impaired. Review of the incident report dated 7/19/2025, revealed .During AM [morning] care, noted a 1 cm [centimeter] s/t [skin tear] to R [right] elbow. Unknown cause, area cleaned with NS [normal saline] pat dry. Wound approxamated [approximated-to bring the edges of a wound together] and steri [sterile] strips applied will monitor q [every] shift until healed . The facility was unable to provide an investigation with the incident report. 5. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Spinal Stenosis, Chronic Kidney Disease, Diabetes, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #23 was moderately cognitively impaired. Review of the incident report dated 7/26/2025, revealed .abrasion to L [left] shin. unknown origin . The facility was unable to provide an investigation with the incident report. 6. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, and Chronic Kidney Disease. Review of the .BIMS Evaluation assessment dated [DATE], revealed a BIMS score of 0, which indicated Resident #25 was severely cognitively impaired. Review of the incident report dated 9/22/2025, revealed .Pt [patient-Resident #25] up into chair sitting in hallway, notice skin tear to left forearm . The facility was unable to provide an investigation with the incident report. 7. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Depression, Cerebral Infarction, and Anxiety. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 7, which indicated Resident #35 was severely cognitively impaired. Review of the incident report dated 8/28/2025, revealed .noted c [with] Purple Discoloration on R [right] outer, upper Arm . The facility was unable to provide an investigation with the incident report. 8. During an interview on 9/30/2025 at 11:28 AM, the Director of Nursing (DON) was asked if the facility completes investigations on skin incidents. The DON stated, On the skin we just ask the nurses. The DON was asked if the discussion with staff regarding skin incidents are documented. The DON stated, Yes, usually, and I put that with the incident report. During an interview on 10/1/2025 at 2:55 PM, the DON was asked if there were investigations to go with Resident #8, #16, #20, #23, #25, and #35's incident reports. The DON replied, .any investigation we put with the incident form. During an interview on 10/1/2025 at 4:19 PM, the Administrator was asked if an incident is documented of unknown origin is an investigation done. The Administrator responded, No, not really cause sometimes they [Residents] will scratch themselves and do whatever. The Administrator was asked if an investigation was completed on Resident #23. The Administrator stated, .unfortunately the nurse should not have put that on there [should not have put unknown origin on the incident report]. The Administrator was asked if an investigation was completed on Resident #35. The Administrators responded, [Resident #35] could tell you if someone did something to her [Resident #35 had a BIMS of 7 and was severely cognitively impaired]. The Administrator was asked if an investigation was completed on Resident #16. The Administrator replied, .we talked to her [Resident #16] about her arm, and she don't know what happened.several staff talked to her.I didn't write anything down. The Administrator was asked if an investigation was completed on Resident #25. The Administrator stated, .[Resident #25] is one that has been swinging her arms every which way. The Administrator was asked if an investigation was completed on Resident #20. The Administrator commented, .[Resident #20] probably would have said I don't know. The Administrator was asked if an investigation was completed on Resident #8. The Administrator remarked, .[Resident #8] can't tell you anything.could have done it herself. The Administrator was asked if the resident can't tell you and the staff can't tell you what happened then how do you know it's not abuse if you don't do an investigation. The Administrator responded, .I wasn't actually in the room with them .I trust the staff .

Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 6 of 6 (Resident #8, #16, #20, #23, #25, and #35) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, ABUSE, revealed .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.if an incident is determined to have unknown origin or is suspicious in nature.then that incident shall be reported to the State of Tennessee within 2 hours of the occurrence, even if the patient has osteoporosis for a diagnosis. Review of the undated facility policy titled, ACCIDENT/INCIDENT REPORTS (RESIDENTS), revealed .When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/incident should be immediately directed to the Director of Nursing or the Administrator.the incident will be reported to the TDH [Tennessee Department of Health] as per the department's guidelines. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, and Insomnia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood, which indicated Resident #8 was severely cognitively impaired. Resident #8 had no behaviors and required staff assistance for Activities of Daily Living (ADLs), bed mobility, and transfers. Review of a Progress Note dated 6/15/2025, revealed .RESIDENT [Resident #8] NOTED WITH SKIN TEAR TO RIGHT FOREARM. AREA CLEANSED WITH NS [Normal Saline], STERI-STRIPS APPLIED. ROUTINE ORDERS IN PLACE TO MONITOR STERI [sterile]-STRIPS Q [every] SHIFT, FOR S/SX [signs/symptoms] INFECTION, UNTIL HEALED. RP/MD [Responsible Party/Medical Doctor] NOTIFIED . Review of the incident report dated 6/15/2025, revealed .notified by CNA [Certified Nursing Assistant] that resident [Resident #8] had superficial skin tear to R [right] forearm; unknown cause . Review of the facility Investigation dated 6/15/2025 revealed the facility failed to report the injury of unknown origin for Resident #8 to the state agency. 3. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Osteoarthritis, Osteoporosis, Depression, and Anemia. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 6, which indicated Resident #16 was severely cognitively impaired. Resident #16 required staff's assistance with ADLs, bed mobility, and transfers. Review of a Progress Note dated 8/10/2025, revealed .RESIDENT [Resident #16] SITTING IN RECLINER CHAIR AWAITING LUNCH. 6 [inch] HEMATOMA [closed wound where blood pools under the skin] NOTED TO LEFT FOREARM. RESIDENT UNABLE TO TELL US WHAT HAPPENED. LEFT ARM WRAPPED IN AN ACE BANDAGE, ICE APPLIED AND ARM ELEVATED ON A PILLOW. SON NOTIFIED. Review of the incident report dated 8/10/2025, revealed .Resident [Resident #16] was found to have a 6 hematoma to left forearm when lunch tray taken into Room. Resident sitting up in a recliner . Review of the facility investigation revealed the facility failed to report the injury of unknown origin for Resident #16 to the state agency. 4. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Bronchitis, Alzheimer's Disease, and Transient Cerebral Ischemic Attacks. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #20 was severely cognitively impaired, required staff's assistance with ADLs, bed mobility, and was dependent of staff for transfers. Review of a Progress Note dated 7/19/2025, revealed .9:30 AM NOTED DURING AM [morning] CARE A1 [a 1] CM [centimeter] S/T [skin tear] TO RIGHT ELBOW, UNKNOWN CAUSE. AREA CLEANED WITH N/S, APPROXAMATED [approximated meaning to bring the edges of a wound together] AND STERI [sterile] STRIPS APPIED [applied] AND MONITOR Q [every] SHIFT . Review of the incident report dated 7/19/2025, revealed .During AM care, noted a 1 cm s/t to R [right] elbow. Unknown cause, area cleaned with NS pat dry. Wound approxamated [approximated] and steri strips applied will monitor q shift until healed . Review of the facility investigation revealed the facility failed to report the injury of unknown origin for Resident #20 to the state agency. 5. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Spinal Stenosis, Chronic Kidney Disease, Diabetes, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #23 was moderately cognitively impaired without behaviors, and required staff assistance for ADLSs, bed mobility and transfers. Review of a Progress Note dated 7/26/2025, revealed .RES. [Resident #23] HAS ABRASION NOTED TO LEFT SHIN. SCAB RUBBED OFF, SLIGHT BLEEDING NOTED. AREA CLEANED, FOAM DRESSING APPLIED. DRESSING TO BE CHANGED EVERY 3 DAYS AND PRN [as needed] FOR SOILAGE OR DISPLACEMENT UNTIL AREA RESOLVED. Review of the incident report dated 7/26/2025 revealed .abrasion to L [left] shin. unknown origin . Review of the facility investigation revealed the facility failed to report the injury of unknown origin to the state agency. 6. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Dementia, Hyperlipidemia, Anxiety, and Chronic Kidney Disease. Review of the .BIMS Evaluation assessment dated [DATE], revealed a BIMS score of 0, which indicated Resident #25 was severely cognitively impaired. Review of the incident report dated 9/22/2025, revealed .Pt [patient- Resident #25] up into chair sitting in hallway, notice skin tear to left forearm . No investigation was included in the report. Review of a Progress Note dated 9/28/2025, revealed .late entery [entry] 9-22-25 [9/22/2025] observed a skin tear to patient left forearm. Unknown origin, order written to clean and dress until healed. Review of the facility investigation revealed the facility failed to report the injury of unknown origin for Resident #25 to the state agency. 7. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Depression, Cerebral Infarction, and Anxiety. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 7, which indicated Resident #35 was severely cognitively impaired without behaviors and required staff assistance for ADLs, transfers and bed mobility. Review of a Progress Note dated 8/28/2025, revealed UP TO W/C [wheelchair] FOR WEEKLY WEIGHT ,WHEN CNA WAS ASSISTING BACK ABED [in bed] NOTED A PURPLE DISCOLORATION TO RIGHT, OUTER UPPER ARM, RESIDENT UNAWARE THAT IT WAS THERE. Review of the incident report dated 8/28/2025, revealed .noted c [with] Purple Discoloration on R outer, upper Arm . Review of a Progress Note dated 8/30/2025, revealed .PUPRPLE [purple] DISCOLORATION TO OUTER ASPECT OF RIGHT UPPER ARM SHOWING SIGNS OF HEALING. DENIES PAIN TO SITE. RESIDENT STATES THAT SHE DOES NOT NOTICE IT UNLESS POINTED OUT. RESIDENT CANNOT RECALL WHAT HAPPENED TO IT AT THIS TIME. Review of the facility investigation revealed the facility failed to report injury of unknown origin for Resident #35 to the state agency. 8. During an interview on 10/1/2025 at 4:19 PM, the Administrator was asked what types of incidents are required to be reported to the state. The Administrator stated, .incidents of unknown origin. The administrator was asked if these (Resident #8, #16, #20, #23, #25, and #35's) injuries should have been reported since the facility did not know how the injuries occurred. The Administrator stated, .well yes, it's unknown. The Administrator was asked should it be reported if a resident has a 6 inch hematoma of unknown origin. The Administrator stated, We didn't feel like that was something that needed to be reported . The Administrator was asked if the resident can't tell you and the staff can't tell you what happened then how do you know it's not abuse if you don't do an investigation. The Administrator responded, .I wasn't actually in the room with them .I trust the staff .

