Every finding on record at Lakeview Nursing Center

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure oxygen cautionary signage was posted on a resident's door for one (1) of 20 sampled residents (Resident #59).Findings include:A review of the facility's policy, Oxygen Administration, dated 7/24/23, revealed, .Oxygen is administered to residents who need it, consistent with professional standards of practice.Policy Explanation and Compliance Guidelines.6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.On 9/15/25 at 12:05 PM, an observation revealed no oxygen signage was posted on the door of Resident #59, where an oxygen concentrator was noted inside the room.On 9/16/25 at 9:00 AM, during an observation and interview, Resident #59 was observed with an oxygen concentrator in his room and there was no cautionary signage on the door. The resident stated he uses the oxygen sometimes, particularly after dialysis, when he feels tired. On 9/16/25 at 1:45 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that Resident #59 did not use his oxygen continuously, but rather as needed after dialysis if short of breath. She confirmed there was no oxygen signage posted on the resident's door.On 9/16/25 at 4:45 PM, during an interview with the Director of Nursing (DON), she confirmed oxygen signage should have been posted on Resident #59's door because of his oxygen use.A record review of the admission Record revealed the facility initially admitted Resident #59 on 6/18/23 and he has current diagnoses including chronic kidney disease.A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/25 revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.A record review of the Order Summary Report revealed Resident #59 had a physician order, dated 6/6/25, for oxygen to be administered continuously.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration, for one (1) of 20 sampled residents. Resident #86Findings include:A review of the facility's policy, Resident Self-Administration of Medication, dated 8/2024, revealed, .Policy Explanation and Compliance Guidelines.7. Bedside medication storage is permitted only when it does not present a risk to confused residents.The following conditions are met for bedside storage to occur- a. The manner of storage prevents access by other residents.8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage.On 9/15/25 at 2:45 PM, during an observation, Resident #86 had eye drops in the room on the overbed table in plain view.On 9/16/25 at 9:00 AM, during an observation, Resident #86 had two (2) small bottles of eye drops sitting on the overbed table in front of her. She stated she takes Timolol Maleate Ophthalmic drops at night and Systane during the day.On 9/16/25 at 3:25 PM, during an observation and interview with Licensed Practical Nurse (LPN) #2, she reviewed the resident's electronic Medication Administration Record (eMAR) and confirmed that Resident #86 had an active physician's order for Timolol Maleate eye drops, which were to be administered by staff and were stored in the medication cart. LPN #2 observed and confirmed that Resident #86 had a container of Timolol Maleate eye drops and Systane on the overbed table in front of her. LPN #2 noted the Timolol drops were dispensed from an acute care hospital pharmacy and stated the resident must have brought the drops from home or from the hospital. Resident #86 stated someone at the facility had given her the drops and she had been using them but could not recall if she self-administered or if staff administered them. Upon leaving the room, LPN #2 stated Resident #86 was confused and not capable of safely self-administering medications. She confirmed it was unsafe for medications to be left in the resident's room and that she had not noticed the drops on the overbed table earlier in the day when administering medications.On 9/16/25 at 4:45 PM, during an interview with the Director of Nursing (DON), she acknowledged the facility had not assessed Resident #86 for safe self-administration of medications. She stated it was her expectation that all medications be stored appropriately and that medications should not be left at the bedside unless specifically authorized and assessed.A record review of the admission Record revealed the facility admitted Resident #86 on 9/11/25 with diagnoses including Aftercare Following Joint Replacement Surgery.A record review of the Order Summary Report revealed Resident #86 had a Physician's Order, dated 9/11/25, for Timolol Maleate Ophthalmic Solution. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/18/25 revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she was moderately cognitively impaired.

Based on observation, interviews, and record review, the facility failed to provide residents with an alternative meal choice of equal nutritive value for one (1) of 22 sampled residents (Resident #62).Findings included:On 9/17/25 at 11:00 AM, during an observation, the posted menu consisted of barbecue chicken, baked beans, and mixed vegetables, with no alternative entree listed.On 9/17/25 at 11:30 AM, during an observation and interview with the Dietary Manager (DM), there was no alternative entree or vegetables on the steam table. The DM stated that residents were provided with a Between Meal dining sheet, which included choices of hamburger with chips, grilled cheese with chips, cream of chicken soup with crackers, chicken noodle soup with crackers, peanut butter and jelly sandwich, or deli sandwich. She further explained that salad and chicken tenders were also available but verified the facility did not prepare any readily available alternative entrees. She stated residents requested an item from the Between Meal menu, and staff submitted the request using the sheet.On 9/17/25 at 12:45 PM, during an interview with the Registered Dietitian (RD), she reported that the facility's resident council voted a few years ago to switch from an alternative entree to the current Between Meal menu system. She explained that the Between Meal dining options did not provide the same nutritive value as the main menu but did allow residents a choice.On 9/17/25 at 1:07 PM, during an observation and interview with Resident #62, he stated he grew tired of eating the same foods over and over from the Between Meal menu. He had several boxes of snacks in his room and reported he purchased those to eat when he was served food he did not like.On 9/18/25 at 11:30 AM, during an interview with the Administrator, she confirmed the facility did not provide a readily available alternative entree of equal nutritive value. Instead, residents were allowed to choose items from the Between Meal menu as an alternative food choice.A record review of the Between Meal Dining menu revealed choices included Cheeseburger and Fries, Hamburger and chips, Grilled Cheese and chips, Cream of Chicken soup and crackers, Chicken Noodle soup and crackers, Peanut Butter and Jelly sandwich, and Deli sandwich and chips.A record review of the admission Record revealed the facility admitted Resident #62 on 11/15/2019 with current diagnoses including Hemiplegia and Hemiparesis.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/25 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated his cognition was intact.

Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day. Findings included: A record review of the Payroll Based Journal (PBJ) Staffing Data Report for the fourth (4th) quarter (July 1-September 30, 2024) revealed the facility triggered for Excessively Low Weekend Staffing, No RN Hours, and Failed to Have Licensed Nursing Coverage 24 Hours/Day. Further review revealed the Infraction Dates for No RN Hours and Failure to Have Licensed Nursing Coverage 24 Hours/Day were 7/6, 7/7, 7/13, and 7/14 of 2024. A record review of the Staffing Grid completed by the Director of Nursing (DON) revealed the facility had RN and nursing coverage on 7/6/24, 7/7/24, 7/13/24 and 7/14/24. On 03/31/25 at 1:30 PM, during an interview with the Administrator, DON, Human Resources (HR) Director, and [NAME] Manager, the Administrator explained the facility became aware there was a reporting issue at the end of the quarter, ending September 2024. She confirmed the facility had nursing coverage for those dates; however, by the time the issue was identified, it was too late to submit corrections. The Administrator explained the current process is that nurses and Certified Nurse Aides (CNAs) clock in using their handprint. The [NAME] Manager manually enters time and makes adjustments when salaried staff perform direct care, such as when the Minimum Data Set (MDS) nurse takes a medication cart. The [NAME] Manager believed there was a coding error in the reporting by the payroll vendor system. The HR Director now reviews daily hours worked for RNs, Licensed Practical Nurses (LPNs), and CNAs and balances this data against what is submitted in PBJ to ensure accuracy. The Administrator stated the facility does not have any contract direct care nurses or CNAs. The error was discovered while reviewing the MDS PBJ Report 17025, which provides a breakdown of staffing hours. The Administrator stated they worked hard to determine what occurred during the two weekends in question and believes the issue was a reporting and/or coding error.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey. Findings included: A review of the facility's policy titled, Safe and Homelike Environment, revised 07/24/2023, revealed, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . A review of the facility's document related to Housekeeping, undated, revealed, . Duties and Responsibilities: Ensures the provision of a clean environment for our residents and staff, providing high quality services and high standards of cleanliness .Functions .2. Ensures that daily and deep cleaning schedules are adhered to .14. Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting .22. Moves furniture and other heavy objects as required . On 03/30/25 at 11:52 AM, during an observation and interview, Resident #17 was observed in bed with a family member at the bedside. The family member reported that his primary concern was the cleanliness of the room, and he expected his mother's room to be clean when he visits. He stated the floors are always dirty and appear not to be wiped down. Dirt and loose particles were observed under the bed and around the nightstand. On 03/31/25 at 2:15 PM, during an interview and observation of Resident #17's room, Housekeeper #2 explained that each housekeeper had assigned halls, but recently the housekeepers were required to split halls due to staffing issues. She stated every room is cleaned daily and that cleaning duties include mopping, dusting, bathroom sanitation, trash removal, and restocking paper supplies. She explained she does not move furniture or beds when residents are present. Housekeeper #2 confirmed debris and dirt were present around the visitor chair, nightstand, and under the resident's bed. On 04/01/25 at 3:00 PM, during an interview with Housekeeper #4, she stated that all rooms are cleaned daily, including sweeping, mopping, wiping furniture, and cleaning bedrails. She stated that if a resident is present, she will return later to clean, and that although she attempts to complete all cleaning tasks, sometimes it is difficult due to picking up extra rooms. On 04/02/25 at 2:14 PM, during an interview with the Administrator, she stated that the facility had been actively working on improving the facility's cleanliness and had recently hired a new housekeeper. She stated that her expectation was that staff complete all duties, even on weekends, and ensure rooms are maintained in a clean condition.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents. Resident #13. Findings included: A review of the facility's policy, Comprehensive Care Plans, dated 3/5/2025, revealed, .It is the policy of this facility to . implement a comprehensive person-centered care plan for each resident . that includes measurable objectives .and meet professional standards of quality .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be of their roles and responsibilities for carrying out the interventions, initially and when changes are made . During an observation on 03/30/25 at 11:16 AM, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed. During an observation and interview on 04/01/25 at 11:01 AM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #13 was in bed and the fall mat was folded on the left side of the bed, instead of unfolded on the floor bedside the bed in a position to prevent injury from falling. LPN #1 stated the fall mat was not supposed to be folded and should be laid out on the floor beside the bed. During an interview on 04/02/25 at 9:56 AM, the Director of Nursing (DON) explained that staff were trained to keep fall mats flat on the floor to prevent injuries from falls. The DON stated that she expected the staff to implement care plan interventions. A record review of Resident #13's Admission Record revealed the facility admitted the resident on 8/6/2024 and she had current diagnoses including Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Further review revealed she has had falls since admission. A record review of the Comprehensive Care Plan revealed Resident #13 was at risk for falls related to decreased mobility, generalized weakness, and a history of a fall with a hip fracture. The care plan included an intervention, initiated on 12/6/24, for Floor mats on both side of bed .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when a fall mat intended to prevent injury during falls was not properly placed for one (1) of three (3) residents reviewed for accidents/hazards, Resident #13. Findings included: A review of the facility's policy titled Accidents and Supervision, dated 2/19/2019 and revised 12/9/2020, revealed, .The resident environment will remain free of accidents hazards as is possible .this includes .3. Implementing interventions to reduce hazard(s) and risk(s) . On 03/30/25 at 11:16 AM, during an observation, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed. On 04/01/25 at 11:01 AM, during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed that Resident #13 was in bed and the fall mat was folded on the left side of the bed, instead of being unfolded on the floor bedside the bed in a position to prevent injury from falling. LPN #1 stated the fall mat was not supposed to be folded and should be laid out on the floor beside the bed. On 04/02/25 at 9:56 AM, during an interview with the Director of Nursing (DON), she explained that staff were trained to keep fall mats flat on the floor to prevent injuries from falls. A record review of Resident #13's Admission Record revealed the facility admitted the resident on 8/6/2024 and she had current diagnoses including Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Further review revealed she had falls since admission.