Number of residents sampled:1Number of residents cited:1 resident #22 Based on policy review, job description review, review of the facility Infection Control Program documents, medical record review, observation, and interview, the facility failed to establish and implement a program to identify, report, investigate, and control infections and communicable diseases when the Infection Preventionist (IP)/Director of Nursing (DON) failed to track organisms being treated in the facility, monitor for outbreaks and cross contamination, and failed to ensure practices to prevent the potential spread of infection were maintained when Enhanced Barrier Precautions (EBP) were not followed for 1 of 1 (Resident #22) sampled residents. This had the potential to affect 38 of 38 residents in the facility. The findings include: 1.Review of the undated facility policy titled, Infection Control Program, revealed .The goals of the infection control program are to.Decrease the risk of infection to patients and personnel.Monitor for occurrence of infection and implement appropriate control measures .Identify and correct problems relating to infection control practices.Insure compliance with state and federal regulations relating to infection control.There is on-going monitoring for infections among patients and personnel and subsequent documentation of infections that occur.Responsibility is delegated to the Infection Control Practitioner (ICP) to carry out the daily functions of the Infection Control Program Those functions are described in the ICP job description. Review of the undated facility policy titled, Infection Control Surveillance, revealed Purpose: To have knowledge of patient and employee infections so appropriate actions/follow-up may be done and to guide prevention activities.The Infection Control Practitioner does surveillance of infections among patients and employees.Nosocomial infections are reported monthly on the .Nosocomial Infection Summary.Line Listing of Patient Infections . Review of the undated facility policy titled, .Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions.signage will be posted on the door or wall of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.An order for enhanced barrier precautions will be obtained for residents with any of the following.Wounds.Implementation of Enhanced Barrier Precautions.Gowns and gloves are available near or outside the resident's room.High-Contact Resident Care Activities.Wound Care: any skin opening requiring a dressing. 2. Review of the undated and unsigned facility job description titled Infection Control Practitioner, revealed .Evaluate quality of patient care and patient outcomes as they relate to nosocomial infections; collects, prepares and analyzes nosocomial infection data.Does on-going monitoring of nosocomial infections.Conducts outbreak investigation and initials control measures. 3. Review of the NOSOCOMIAL INFECTION SUMMARY, monitoring documents dated June 2025, July 2025, August 2025, and September 2025, revealed .INFECTION.UTI [urinary tract infection].RESPIRATORY .WOUNDS DECUBITIS [bed sore].INFECTIONS OF THE EYE/CONJUNCTIVITIS.GASTROENTERITIS [intestinal infection].SEPSIS.OTHER . Review of the LINE LISTING OF PATIENT INFECTIONS, monitoring documents dated 8/2025 and 9/2025, revealed Name/Rm# [Room number] .DX [Diagnosis].TX [Treatment] Date/C&S [Culture and Sensitivity].TREATMENT .ACTION IF NEEDED .NI [Nosocomial Infection] CAI [Community Acquired Infection] . Further review of the facility NOSOCOMIAL INFECTION SUMMARY and LINE LISTING OF PATIENT INFECTIONS revealed there was no documentation that named the organism that was being tracked. Review of the facility Tracking and Trending documentation for July 2025, revealed 1 UTI on the Corner Hall and 5 UTIs on the New Hall. During an interview on 10/1/2025 at 1:00 PM, the IP/DON confirmed that she does not track infections by the organisms in the INFECTION CONTROL PROGRAM. The IP/DON was asked to provide documentation she was tracking infections to rule out cross contamination or outbreak of infection for 5 UTIs occurring on the same hallway in the month of July. The IP/DON stated, Most of ours [UTIs] are from E coli [Escherichia coli]. The IP/DON was unable to provide documentation that the facility monitors for cross contamination between residents. 4. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Deep Tissue Damage of Left Heel, Osteomyelitis, and Malignant Neoplasm of Prostate. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 9/22/2025, revealed a BIMS score of 13, which indicated Resident #22 had intact cognition. Review of the Physician's Order dated 9/17/2025, revealed .ENHANCED BARRIER PRECAUTIONS. Review of the Physician's Order dated 9/25/2025, revealed .CLEANSE LEFT POSTERIOR SHOULDER.COVER WITH FOAM DRESSING. Observation of Resident #22's door on 9/29/2025 at 9:04 AM, 11:30 AM, 12:24 PM, and 2:33 PM, and on 9/30/2025 at 8:06 AM, 3:30 PM, and 3:50 PM, revealed there was no Enhanced Barrier Precaution (EBP) signage posted identifying that Resident #22 was in EBP. Observation in Resident #22's room on 9/30/2025 at 3:36 PM, revealed Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B entered Resident #22's room, donned gloves, failed to don gown, loosened the dressing to the left shoulder exposing the wound, recovered the wound, removed gloves and exited the room. During an interview on 9/30/2025 at 3:38 PM, LPN A was asked if Resident #22 was in EBP. LPN A stated, Yes. LPN A was asked when PPE should be worn for Resident #22's care. LPN A stated, When I change the dressing . During an interview on 9/30/2025 at 3:50 PM, the Assistant Director of Nursing (ADON) confirmed EBP signage should have been on Resident #22's door identifying the type of isolation. The ADON was asked when removing a dressing to view a wound, what PPE should be worn. The ADON confirmed a gown, and gloves should be worn with open wounds.

Based on facility policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held on admission and quarterly for 2 of 12 (Resident #5 and #19) sampled residents reviewed for Care Plan meetings. Based on facility policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held on admission and quarterly for 2 of 12 (Resident #5 and #19) sampled residents reviewed for Care Plan meetings. The findings include: 1. Review of the undated facility policy titled, Care Plan Meeting Policy, revealed .To ensure each resident receives a person-centered, up-to-date plan of care developed by an interdisciplinary team, with resident/family participation, per federal and state standards.A care plan meeting will be held within 7 days following a new comprehensive assessment. Care plan meetings will be reviewed and updated at least quarterly.The resident, and/or the resident's family or legal representative, should be invited and encouraged to participate.A written summary of the meeting must be entered into the resident's record.including participant names and roles.If the resident or representative chooses not to participate, that decision.must be documented.Residents have the right to be involved in decisions about their care.The facility administrator or designated quality manager will periodically audit care plan meetings and documentation for compliance. 2. Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE], with diagnoses including Traumatic Subarachnoid Hemorrhage, Convulsions, Cerebral Infarction, and Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 13 on the Brief Interview of Mental Status (BIMS) assessment, which indicated Resident #5 was cognitively intact. The facility was unable to provide documentation that Resident #5 and/or her representative was invited to the Care Plan meeting after the completion of the 12/17/2024 quarterly MDS assessment. Review of the annual MDS assessment dated [DATE], revealed Resident #5 scored a 1 on the BIMS assessment, which indicated Resident #5 was severely cognitively impaired. The facility was unable to provide documentation that Resident #5 and/or her representative was invited to the Care Plan meeting after the completion of the 3/1/2025annual MDS assessment. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 12 on the BIMS assessment, which indicated Resident #5 was moderately cognitively impaired. The facility was unable to provide documentation that Resident #5 and/or her representative was invited to the Care Plan meeting after the completion of the 8/26/2025 quarterly MDS assessment. Review of the medical record revealed Resident #5 Care Plan was last reviewed and revised on 9/15/2025 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Fracture of Right Femur, Fracture of Left Femur, and Seizures. Review of admission MDS assessment dated [DATE], revealed Resident #19 scored a 12 on the BIMS assessment, which indicated Resident #19 was moderately cognitively impaired. Review of the medical record revealed Resident #19's Care Plan was reviewed and revised on 9/15/2025. The facility was unable to provide documentation that Resident #19 and/or his representative was invited to the admission Care Plan meeting after the completion of the 8/21/2025 admission MDS assessment. During an interview on 9/30/2025 at 4:55 PM, the Interim Director of Nursing (DON) was asked, can you provide any documents to show that a care plan meeting was held with Resident #5 and/or her representative following the assessments on 8/26/2025, 3/1/2025, and 12/17/2024. The Interim DON searched her computer for each date given and verified she was unable to provide any documentation that the care plan meetings were completed. The Interim DON was asked how soon should a care plan meeting be scheduled with the resident and/or their representative after admission. The Interim DON stated, .2-3 weeks. The Interim DON was asked if a care plan meeting had been scheduled or completed for Resident #19. The DON stated, .It had not.