Based on interviews, record review, and facility policy review, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one (1) of 18 residents reviewed for PASRR. Resident #37. Findings include: A record review of the facility's policy Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, dated 01/10/25 revealed .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Policy Explanation and Guidelines .9. Any residents who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include .c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. On 03/30/25 at 11:31 AM, during an interview, Resident #37 reported that he was sent to a Behavioral Health Unit (BHU) last year because he would throw his unwanted food on the floor. A record review of the Transfer/Discharge Report revealed the facility admitted Resident #37 on 11/15/2019 with current diagnoses including Anxiety Disorder, A record review of the Physician's Order Sheet dated 05/15/24 revealed .Send to (Proper Name) Behavioral Health for eval (evaluation) and treatment . A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed Resident #37 required a staff assessment for mental status and his cognitive skills for daily decision making he made decisions regarding tasks of daily life with modified independence with some difficulty in new situations only. Record review of the medical record revealed there was no Change in Status Form completed or submitted to the mental health authority for a Level II resident review after Resident #37 returned from an inpatient psychiatric facility in which he was admitted on [DATE]. On 03/31/25 at 10:05 AM, during an interview with Social Services #1, she confirmed a Change in Status Form was not completed for Resident #37 that would have generated a request for a PASRR Level II assessment. She explained that the only time a Change in Status form for a Level II assessment was completed was when a resident received a new diagnosis of mental illness. On 04/01/25 at 03:00 PM, during an interview with the Director of Nursing (DON), she confirmed Resident #37 was admitted to a BHU in May of 2024.

Based on interviews, record review, and facility policy review, the facility failed to ensure timely administration of pneumonia vaccinations for one (1) of five (5) residents reviewed for immunizations (Residents #70). Findings include: A record review of the facility's policy, Pneumococcal Vaccine (Series), dated 6/19/23, revealed .It is our policy to offer residents .immunizations against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2 .Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . A record review of the Admission Record revealed the facility admitted Resident #70 on 2/3/25 with diagnoses including Encounter for Surgical Aftercare following surgery on the Digestive System. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/25 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. A record review of the Vaccination Record, dated 2/3/25, revealed Resident #70 had not received the Pneumonia vaccine and requested to receive the vaccine upon the Physician's recommendation. On 04/02/25 at 9:58 AM, an interview with the Resident Representative (RR) for Resident #70 revealed she acknowledged the resident was admitted on [DATE] and the consent to receive the pneumonia vaccine was signed 2/3/25. The RR acknowledged that she was not informed of any delay in getting the vaccine and was unaware that the resident had not received her pneumonia vaccine. The RR stated she expected the resident to have had his pneumonia vaccine. On 04/02/25 at 10:15 AM, an interview with the Infection Preventionist (IP) revealed she acknowledged Resident #70 have not received their pneumonia vaccine from time they were admitted . The IP nurse confirmed it was her responsibility to ensure residents received vaccines and the process was to allow a couple of residents to be admitted to the facility before she calls the pharmacist to administer the vaccines. The IP nurse stated she has been focusing on the flu vaccines and had hoped to get the pneumonia vaccines caught up this April. On 04/02/25 at 1:05 PM, an interview with the Director of Nursing (DON) revealed she acknowledged that Residents #70 had not received the pneumonia vaccinations since admission. The DON stated it was the responsibility of the IP nurse to make sure the residents are vaccinated. The DON noted that going forward she will arrange to have the immunizations done in-house rather than outsourcing to pharmacies to help get better control the timeliness of administering the pneumonia vaccine.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a clean environment and implement comprehensive care plan interventions during an annual recertification survey on 7/20/2023 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F584 and F656. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, dated 2/24/2021, revealed, .It is the policy of this facility to .maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .Policy Explanation and Compliance Guidelines .2. The QA Committee shall .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . Record review of the Provider History Profile revealed the facility received a citation for F584-Safe/Clean/Comfortable/Homelike Environment and F656-Develop/Implement Comprehensive Care Plan. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 7/20/2023, revealed the facility received a citation for F584, .Based on observation, interviews, record review, and facility policy review, the facility failed to maintain a clean environment for two (2) of 20 resident rooms . and for F656, .Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan . Record review of the Statement of Deficiencies and Plan of Correction (Form 2567) from the previous annual survey in July 2023, revealed F584 was cited due to stains on the privacy curtain and large pieces of missing paint on the wall behind the bed and F656 was cited regarding prescription medicine being left on the residents overbed table. During the current recertification survey, failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey and failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents. On 04/02/25 at 03:52 PM, during an interview with the Administrator, she affirmed that deficiencies from the previous annual survey were found during the current survey. The Administrator reported the facility has hired several new staff and particularly a floor tech to keep the facility clean. The Administrator stated the facility staff are working to make things better and keep the facility clean and free of odors. The Administrator stated she will have a meeting with the nursing staff to come up with a plan to meet the residents' needs and promote individualized care.