Based on medical record review and interview, the Administrator failed to administer the facility in a manner to ensure resident care plans were revised and to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 of 1 resident (Resident #39) who was an elopement risk. The administrator's failure to ensure resident care plans were revised and to provide supervision and keep residents safe placed the residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The findings include: Review of the medical record revealed Resident #39 eloped from the facility a total of 7 times from 4/23/2022 through 5//23/2022. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Continued review revealed Resident #39's care plan was not updated after each elopement attempt to reflect the resident's current needs. The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: During an interview on 7/13/2022 at 4:30 PM, the Administrator confirmed Resident #39 went out of the building without supervision. She stated she was aware of her history of successful elopement attempts at a previous facility. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education that began on 7/12/2022 and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through observation and interview the exit doors at the end of the ward hall alarmed when a wander guard was within 3 feet of the exit door while opened and when the surveyor walked through the exit door. 3.) The surveyors verified through review of the list of wandering/elopement residents dated 7/12/2022. 4). The surveyors verified the care plans for residents at risk for elopement were updated with current interventions. 5). The surveyors verified the facility conducted an ad hoc QAPI meeting on 7/12/2022.

Based on facility documentation, facility policy review, medical record review, and interview, the facility failed to revise a wandering/elopement care plan for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). The facility failed to update Resident #39's care plan with new interventions which resulted in an elopement from the facility on 5/23/2022 with a fall with major injury, a Right Femoral neck fracture (hip fracture). The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-657. The facility was cited a F-657 at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-657 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility's undated policy titled, Policy for Care Plan Updates and Review, revealed, .Review for your department, initial assessment, current (last) update, and any mini assessments (assessments for identifying residents at risk or any other tool utilized as a supplement to the MDS [Minimum Data Set]) and discipline specific assessment tools completed on admission .Update the assessment so that it describes the functional and dysfunctional changes since the last assessment .Review the most recent care plan .Modify or re-write problems/goals/approaches for the department based upon future needs of the resident described in your progress note. Confer with other pertinent departments if appropriate .At care plan conference, integrate your input with other departments . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 required a wander guard daily because she exhibited behaviors of wandering. Continued review revealed the resident required supervision with walking in the room, in corridor and with locomotion on/off the unit. Review of Resident #39's care plan dated 3/21/2022 revealed .CODE ALERT BRACELET R/T [RELATED TO] ELOPEMENT RISK .Alert staff to resident's wandering behavior .If resident elopes from facility protocol for locating resident .Monitor and document resident behavior at least twice daily .Report increase in negative findings to physician . Review of Resident #39's physician notes dated 3/9/2022 revealed Resident #39 was prescribed a Code Alert Bracelet related to a history of elopement at another facility. Review of Resident #39's Progress Notes dated 4/23/2022 revealed .RES. [Resident] WENT OUT BACK DOOR AND DOWN THE RAMP, WAS RE-DIRECTED BACK IN PER STAFF. RES. HAS BEEN WALKING ALL OVER THE FACILITY TODAY. GETS VERY AGITATED WHEN STAFF RE-DIRECTS. AT THIS TIME RES. IS SITTING IN HER RECLINER . Review of Resident #39's Progress Notes dated 4/24/2022 revealed .RES. WENT OUT FRONT DOOR WITH RW [Rolling Walker] ALARM SOUNDED D/T [due to] WANDER GUARD. RE-DIRECTED BACK IN . Review of Resident #39's Progress Notes dated 5/6/2022 revealed .DOOR ALARM SOUNDED AND TECHS WENT TO FRONT DOOR. RESIDENT WAS FOUND ABOUT 100 FEET OUTSIDE FACILITY . Review of Resident #39's Progress Notes dated 5/20/2022 revealed .RES. ELOPED OUT THE DOOR ON THE WARDS HALL, WAS RE-DIRECTED BACK IN. RES. NOW SITTING IN DR [dining room] FOR SUPPER . Review of Resident 39's Progress Notes dated 5/21/2022 revealed .RES. HAS BEEN WANDERING AROUND FACILITY ALL DAY AT A FAST PACE. DID ELOPE OUT THE PATIO DOOR. RES. DID REFUSE TO COME BACK IN FOR CNA [Certified Nursing Assistant], BUT NURSE RE-DIRECTED RES. BACK IN. RES. VERY AGITATED WHEN RE-DIRECTED FOR ANY REASON. RES. AT THIS TIME SITTING IN THE BIRD ROOM . Review of Resident #39's Progress Notes dated 5/22/2022 revealed .RES. FOLLOWED STAFF OUT BACK DOOR, WAS RE-DIRECTED BACK IN AND ENCOURAGED TO SIT IN HER RECLINER. RES. HAS STAYED IN HER ROOM FOR A WHILE . Review of Resident #39's Progress Notes dated 5/23/2022 revealed .FOR APPROX 6:30 PM RESIDENT CODE ALERT ALARM WAS HEARD SOUNDING TO ALERT STAFF OF EXIT OUTWARD HALL BACK DOOR. CNA TO BACK DOOR AND RESIDENT OBSERVED WALKING ACROSS BACK PARKING LOT. WHEN CNA CALLED FOR RESIDENT TO STOP SHE TOOK OFF RUNNING, SHE THEN TRIPPED OVER CONCRETE CAR STOP AND STRUCK HER HEAD ON HANDICAPPED PARKING SIGN ON THE WAY DOWN. SHE THEN LANDED ON HER RIGHT-SIDE HIP AREA AND WHEN NURSES STAFF GOT TO HER FOR ASSESSMENT SHE COMPLAINED OF RIGHT LEG AND HIP PAIN AND COULD NOT STRAIGHTEN HER RIGHT LEG. SHE WAS KEPT IN THE POSITION SHE WAS FOUND IN UNTIL EMS [Emergency Medical Service] ARRIVED FOR TRANSPORT. SON WAS CONTACTED BY [named nurse] TO NOTIFY OF FALL AND THEN AGAIN BY [named nurse] TO CONFIRM AS TO WHICH HOSPITAL FAMILY WOULD PREFER TRANSPORT TO THEY CHOSE [named hospital]. SHE DID NOT APPEAR TO HAVE ANY OTHER INJURY NOTED INCLUDING NO INJURY NOTED TO HEAD DESPITE STRIKING HEAD. WILL AWAIT FURTHER REPORT FROM HOSPITAL . Review of Resident #39's Progress Notes dated 5/24/2022 revealed .REPORT RECEIVED FROM NURSE [named nurse] FROM ED [Emergency Department][named hospital]. RESIDENT NOTED BROKEN RT [right]. HIP. SX [surgery] SCHEDULED TOMORROW 5/24/22 AT [named hospital]. FAMILY PRESENT AT [named resident] AND AWARE OF ALL FINDINGS PER [named nurse] . Review of the History and Physical dated 5/23/2022 revealed, XXX[AGE] year-old female presents to clinic today from the Emergency Department for right hip pain. She stated that yesterday evening while walking outside she tripped and fell and landed on right hip. She had immediate pain and swelling to the area and was transported via EMS [emergency medical services] to [named hospital] for she was seen in the emergency department and received x-rays. X-rays revealed a fracture of the right femoral neck .Patient reports decreased range of motion secondary to pain as well as a palpable deformity along the lateral hip at the proximal femur area . During an interview on 7/12/2022 at 11:19 AM, the MDS Coordinator confirmed Resident #39's care plan had not been updated after each elopement since 3/21/2022 when she was admitted to the facility. Continued interview she confirmed there should be new interventions in place after each elopement event. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education completed on 7/12/2022 and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through review of the care plans completed on 7/12/2022 residents were identified as risk for wandering and elopement and interventions were put in place or updated.

Based on facility documentation review, facility policy review, medical record review, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 2 sampled residents (Resident #39) reviewed for wandering and elopement risk (Residents who have a history of leaving or trying to leave the facility, or have wandered or have potential to wander into unsafe areas), placing the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident). The facility's failure to supervise Resident #39 resulted in an elopement from the facility on 5/23/2022 and a fall with major injury resulting in a Right Femoral neck fracture (hip fracture). The facility also failed to prevent a fall for 1 of 7 sampled residents (Resident #16) which resulted in a major injury, a left Femoral Neck fracture (hip fracture), which caused an actual harm but did not rise to the level of IJ. The Administrator was notified of the Immediate Jeopardy on 7/12/2022 at 12:47 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-689. The facility was cited a F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 4/23/2022 to 7/12/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 7/12/2022 at 7:29 PM. The corrective actions were validated on site by surveyors on 7/12/2022. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: Review of the facility documentation 9/2017 revealed .Upon discovery of a missing resident: Alert all staff on the unit. Conduct a quick but thorough search of the unit and logical places where resident may have gone. If a resident cannot be located, the Nurse in charge of the area shall be responsible for notifying the Administrator and page overhead. This will alert all staff that a resident is missing. Immediate attempts shall be made to determine where the resident was last seen and what the resident was wearing . Review of the undated facility policy titled, Wandering/Eloping Patients revealed .Patients shall be assessed upon admission to determine the possibility of the patient trying to leave the facility. If there is a concern, a Code Alert Bracelet shall be placed on the patient, the patient walker, or the patient wheelchair as per the determined need. The Code Alert Bracelet will set off the Alarm should the patient go out any exit door. If a patient should exit the building without the knowledge of staff and it is discovered, a facility-wide search shall be made for the patient, both inside the facility and the area of the entire campus grounds. If the patient is not found within 15 minutes, the police shall be called, and the Administrator notified if not on the premises. The patient's family shall be notified . Review of the facility undated policy titled, Fall Prevention Policy, revealed, .[Named Facility] wants to provide a safe environment for all residents. And therefore utilizes different steps to prevent harm .A fall risk assessment shall be done on any resident who is considered at risk for falls .The Director of Nursing shall do an investigation following each fall to determine if proper interventions have been implemented; to ensure the care plan has been updated; and to monitor the results of the planned interventions .Incident reports shall be completed upon any incidental fall and charge nurses shall monitor patient for any sign of injury. Family member/responsible party shall be notified regarding the incident; the patient physician; the pharmacy consultant; and the therapy department .Resident-centered interventions shall be implemented following each fall to try to reduce the resident's risk of future falls .Falls shall be reviewed by the QA Committee during each meeting to monitor the number of falls, the effectiveness of the interventions, and to review and assess for any patterns that might be pertinent to the cause of any of the falls . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances and [CONDITION(S)]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 required a wander guard daily because she exhibited behaviors of wandering. Continued review revealed the resident required supervision with walking in the room, in corridor and with locomotion on/off the unit. Review of Resident #39's care plan dated 3/21/2022, revealed .CODE ALERT BRACELET R/T [RELATED TO] ELOPEMENT RISK .Alert staff to resident's wandering behavior .If resident elopes from facility protocol for locating resident .Monitor and document resident behavior at least twice daily .Report increase in negative findings to physician . Review of Resident #39's physician notes dated 3/9/2022, revealed Resident #39 was prescribed a Code Alert Bracelet related to a history of elopement at a previous facility. Review of Resident #39's Progress Notes dated 4/23/2022, revealed .RES. [Resident] WENT OUT BACK DOOR AND DOWN THE RAMP, WAS RE-DIRECTED BACK IN PER STAFF. RES. HAS BEEN WALKING ALL OVER THE FACILITY TODAY. GETS VERY AGITATED WHEN STAFF RE-DIRECTS. AT THIS TIME RES. IS SITTING IN HER RECLINER . Review of Resident #39's Progress Notes dated 4/24/2022, revealed .RES. WENT OUT FRONT DOOR WITH RW [Rolling Walker] ALARM SOUNDED D/T [due to] WANDER GUARD. RE-DIRECTED BACK IN . Review of Resident #39's Progress Notes dated 5/6/2022, revealed .DOOR ALARM SOUNDED AND TECHS WENT TO FRONT DOOR. RESIDENT WAS FOUND ABOUT 100 FEET OUTSIDE FACILITY . Review of Resident #39's Progress Notes dated 5/20/2022, revealed .RES. ELOPED OUT THE DOOR ON THE WARDS HALL, WAS RE-DIRECTED BACK IN. RES. NOW SITTING IN DR [dining room] FOR SUPPER . Review of Resident 39's Progress Notes dated 5/21/2022, revealed .RES. HAS BEEN WANDERING AROUND FACILITY ALL DAY AT A FAST PACE. DID ELOPE OUT THE PATIO DOOR. RES. DID REFUSE TO COME BACK IN FOR CNA [Certified Nursing Assistant], BUT NURSE RE-DIRECTED RES. BACK IN. RES. VERY AGITATED WHEN RE-DIRECTED FOR ANY REASON. RES. AT THIS TIME SITTING IN THE BIRD ROOM . Review of Resident #39's Progress Notes dated 5/22/2022, revealed .RES. FOLLOWED STAFF OUT BACK DOOR, WAS RE-DIRECTED BACK IN AND ENCOURAGED TO SIT IN HER RECLINER. RES. HAS STAYED IN HER ROOM FOR A WHILE . Review of Resident #39's Progress Notes dated 5/23/2022, revealed .FOR APPROX 6:30 PM RESIDENT CODE ALERT ALARM WAS HEARD SOUNDING TO ALERT STAFF OF EXIT OUTWARD HALL BACK DOOR. CNA TO BACK DOOR AND RESIDENT OBSERVED WALKING ACROSS BACK PARKING LOT. WHEN CNA CALLED FOR RESIDENT TO STOP SHE TOOK OFF RUNNING, SHE THEN TRIPPED OVER CONCRETE CAR STOP AND STRUCK HER HEAD ON HANDICAPPED PARKING SIGN ON THE WAY DOWN. SHE THEN LANDED ON HER RIGHT-SIDE HIP AREA AND WHEN NURSES STAFF GOT TO HER FOR ASSESSMENT SHE COMPLAINED OF RIGHT LEG AND HIP PAIN AND COULD NOT STRAIGHTEN HER RIGHT LEG. SHE WAS KEPT IN THE POSITION SHE WAS FOUND IN UNTIL EMS [Emergency Medical Services] ARRIVED FOR TRANSPORT. SON WAS CONTACTED BY [named nurse] TO NOTIFY OF FALL AND THEN AGAIN BY [named nurse] TO CONFIRM AS TO WHICH HOSPITAL FAMILY WOULD PREFER TRANSPORT TO THEY CHOSE [named hospital]. SHE DID NOT APPEAR TO HAVE ANY OTHER INJURY NOTED INCLUDING NO INJURY NOTED TO HEAD DESPITE STRIKING HEAD. WILL AWAIT FURTHER REPORT FROM HOSPITAL . Review of Resident #39's Progress Notes dated 5/24/2022, revealed .REPORT RECEIVED FROM NURSE [named nurse] FROM ED [Emergency Department][named hospital]. RESIDENT NOTED BROKEN RT [right]. HIP. SX [surgery] SCHEDULED TOMORROW 5/24/22 AT [named hospital]. FAMILY PRESENT AT [named resident] AND AWARE OF ALL FINDINGS PER [named nurse] . Review of the History and Physical dated 5/23/2022, revealed XXX[AGE] year-old female presents to clinic today from the Emergency Department for right hip pain. She stated that yesterday evening while walking outside she tripped and fell and landed on right hip. She had immediate pain and swelling to the area and was transported via EMS to [named hospital] for she was seen in the emergency department and received x-rays. X-rays revealed a fracture of the right femoral neck .Patient reports decreased range of motion secondary to pain as well as a palpable deformity along the lateral hip at the proximal femur area . During an interview 7/12/2022 at 2:36 PM, CNA #5 stated Resident #39 did wander the building because she was confused and there were times she would go to the exit door and staff would redirect or she would exit the building and staff would have to go after her and bring her back in. Resident #39 had a wander guard. It would go off if a resident tried to open the door; if they were near the door; if it was opened; and if they went outside. Continued interview revealed the alarm was heard throughout the building. During an interview on 7/12/2022 at 4:10 PM, CNA #4 stated Resident #39 was not assigned to her but had heard the alarm and was the one who arrived at the door where Resident #39 eloped. Resident #39 had gone out the door on the ward side in the middle hall in the evening. When CNA #4 heard the alarm she went to the box at the round station to figure out which door was alarming. Once CNA #4 figured out which door it was CNA #4 went down the hall and saw Resident #39 outside and opened the exit door and called Resident #39's name. Resident #39 started running towards the adjacent building and tripped over a concrete parking block which caused her to fall and hit her head on the handicap sign. Resident #39 had left the building on occasions but staff had brought her back inside the building without injuries. During an interview on 7/12/2022 at 6:43 PM, LPN #3 stated on the day she fell Resident #39 was wandering in the building. Resident #39 did not like redirection. LPN #3 did not see her leave the facility but heard the alarm go off. CNA #4 told LPN #3 when she got to the door she saw Resident #39 outside and yelled her name and the resident started running and then tripped over the parking medium and fell . LPN #3 stated she had assessed Resident #39 and called EMS. During an interview on 7/12/2022 at 2:26 PM, the Director Of Nursing (DON) stated she had known Resident #39 was a wanderer. The DON was not at the facility as she had already gone home for the day. The DON stated, Typically, if the alarm goes off we are out the door. I'm sure we had conversations about the wandering. Talked to son about psych services. He refused and said she [Resident #39] was at her baseline. The DON was unaware Resident #39 was leaving the facility unattended and thought staff was redirecting her. When asked if she had reviewed the nurses notes explaining Resident #39's exit seeking behaviors and elopements, the DON stated, I do not come to work during the day and have time to read the nurses notes. The DON confirmed Resident #39's leaving the building was considered elopement from the facility. During an interview on 7/13/2022 at 4:30 PM, the Administrator confirmed Resident #39 went out of the building on the ward door on the middle hall without supervision. The surveyors verified acceptable Immediate Action Removal Plan on 7/12/2022 by: 1.) The surveyors verified through review of the education completed for staff on duty on 7/12/2022, and interviews with various Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Housekeeping, and Maintenance regarding verifying elopement, missing person, policies, and procedures. 2). The surveyors verified through observation and interview the exit doors at the end of the ward hall alarmed when a wander guard was within 3 feet of the exit door while opened, and when the surveyor walked through the exit door. 3.) The surveyors verified the facility's updated list of wandering/elopement residents dated 7/12/2022. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances and History of Falls. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 0, which indicated severe cognitive impairment. Review of Resident #16's medication administration record (MAR) dated 7/2021 revealed .Non-Skid Pad to Recliner at all times for risk of fall .Non-skid Mat in front of recliner at all times . Review of Resident #16's care plan dated 7/7/2021 .Fall: I WILL HAVE A DECREASE IN THE NUMBER OF FALLS X 90 DAYS .1 NON-SKID SOCKS AT ALL TIMES .NON-SKID MESH TO RECLINER OR WHEELCHAIR R/T FALL RISK . Review of the fall investigation dated 7/26/2022 revealed Resident #16 did not have the ordered non-slip mat on the recliner or the non-skid mats on the floor in front of the recliner at the time of the fall. Review of Resident #16's progress notes dated 7/26/2021, revealed .CALLED FOR ASSISTANCE TO ROOM 18[Resident #16's room], RESIDENT FOUND IN LEFT SIDE LYING POSITION. RESIDENT ASSESSED PRIOR TO STANDING STATES NO PAIN. NO OBVIOUS INJURY NO REDNESS OR BRUSING NOTED. ASSISTED TO STANDING POSITION .DID COMPLAIN OF MILD PAIN LEFT KNEE/LEG UPON STANDING NO DEFORMITIES NOTED. [named family member] NOTIFIED. DOES NOT WISH FOR PATIENT TO GO TO ER [emergency room ]. STATES IF X-RAY HAS TO BE DONE PLEASE CALL MOBILE X-RAY . Review of Resident #16's progress notes dated 7/26/2021 revealed .@ [at] 8:56 PM - WHILE ASSISTING RESIDENT TO BED, RESIDENT NOTED TO BE UNABLE TO BEND LT. [left] KNEE TO TRANSFER NORMALLY TO STANDING POSITION. RESIDENT VERBALLY STATED, I CANT STAND UP. RESIDENT ASSISTED TO STANDING POSITION AND RESIDENT RETAINED THE POSTURE OF A STRAIGHT LEG BILATERALLY THE ENTIRE TRANSFER. RESIDENT NOTED TO HAVE A LIMP DURING AMBULATION. RESIDENT UNABLE TO PUT WEIGHT ON LT. LEG. MOBILE IMAGES CALLED AND STAT 5-VIEW BILATERAL HIP INCLUDING PELVIS WITH BILATERAL TIBULA/FIBULA X-RAYS ORDERED TO RULE OUT INJURY. [named family member] NOTIFIED OF ORDERS. DAUGHTER EXPRESSED THAT IF THERE WERE ANY INJURIES TO CALL HER BACK REGARDLESS OF TIME AND NOTIFY HER. THIS LPN VOICED UNDERSTANDING OF TEACHING . Review of Resident #16's progress notes dated 7/27/2021 revealed .THIS LPN CALLED [named hospital] AND GAVE VERBAL REPORT TO [named nurse] REGARDING RESIDENTS STATUS. FLOOR NURSE VERBALIZED UNDERSTANDING . Review of the Mobile Images dated 7/27/2021 revealed .Pelvis, and bilateral hip 5 view .There is acute fracture involving left femoral neck . During an interview on 7/12/2022 at 6:35 PM, LPN #3 immediately went into the room and saw her (Resident #16) lying on the floor. LPN #3 did not recall seeing a non-skid mat on the floor in front of the recliner or a non-skid mats in the recliner. During an interview on 7/12/2022 at 5:44 PM, the DON confirmed there were no non-skid mats in front of the recliner or a non-skid mat in the recliner at the time of the fall. The DON stated, Staff did not follow the care plan. The DON also confirmed the intervention after the fall was to re-educate the staff of the fall precautions for Resident #16. The DON stated if the staff had followed the care plan interventions it would have prevented the fall which caused Resident #16's injury. During an interview on 7/14/2022 at 8:00 AM, LPN #4 stated he had observed LPN #3 in Resident #16's room while the resident was on the floor. LPN #3 was already conducting an assessment of Resident #16 and she did not find any acute injuries. After two hours LPN #4 with a CNA, was helping Resident #16 and noticed she could not bend her left leg or bear weight on it. Mobile x-ray was notified and it was discovered she had a left hip fracture. LPN #4 stated he did not see any non-skid mats in front of the recliner or on the recliner at the time of the resident's fall.