Based on observation, staff interview, and facility policy review, the facility failed to store food using sanitary methods to prevent cross-contamination, as evidenced by a plastic cup used as a scoop stored directly inside a container of cornmeal for one (1) of four (4) days of kitchen observations. Findings included: A review of the facility's document ServeSafe Manager, undated, revealed, .Preventing Cross-Contamination .Food, equipment, utensils .must be stored in ways that prevent cross-contamination .Storing .you need to store items in a way that prevents cross-contamination . On 03/30/25 at 10:34 AM, during an observation of the kitchen and interview with the Dietary Manager, there was a clear plastic cup inside the fish fry/corn meal container dry goods container. The Dietary Manager confirmed the clear plastic cup was being used as a scoop and acknowledged this constituted cross-contamination. On 04/01/25 at 12:25 PM, during an interview with the Registered Dietitian (RD), she explained the dietary department uses Serve Safe guidelines for policy and procedures related to food handling. She confirmed she had been made aware of a plastic cup used as a scoop was stored inside the corn meal container.

Based on observation, interviews and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection, for one (1) of four (4) observations of staff entering and exiting residents' rooms. Findings include: Record review of the facility's policy titled, Hand Hygiene: Clean Hands Save Lives, with date implemented 1/21/21 revealed, . It is the policy of this facility that hand hygiene will be handled as follows: . Hand hygiene is a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands . Facts to Consider: .Germs can spread from .surfaces when you .touch a contaminated surface or objects .Washing hands can keep you healthy and prevent the spread of .infections from one person to the next . Record review of the facility's policy titled, Perineal Care Policy, revised 2/21 revealed, .Policy: Peri care is to be performed following this procedure to ensure . cross contamination if avoided remove gloves .wash hands with soap and water. On 7/2/24 at 12:15 PM, during an observation and interview Certified Nurse Aide (CNA) #1, was observed coming out of a resident's room on the 400 Hall, with a brief rolled up in her gloved hands. CNA#1 was observed walking down the hall to the soiled utility room and opened the door with her gloved hand and entered the room. CNA #1 was not observed using hand sanitizer or washing her hands. During an interview with CNA #1, she confirmed that she had a brief in her gloved hands. She explained she did not have a trash bag to put the brief into, so she just took it to the soiled room. She reported the brief should have been placed in a trash bag and then taken to the soiled room and she knows not to wear gloves in the hallway. On 7/2/24 at 12:50 PM, during an interview with the Infection Preventionist (IP) Nurse/Registered Nurse #1, she confirmed a staff member should never come out of a resident's room with a soiled brief in their hands and gloves on. The IP Nurse stated all staff have had education regarding the importance of not wearing gloves in the hallways. The IP Nurse added that CNA #1 should have placed the brief in a bag and disposed of it properly. At 1:00 PM on 7/2/24, during an interview with the Director of Nursing (DON), she confirmed CNA #1 had reported to her that she was wearing gloves and had a brief rolled up in her hands while she transported the soiled brief to the soiled utility room. The DON stated she expects all staff to follow infection control guidelines at all times.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide a safe smoking environment when the facility staff did not remove an oxygen (O2) canister from Resident #1 prior to entering the smoking area and did not secure a cigarette lighter to prevent Resident #1 from lighting a cigarette. This failure resulted in Resident #1 receiving burns to his face. This was for one (1) of three (3) sampled residents reviewed for smoking. Findings Include: Review of the facility's policy, Accidents and Supervision, dated 12/9/2020, revealed, Policy: The resident environment will remain as free of accident hazards as is possible .This includes .3. Implementing interventions to reduce hazard(s) and risk(s) . Policy Explanation and Compliance Guidelines .3. Implementation of Interventions .i. Resident-directed approaches may include .supervising .residents . Review of the facility's policy, Resident Smoking, Smokeless Tobacco, and Vaping Policy, dated 3/29/22, revealed, Policy: This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation and Compliance Guidelines .2. Safety measures for the designated smoking area will include .e. Prohibition of oxygen use in the smoking area .11. All safe