Based on facility policy review, medical record review, observation, and interview the facility failed to implement a fall care plan for 1 of 7 sampled residents (Resident #16) which resulted in a left Femoral Neck fracture (hip fracture) which caused harm, and the facility also failed to implement a behavioral care plan for [CONDITION(S)] for 1 of 25 sampled residents (Resident #8) which did not rise to the level of G. The findings include: Review of the facility's undated policy titled, Policy for Care Plan Implementation, revealed, The resident assessment process shall be completed by the following steps: 1. Initial assessment(s) of resident- completed by each department, utilizing discipline specific assessment tools that recognize factors that place the resident at risk for negative outcome and that also supplement the MDS [Minimum Data Set] in gathering baseline data on mental, psychosocial, and physical functional status .At care planning conferences, offer input for each Protocol triggered and assist with integration with other departments . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 0 which indicated severe cognitive impairment. Review of Resident #16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Non-skid Mat in front of recliner at all times . Review of Resident #16's care plan dated 7/2/2021 .Fall: I WILL HAVE A DECREASE IN THE NUMBER OF FALLS X 90 DAYS. PRESSURE PAD ALARM AT ALL TIMES WHEN UNATTENDED RELATED TO RISK FOR FALLS SECONDARY TO NEW PLACEMENT. NON-SKID SOCKS AT ALL TIMES .STAFF EDUCATION RELATED TO RESIDENTS FALL PREVENTIVE INTERVENTIONS NON-SKID MESH TO WHEELCHAIR R/T FALL RISK . Review of Resident #16's progress notes dated 7/26/2021 revealed, .CALLED FOR ASSISTANCE TO room [ROOM NUMBER][Resident #16's room], RESIDENT FOUND IN LEFT SIDE LYING POSITON .RESIDENT ASSESSED PRIOR TO STANDING STATES NO PAIN. NO OBVIOUS INJURY NO REDNESS OR BRUSING NOTED. ASSISTED TO STANDING POSITION .DID COMPLAIN OF MILD PAIN LEFT KNEE/LEG UPON STANDING NO DEFORMITIES NOTED. [named family member] NOTIFIED. DOES NOT WISH FOR PATIENT TO GO TO ER [emergency room ]. STATES IF X-RAY HAS TO BE DONE PLEASE CALL MOBILE X-RAY . Review of Resident #16's progress notes dated 7/26/2021 revealed .@ [at] 8:56 PM - WHILE ASSISTING RESIDENT TO BED, RESIDENT NOTED TO BE UNABLE TO BEND LT. [left] KNEE TO TRANSFER NORMALLY TO STANDING POSITION. RESIDENT VERBALLY STATED, I CANT STAND UP. RESIDENT ASSISTED TO STANDING POSITION AND RESIDENT RETAINED THE POSTURE OF A STRAIGHT LEG BILATERALLY THE ENTIRE TRANSFER. RESIDENT NOTED TO HAVE A LIMP DURING AMBULATION. RESIDENT UNABLE TO PUT WEIGHT ON LT. LEG. MOBILE IMAGES CALLED AND STAT 5-VIEW BILATERAL HIP INCLUDING PELVIS WITH BILATERAL TIBIA/FIBULA X-RAYS ORDERED TO RULE OUT INJURY. [named family member] NOTIFIED OF ORDERS. DAUGHTER EXPRESSED THAT IF THERE WERE ANY INJURIES TO CALL HER BACK REGARDLESS OF TIME AND NOTIFY HER. THIS LPN [Licensed Practical Nurse] VOICED UNDERSTANDING OF TEACHING . Observation in Resident #16's room on 7/12/2022 at 6:15 PM, revealed the recliner did not have a non-skid mat in the chair nor a non-skid mat in front of the recliner on the floor. Observation and interview in Resident #16's room on 7/12/2022 at 6:18 PM with the Director Of Nursing (DON), she confirmed there were no non-skid mats on the recliner or in front of the recliner. During an interview on 7/12/2022 at 5:44 PM, the DON confirmed there were no non-skid mats present at the time of the fall. She stated, Staff did not follow the care plan. The DON stated, If the staff had followed the care plan interventions, it would have prevented the fall which caused Resident #16's injury. During an interview on 7/12/2022 at 6:35 PM, LPN #3 stated she did not recall seeing any non-skid fall mats on the floor or a non-skid mat in the recliner. Review of the medical record for Resident #8 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated severe cognitive impairment. Further review of the MDS revealed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the hospital Discharge Summary for Resident #8 dated 4/13/2022 revealed, .admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .patient expressed he cannot live anymore .he has a gun at home .tried to elope twice in the past week .wife reported angry outbursts more often .due to the behaviors .patient was admitted to the psychiatric unit . Review of the Psychiatric Evaluation for Resident #8 revealed, .4/27/2022 .Prior to admission, he was inpatient .for suicidal ideation .he reports feeling down/depressed at times . Review of the active Comprehensive Care Plan revealed, no Care Plan to address risk of [CONDITION(S)]. During an interview on 7/14/2022 at 12:45 PM, the MDS Coordinator confirmed Resident #8's Comprehensive Care Plan did not reflect the risk for [CONDITION(S)]. The MDS Coordinator was asked if staff should be aware of [CONDITION(S)], she stated, Yes, that should have been care planned.