smoking measures will be documented on each resident's care plan and communicated to all staff .who will be responsible for supervising residents while smoking .14. All smoking materials of residents will be maintained by nursing and/or activity staff . A record review of the facility's investigation, dated 2/23/24, revealed on 2/21/24, when the Activities Director (AD) was assisting with the smoke breaks with her back turned, she heard a popping/clicking sound. Upon turning, she observed sparks coming from Resident #1's oxygen nasal cannula. She immediately removed the cannula and turned his oxygen off. Record review of the local hospital report, dated 2/21/24, revealed . Arrival Complaint FACIAL BURN Chief Complaint . Complaint of facial burns to bilateral nostrils after lighting a cigarette while wearing home O2 .singed hair at nares .Final diagnoses Second degree burn of nose. Partial thickness burns of face . Discharge Orders revealed Resident #1 received Keflex (antibiotic medication) and a Bacitracin Ointment (treatment order) upon discharge. Record review of the Physician Orders for the month of February 2024 revealed Resident #1 had an order, dated 11/9/23, for Oxygen at 2 LPM (Liters per minute) via nasal cannula as needed . A record review of the Resident Safe Smoking Assessment, dated 11/13/23, revealed Resident #1 was able to verbalize the safety risks of smoking and was aware of smoking procedures. On 2/26/24 at 3:45 PM, during an interview with Resident #1, he confirmed on 2/21/24, he went into the smoking area with an O2 canister on the back of his wheelchair and the O2 was being delivered through a nasal cannula. Resident #1 expressed that it was his fault because he was rushing to make it to the smoke area and forgot to have his oxygen canister removed from his wheelchair. He said he was anxious about being late, so he got the lighter from the box that holds the smoking items and he lit his cigarette instead of waiting for staff to light it for him. He stated that the lighter sparked and he pulled the nasal cannula off. He said that it did not hurt him and he did not want to go to the hospital, but the facility insisted he get checked out. On 2/26/24 at 4:00 PM, during an observation of the residents during the smoking break, the cigarettes and lighters were observed in a plastic container with the top not secured on a table in the smoking area. There were two (2) facility staff supervising and assisting the residents and were using the container to pass out cigarettes for the residents and then using a lighter to light the cigarettes. On 2/27/24 at 10:21 AM, during an interview with the AD, she confirmed that on 2/21/24 at approximately 4:00 PM, she assisted Resident #1 during the smoke break. She confirmed that she did not remove his oxygen canister as she usually did before he entered the smoke area. The AD explained Resident #1 was late getting to the smoking area and while she was assisting another resident through the doorway, he got a lighter out of the box that was left on a table. She heard a clicking/popping sound and observed sparks coming from the nasal cannula. She assisted with removing the nasal cannula, turned the oxygen off, and got a nurse to assist. On 2/27/24 at 10:50 AM, during an interview with License Practical Nurse (LPN) #1, she confirmed on 2/21/24, the AD called out for assistance in the smoking area. LPN #1 stated she observed Resident #1 having soot (ashes) on his nasal passages, bridge of his nose, and inside his nares, face, and right shoulder. She explained that the sparks had been put out before she went to the smoking area. She stated that she immediately notified the Director of Nursing (DON) and the Administrator. On 2/27/24 at 12:00 PM, during an interview with the DON, confirmed that Resident #1 was brought to the smoking area while wearing O2 and had an O2 canister on the back of his wheelchair. The DON stated the AD failed to remove both the resident's oxygen and nasal cannula during his smoke break, which caused sparks. Resident #1 went to the hospital and was treated for a second degree burn of the nose and partial thickness burn of the face. During an interview with the Administrator on 2/27/24 at 2:33 PM, she confirmed that on 2/21/24, Resident #1 lit his cigarette before the AD checked or removed his O2. The Administrator stated safety is the utmost priority of the facility, and moving forward, the facility has placed more checks and balances to prevent further incidents or accidents. A record review of the Face Sheet revealed the facility admitted Resident #1 on 11/6/23 with current diagnoses including Chronic Obstructive Pulmonary Disease and Heart Failure. Record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. Section J revealed Resident #1 currently uses tobacco. Section O revealed Resident #1 used oxygen therapy.