Based on medical record review, observation, and interview, the facility failed to perform side rail assessments for 16 sampled residents (Resident #2, #8, #12, #13, #15, #16, #20, #21, #22, #23, #24, #26, #35, #37, #39, and #290) of 25 reviewed. The finding include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #2 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #2's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #8 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 10:55 AM and 12:58 PM, on 7/12/2022 at 9:02 AM, and on 7/13/2022 at 10:35 AM, in Resident #8's room, revealed side rails were noted to both sides of the resident's bed. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #12 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 11:22 AM and at 12:22 PM, 7/12/2022 at 8:59 AM, and 7/13/2022 at 10:25 AM, in Resident #12's room, revealed side rails were noted to be up on both sides of the resident's bed. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #13 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM in Resident #13's room revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #15 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 11:01 AM and at 12:58 PM, on 7/12/2022 at 9:03 AM, and on 7/13/2022 at 10:30 AM, in Resident #15's room, revealed side rails were noted to both sides of the resident's bed. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #16 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 9:30 AM, in Resident #16's room, revealed side rails were noted to the resident's bed. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #20 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #20's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #21 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 10:24 AM and on 7/13/2022 at 9:15 AM and 12:48 PM, in Resident #21's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #22 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #22's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #23 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 1:06 PM and on 7/13/2022 at 12:50 PM, in Resident #23's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #24 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 10:49 AM and on 7/13/2022 at 9:14 AM, in Resident #24's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #26 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #26's room, revealed side rails were noted to the resident's bed. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #35 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #35's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #37 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 10:31 AM and on 7/13/2022 at 9:12 AM, in Resident #37's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #39 revealed no side rail assessment was performed for the resident. Observation on 7/13/2022 at 12:08 PM, in Resident #39's room, revealed ¼ side rails were noted to the resident's bed. Review of the medical record revealed Resident #290 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #290 revealed no side rail assessment was performed for the resident. Observation on 7/11/2022 at 11:04 AM and 1:04 PM, on 7/12/2022 at 9:09 AM, and on 7/13/2022 at 10:40 AM, in Resident #290's room, revealed side rails were noted to be up on both sides of the resident's bed. During an interview on 7/12/2022 at 3:30 PM, the Director of Nursing confirmed the facility had not performed side rail assessments for residents prior to placement of the side rails on the residents' beds. During an interview on 7/13/2022 at 9:57 AM, the Maintenance Director stated, All the beds come with bed rails already attached to them; all the bed controls are built into the rail, they can't be taken off the bed. We inspect the bed and rails each year. During an interview on 7/13/2022 at 10:45 AM, the Administrator stated, Most of our families want the long side rails and we tell them on admission that we don't use those. We used to do side rail assessments long ago but now that we use the beds that have the ¼ side rails attached we don't do an assessment because they can't get trapped in the bed with those rails. During an interview on 7/13/2022 at 10:56 AM, the Social Services Director confirmed side rail assessments weren't completed on residents in the facility. She stated, I talk to families on admission that our side rails are considered enablers, not restraints. We haven't done side rail assessments on anyone here because we don't consider them as restraints.

Based on facility policy review, medical record review, and interview the facility failed to notify the State Agency of an elopement for 1 of 2 sampled residents (Resident #39) which resulted in a major fall with major injury. The findings include: Review of the facility's undated policy titled, Accident/Incident Reports (Residents), revealed, .When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes, an accident/incident should be immediately directed to the Director of Nursing or the Administrator .Purpose: To assure appropriate follow-through on all accidents and incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action .When indicated, the incident will be reported to the [named state agency] as per the department's guidelines . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 required a wander guard (a device that alerts the staff by alarming loudly when a resident who is an elopement risk exits the building, going from a safe area to an unsafe area) daily because she exhibited behaviors of wandering. Further review revealed the resident required supervision with walking in the room, in the corridor and with locomotion on/off the unit. Review of Resident #39's care plan dated 3/21/2022 revealed .CODE ALERT BRACELET R/T [RELATED TO] ELOPEMENT RISK .Alert staff to resident's wandering behavior .If resident elopes from facility protocol for locating resident .Monitor and document resident behavior at least twice daily .Report increase in negative findings to physician . Review of Resident #39's Progress Notes dated 4/24/2022 revealed the resident eloped from the facility through the front door. Review of Resident #39's Progress Notes dated 5/6/2022 revealed the resident eloped through the front door and was found 100 feet from the facility. Review of Resident #39's Progress Notes dated 5/20/2022 revealed the resident eloped from the facility through the Wards Hall door. Review of Resident 39's Progress Notes dated 5/21/2022 revealed the resident eloped from the facility through the patio door. Review of Resident #39's Progress Notes dated 5/22/2022 revealed the resident eloped from the facility through the back door. Review of Resident #39's Progress Notes dated 5/23/2022 revealed the resident eloped from the facility through the Outward Hall door. Continued review revealed the resident was observed running and fell sustaining a fall with major injury. During an interview on 7/12/2022 at 12:47 PM, the Administrator confirmed she had not reported the elopements to the state agency. The Administrator stated she did not think the previous elopements were considered reportable since she was found on the property.

Based on facility policy review, medical record review, and interview, the facility failed to administer pneumonia vaccinations post signed consents reviewed for 4 of 25 sampled residents (Residents #9, #14, #16, and #30.) The findings include: Review of the facility's undated policy titled, Policy for Influenza/Pneumococcal Immunizations, revealed, .All patients of [Named facility] shall have flu shots annually per their permission. Information shall be provided to each patient and/or their representative regarding influenza and the vaccination .Patients and/or their family will be notified upon admission regarding our policy for flu vaccination .Pneumococcal Immunizations shall be given per the assessed need of our population . Review of the facility 2022 Immunization Log: [Named facility] revealed 4 residents on the facility list that has no history of Pneumonia Vaccination. Review of the medical record for Resident #9 revealed she was admitted to the facility on [DATE] and the Notification And Consent Agreement For Nursing Home Services dated 10/4/2021, revealed initials to grant permission for inoculation with the pneumonia vaccine. Review of the medical record for Resident #14 revealed she was admitted to the facility on [DATE] and the Notification And Consent Agreement for Nursing Home Services dated 4/7/2021, revealed initials to grant permission for inoculation with the pneumonia vaccine. Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE] and the Notification And Consent Agreement for Nursing Home Services dated 4/8/2021, revealed initials to grant permission for inoculation with the pneumonia vaccine. Review of the medical record for Resident #30 revealed she was admitted to the facility on [DATE] and the Notification And Consent Agreement For Nursing Home Services dated 8/25/2021, revealed intitials to grant permission for inoculation with the pneumonia vaccine. During an interview on 7/14/2022 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #9, #14, #16, and #30 had no history of pneumonia vaccine and stated, The hospital doesn't ask those questions anymore, I don't have anything showing I have offered the vaccination.

Based on medical record review and interview the facility failed to transmit a Quarterly and a Discharge Minimum Data Set (MDS) assessment for Resident #1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed a Quarterly MDS assessment dated [DATE] for Resident #1 was not transmitted. Review of the medical record revealed Resident #1 was discharged on [DATE]. Continued review revealed the Discharge MDS assessment for Resident #1 was not transmitted. During an interview on 7/12/2022 at 5:36 PM the MDS coordinator, after reviewing Resident #1's MDS assessments on her computer, stated, She [Resident #1] had a Quarterly MDS due on 6/8/2022 and a Discharge due on 6/12/2022. She pointed to her computer and said, I failed to complete and close them; I have a reminder on my computer to transmit them, but I just didn't do it.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store a nebulizer mask for 1 of 4 sampled residents (Resident #290) who received respiratory treatments. The findings include: Review of the facility's undated policy titled, Cleaning and Maintaining Respiratory Equipment, revealed, .Oxygen concentrators are serviced quarterly by [Named Company]. Nasal cannulas are to be changed weekly and dated .Water reservoirs are to be changed monthly and dated .Masks for nebulizer treatments are to be changed every three months/90 days and dated . Review of the facility's undated policy titled, Policy for Nebulizer Treatment Administration, revealed, .1. Wash hands and put on gloves. 2. Open medication and put in canister. 3. Apply mask and/or mouthpiece and reservoir to patient face. 4. Turn on and monitor resident. 5. Upon completion, rinse reservoir, mouthpiece, etc. and place into plastic bag provided for storage. 6. Remove gloves and wash hands. 7. Document on MAR [Medication Administration Record] . Review of the medical record revealed Resident #290 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #290 experienced short breath/trouble breathing. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Iprat-Albut 0.5-3 [2.5] milligram [mg]/3 milliliters [ml] inhale one vial via nebulizer every 6 hours as needed for shortness of air/wheezing . Observation in Resident #290's room on 7/12/2022 at 9:09 AM, revealed a nebulizer mask lying on bedside table not covered. During an interview in Resident #290's room on 7/12/2022 at 9:22 AM, the Director of Nursing (DON) confirmed nebulizer mask was lying unconvered on bedside table. The DON confirmed the nebulizer mask should be stored in a clean plastic bag. The DON removed nebulizer mask and tubing from resident room.

Based on facility policy review, facility documentation review, and interview, the facility failed to have a policy to address the contingency plan related to Covid 19 outbreak. The findings include: Review of the facility's undated policy titled, Policy for COVID-19 Vaccinations, revealed, .All patients of [Named facility] shall have COVID-19 vaccinations and boosters as indicated per their permission. Information shall be provided to each patient and/or their family regarding COVID and the vaccination. Patients and/or their family will be notified upon admission regarding our policy for COVID vaccination .All COVID vaccinations will be given per the COVID protocol of CDC [Center for Disease Control] .All staff will be required to have the COVID-19 vaccinations or be granted an exemption per their decision and [Named facility] approval. Information is provided to all staff regarding the benefits of the vaccination . Review of the CMS (Center for Medicare Services) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO-22-09-All) memorandum dated 1/14/2022, revealed .Medicare facilities are expected to comply with all regulatory requirements .Provider-Specific Guidance: The provider-specific guidance should be used in conjunction with the information in this memo .Attachment A : LTC (Long Term Care) Facilities . Review of the QSO-22-09-ALL Long Term Care and Skilled Nursing Facility Attachment A, revealed .The policies and procedures must include, at a minimum, the following components: (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 .The facility's policies and procedures must address each of the components specified in §483.80(i)(3) .Requiring staff who have not completed their primary vaccination series to use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or equivalent or higher-level respirator for source control . (x) Contingency plans for staff who are not fully vaccinated for COVID-19 . Review of the facility COVID-19 Staff Vaccination Status for Providers revealed 33 partially vaccinated staff without one booster and facility vaccination rate of 48.43%. Review of the employee vaccinated line listing revealed the last completion date of 1/9/2022. Review of the list of resident cases of confirmed COVID-19 over the last 4 weeks revealed 12 residents with positive Covid results from 6/25/2022-6/29/2022 with one resident hospitalized by physician during an outpatient visit and confirmed positive for Covid during hospitalization . Review of the undated facility policy titled, Policy for Covid-19 Vaccinations, revealed it did not address .A process for tracking and securely documenting the COVID-19 vaccination status of any staff .A process by which staff may request an exemption from staff COVID-19 vaccinations requirements based on an applicable Federal Law .A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID -19 vaccination requirements .A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility .COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19 . During an interview on 7/14/2022 at 9:42 AM, the Director of Nursing (DON) confirmed the staff vaccination line listing had not been updated since 1/9/2022. The DON stated, I kept it up to date at one point but have not been able to since January. During an interview on 7/14/2022 at 2:45 PM, Administrator and the DON confirmed the COVID facility policy did not address a contingency plan for staff who are not fully vaccinated.

Based on medical record review and interview the facility failed to complete a Quarterly and a Discharge Minimum Data Set (MDS) assessment for Resident #1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed a Quarterly MDS assessment dated [DATE] for Resident #1 was not completed. Review of the medical record revealed Resident #1 was discharged on [DATE]. Continued review revealed the Discharge MDS was not completed for Resident #1. During an interview on 7/12/2022 at 5:36 PM with the MDS coordinator after reviewing Resident #1's MDS assessments on her computer, she stated, She [Resident #1] had a Quarterly MDS due on 6/8/2022 and a discharge due on 6/12/2022. She pointed to her computer and said, It says open on my end so I didn't complete it. I have a reminder on my computer to do them but I just didn't do it. Continued interview she stated, I didn't do the discharge one either because I had to do the quarterly first or they would be out of sequence.

Based on facility policy review, facility record review and interview, the facility failed to ensure Registered Nurse (RN) coverage 8 hours a day 7 days a week for 3 days ranging from (MONTH) 18, (YEAR) through (MONTH) 25, 2019. The findings include: Facility policy review, Policy for RN Coverage, undated, revealed .Staffing requirements shall include sufficient nursing staff to meet the Federal Requirements plus any addition as is possible each shift, each day .The minimum of 8 hours RN coverage per 24 hour period shall be met . Review of the facility's daily posted Staffing Hours and Resident Census sheet dated Monday (MONTH) 22, 2019, Tuesday (MONTH) 6, 2019 and Saturday (MONTH) 24, 2019 revealed the facility did not have the required 8 hours of RN coverage. Interview with the Director of Nursing on 8/26/19 at 11:00 AM in the conference room confirmed the facility only scheduled 5 hours of RN coverage for 4/22/19, 8/6/19 and 8/24/19. Continued interview when asked to review the daily posted staffing sheets for these dates confirmed the facility did not have the required 8 hours of RN coverage for 4/22/19, 8/6/19 and 8/24/19. Interview with the Administrator on 8/26/19 at 11:35 AM in her office confirmed the facility did not have the required 8 hours of RN coverage for 4/22/19, 8/6/19 and 8/24/19.

Based on facility policy review, medical record review, observation and interview, the facility failed to serve food in a safe and sanitary manner for 1 of 7 residents (#13) during the breakfast meal on 8/26/19. The findings include: Facility policy review, Handling Food During Meal Service, undated revealed .Employees should observe caution when serving meals to residents so as to not touch food when serving the meal . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further medical record review of Resident #13's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #13 required set up with supervision with eating. Observation on 8/26/19 in the Magnolia Dining Room at 8:00 AM revealed Certified Nurse Assistant (CNA) #1 setting up Resident #13's breakfast tray and picked up the resident's toast with her bare left hand and spread butter on the toast then handed it to the resident. Interview with CNA #1 on 8/26/19 at 8:01AM in the Magnolia Dining room confirmed she touched Resident #13's toast with her bare hands and stated she was to wear gloves when handling residents food. Interview with the Director of Nursing on 8/26/19 at 9:35 AM in the conference room confirmed staff were to wear gloves when handling residents food and she expected staff to never touch the residents food with their bare hands.

Based on facility policy review, medical record review, review of facility documentation, observation and interview, the facility failed to thoroughly investigate falls for 1 resident (#37) of 21 residents reviewed. The findings include: Review of the undated facility policy, Fall Prevention Policy, revealed .Incident reports shall be completed upon any incidental fall .The Director of Nursing shall do an investigation following each fall . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #37's Brief Interview for Mental Status (BIMS) score was 00 out of 15, indicating the resident was severely cognitively impaired. Further review revealed there was no change in mental status, and exhibited inattentive behavior which came and went and changed in severity. Further review revealed the resident required extensive 1 staff assistance for bed mobility, transfers, walking in room, and toileting; required limited 1 staff assistance for walking in corridor, and for locomotion on and off the unit. Further review revealed the resident had 1 fall without injury after the prior assessment. Medical record review of the Fall Risk Evaluation form dated 1/17/18 revealed Resident #37 was at high risk for falls. Medical record review of the Care Plan dated 10/15/15 to the present revealed Resident #37 was .At risk for falls r/t (related to) decreased mobility . with .Approaches - Assist with ADL (Activities of Daily Living) as needed, provide walker, cane, quad cane and so forth for use when ambulating resident, rearrange environment to remove barriers for resident, Assist resident in walking to Activities, Dining Room, and so forth .as needed, Assist to bed soon after evening meal as needed, Alarming non-skid mat to threshold of bathroom door, Non-skid mat to bedside at all times, Trochanter roll to left side of bed to prevent falls, Keep hallways clear of debris to prevent falls .Assure patient sits in chairs with back on them at all times to prevent falls, Non-skid pad to be placed under wheelchair cushion when in wheelchair . Review of the facility documentation revealed the .Date of Incident 1/8/18 Time 8:05 AM, Exact Location of incident - Hallway, Resident's condition prior to fall: Normal .Describe exactly what happened .came into facility, found resident in hallway with back facing me. After walking into office heard loud noise - found resident down in floor on bottom with back up to NS (Nursing Station) Lift in front of pt (patient) . Further review of the facility documentation revealed Type of Injury with a handwritten notation of no injuries, the Level of Consciousness - No L[NAME], and .Comments: Educated the importance of using her walker . Further review revealed on .1/8/18 What Happened: came into facility found resident just outside of her room, her back was facing me. I came into my office .heard a loud noise. I then found (resident) in the floor on her bottom with back up to nurses station cabinet + (and) the sit to stand lift in front of the resident. Assisted to standing position x 2 (times 2) - No apparent injuries . Review of facility documentation dated 1/15/18 of the incident reported on 1/8/18 revealed .I was in the DON (Director of Nursing) office when (DON) heard something and said what was that we went out and found resident in the floor in front of the nursing station (old hall) sitting on her bottom with her back against the cabinet and the sit to stand lift in front of her. She had non-skid socks on, her walker was in her room . Further review of the facility documentation revealed no evidence of medication review, laboratory result review, what interventions were in place at time of the fall, last known location of resident prior to fall, continence status, environment in location of fall, if resident hit her head, or the cause of the fall. Medical record review of the Fall Risk Evaluation dated 4/18/18 revealed the resident remained at high risk for falls. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #37 had a BIM score of 3 out of 15 indicating severe cognitive impairment. Further review revealed she continued to have no change in mental status and she continued to exhibit inattentive behavior which came and went and changed in severity. Further review revealed the resident required extensive 1 staff assistance for bed mobility, and toileting; required limited 1 staff assistance for transfers, walking in room, walking in corridor, and for locomotion on and off the unit. Further review revealed the resident had no fall since the prior assessment. Medical record review of the physician telephone order revealed the following: On 5/22/18 .Labs due to decreased appetite, decreased weight, increased diarrhea, CMP (Comprehensive Metabolic Panel), CBC w diff (Complete Blood Count with differential), Mag level (Magnesium Level) . Medical record review of the Fall Risk Evaluation dated 6/3/18 revealed the resident remained at a high risk for falls. Medical record review of the Nurses' Progress Note dated 6/3/18 at 1:20 PM revealed .CNA (Certified Nurse Aide) was going by pt's (patient's) door + pt appeared to let go of walker and fell backwards onto the floor on L (Left) side of bottom. Upon exam No injuries noted, no c/o (complaint) pain or discomfort, no deformities noted .Pt instructed to keep hands on walker at all times while ambulating to prevent falls. Review of the facility documentation dated 6/3/18 revealed .Incident: CNA witnessed resident ambulating from dining room to room and let go of her rolling walker at approximately 1:20 PM on Sunday (MONTH) 3, (YEAR). She fell straight back onto floor on her left side + Buttocks .No apparent injuries or complaint pain. Injuries: None .Witness to fall: CNA .Intervention: Instruct resident to keep hands on walker at all times while ambulating to prevent falls . Further review of facility documentation revealed .date incident 6/3/18 .Time 1:20 PM .Exact Location of incident/accident - Resident room [ROOM NUMBER]A .Resident condition before fall/accident - confused .Describe exactly what happened - CNA witnessed fall, pt had let go of walker + fell backwards on the floor on L side of bottom. After exam No injuries noted .No c/o pain .Type of Injuries None Apparent .Level of Consciousness - Alert .Additional Comments - Instruct pt to keep hands on walker at all times to prevent falls while ambulating . Further review of the facility documentation revealed no evidence of medication review, laboratory result review, what interventions were in place at time of the fall, were the interventions implemented at the time of the fall, last known location of resident prior to fall, continence status, environment in location of fall, if resident hit her head, or the cause of the fall. Medical record review of physician telephone orders revealed the following: On 6/3/18 .Instruct pt to keep hands on walker at all times to prevent falls while ambulating . On 6/28/18 .DC Trazadone (antidepressant medication), Monitor sleep quality and for adverse effects . On 7/11/18 .1) DC current [MEDICATION NAME] ([MEDICAL CONDITION] medication) order, 2) Start [MEDICATION NAME] 250 mg (milligrams) po 3 x (by mouth 3 times) daily for mood d/o (disorder), Monitor for increased confusion/sedation or adverse effect (with) med (medication) adjustment . Medical record review of the Care Plan updated on 7/11/18 and ongoing revealed .Problem - confusion .Interventions: 1) DC current [MEDICATION NAME] order 2) Start [MEDICATION NAME] 250 mg po 3 x daily for mood d/o. Monitor for increase of confusion/sedation or adverse effects (with) med adjustment .Goal - Resident will not demonstrate unstable mood or behaviors x 90 days . Medical record review of the Fall Risk Evaluation dated 7/12/18 revealed the resident remained at high risk for falls. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #37 had a BIM score of 00 out of 15 indicating severe cognitive impairment. Further review revealed she continued to have no change in mental status and continued to exhibit inattentive behavior which came and went and changed in severity. Further review revealed the resident required extensive 2 person assistance with toileting; required extensive 1 staff assistance for bed mobility and transfers; and continued to require limited 1 staff assistance for walking in room, walking in corridor, and for locomotion on and off the unit. Further review revealed the resident fell 1 time with no injury since the prior assessment. Medical record review of physician telephone orders revealed the following: On 8/14/18 .DC [MEDICATION NAME] (antidepressant medication); Start [MEDICATION NAME] (antidepressant medication) 250 mg for anxiety/depression . On 8/15/18 .[MEDICATION NAME] (antianxiety medication) 0.25 mg tab po q (every) 6 hr (hour) as needed for s/sx (signs/symptoms) of anxiety x 14 days . Medical record review of the Nurses' Progress Note dated 9/24/18 at 6:05 PM revealed .while passing resident rm (room) witnessed resident on knees holding onto SR (side rail). Resident had just left DR (dining room) and apparently assisting self abed (bed was in lowest position) assisted up + assist abed. Further review of a note at 11:15 PM revealed resident .saying Hey/Help, come get me! (often says this at N[NAME] (night)) When staff entering rm, resident was lying prone on floor next to bed .No injuries noted, no c/o voiced, no injuries observed .Assist x 2 to get back into bed .Pressure pad alarm to be used in bed as aid to fall prevention . Review of facility documentation revealed .incident/accident on 9/24/18 .Time 11:15 PM .Exact location fall/accident . had no documentation. Further review revealed .Resident condition before fall/accident - Normal (within baseline) .Were bed rails ordered? Yes .Were bed rails present? Yes .If yes - UP .Was height bed adjustable? Yes .If yes - Down .Describe exactly what happened - When staff entered rm (room), resident lying prone on floor next to bed. Unable to tell staff what she's been wanting/trying to do. No injuries noted, no c/o pain voiced .Type Injuries - None apparent .Level of Consciousness - AAO x 1 (Alert and Oriented times 1) (person) .Additional Comments - Pad alarm to be used while in bed (personal alarm if/when pad alarm not available) . Review of facility documentation dated 9/25/18 revealed an .Incident: On 9/24/18 at 11:15 PM .Resident observed lying in floor next to bed. No distress or injuries noted. Res confused (at baseline) and unable to verbalize details r/t being on the floor. No loud noise, heard by staff. It should be noted that resident has a history of laying on floor for attention .Intervention: Pad alarm to be used . Further review of the facility documentation revealed no evidence of laboratory result review, what interventions were in place at time of the fall, were interventions implemented at time of the fall, last known location of resident prior to fall, continence status, environment in location of fall, if the resident hit her head, or the cause of the fall. Medical record review of physician telephone orders revealed the following: On 9/24/18 .Pressure pad alarm to be used in bed; (Personal alarm OK in bed if pad alarm unavailable) . On 9/28/18 .scoop mattress to prevent falls from bed; DC alarming bed pad . Observations on 11/13/18 at 9:54 AM, 10:12 AM, 11:03 AM, and at 3:00 PM revealed Resident #37 in her room in bed, the bed was in the lowest position, the bed was against the wall, a scoop mattress on the bed, non-skid floor mat next to the bed, and the bilateral position side rails were in the up position. Observations on 11/13/18, 11/14/18, and 11/15/18 at 12:00 PM to 1:00 PM revealed Resident #37 in the Heritage Dining Room. Further observation revealed when the resident was ready to go back into her room the resident was assisted by staff to stand, instructed by staff to hold onto the rolling walker, and was assisted by staff while the resident walked to her room. Interview with the DON on 11/15/18 at 12:05 PM in the sunroom revealed .we didn't do neurochecks for any of the falls for Resident #37 .Just assumed she didn't hit her head .What kind of things should we be looking for in investigation? I just did what prior DON taught me .I see what you mean about not a clear investigation .If res said hit their head, or have a knot/wound on head, or staff saw resident head hit floor, or saw a change in mental status, then resident sent to hospital .CNA on 6/3/18 fall told me resident did not hit head and I should have written it in the report .

Based on medical record review, observation and interview, the facility failed to obtain physician orders [REDACTED].#38) of 12 residents reviewed receiving respiratory treatment. The findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 11/13/18 at 9:28 AM, 10:07 AM, and at 3:04 PM revealed Resident #38 in her room wearing oxygen by nasal cannula at 2 liters per minute. Further observation of Resident #38 on 11/15/18 at 1:00 PM revealed the resident sitting up in her room in a recliner with an oxygen concentrator in her room not in operation and not in use by the resident. Medical record review of the physician orders [REDACTED]. Interview with LPN #1 on 11/15/18 at 1:20 PM in the old hall nurse station confirmed Resident #38 did not have an order for [REDACTED].>Interview with the Director of Nursing on 11/15/18 at 1:35 PM in her office confirmed the medical record for Resident #38 did not contain a physician order [REDACTED].