Based on interviews, record reviews, and facility policy reviews, the facility failed to implement care plan approaches related to prohibiting the use of oxygen in the smoking area for one (1) of four (4) sampled resident's care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy date implemented 4/3/20, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . A record review of the Care Plan with a problem onset date of 11/6/23 revealed Problem/Need: SMOKING I am a smoker and requires supervision .Approaches .Supervise all smoking .Prohibition of oxygen use in the smoking area . A record review of the facility investigation revealed on 2/21/24, the Activities Director (AD) was assisting with the smoke break at the facility with her back turned and heard a popping/clicking sound. Upon turning, she observed sparks coming from Resident #1's nasal cannula. She immediately removed the cannula and turned his oxygen off. Record review of the Physician Orders for February 2024 revealed Resident #1 had a physician order dated 11/9/23 for .Oxygen at 2 LPM (liters per minute) VIA (by way of) nasal cannula . During an interview on 2/26/24 at 3:45 PM, with Resident #1, he confirmed on 2/21/24 that while in his wheelchair with his oxygen on, he went to the smoking area without having his oxygen removed before entering the smoking area. In an interview on 2/27/24 at 10:21 AM, with the AD confirmed on 2/21/24 she failed to remove Resident #1's oxygen canister from his wheelchair before he entered the smoking area. On 2/27/24 at 11:00 AM, during an interview with Registered Nurse (RN) #1/Minimum Data Set (MDS) nurse, confirmed Resident #1's care plan was not implemented because his oxygen tank and nasal cannula were still on the resident's wheelchair before he entered the smoking area. She revealed that care plans are individualized for each resident and provide direction for the staff on providing care. She confirmed that she expects staff to follow the care plans. During an interview with the Director of Nurses (DON), on 2/27/24 at 12:00 PM, confirmed Resident #1 was brought to the smoking area with his oxygen and nasal cannula still present. The DON stated the staff did not follow the care plans for removing the resident's oxygen canister before he entered the smoking area. The care plans are in place for staff to care for the residents. It is expected that the facility staff will follow the residents' care plans. A record review of the Face Sheet revealed the facility admitted Resident #1 on 11/6/23 with diagnoses that included Chronic obstructive pulmonary disease and Heart failure.

Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a medication for one (1) of (20) care plans reviewed. Resident #54 Findings Include: Review of the facility's policy, Comprehensive Care Plans, undated, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . In an observation and interview on 7/17/23 at 12:20 PM, with Resident #54 he was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and the cream had remained on his overbed table since he received the medication. Record review of a Physician's Order Sheet, dated 1/24/23, revealed a handwritten order Triamcinolone Acetonide 0.1% topical cream. Apply to affected areas on face and scalp twice daily for one-two weeks then as needed for flares. Review of the medical record revealed there was no comprehensive care plan developed for Resident #54 related to his skin condition of eczema or an approach developed for the Triamcinolone cream as ordered by the physician. On 07/20/23 at 11:34 AM, in an interview with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN #3), RN #2 explained that the facility developed the comprehensive care plans based on the comprehensive Minimum Data Set (MDS) assessments and any other relevant information, including physician orders. RN #2 and LPN #3 stated that Resident #54 went to a dermatology appointment, had a biopsy procedure, and returned to the facility with multiple physician orders. RN #2 and LPN #3 confirmed that although there had been a care plan developed for the skin condition related to the biopsy and that care plan had been resolved, there was no care plan developed related to the eczema flare ups and the medication to be administered as needed. On 07/20/23 at 12:20 PM, during an interview with the Director of Nursing (DON), she stated that care plans should be developed and are used to provide individualized care to residents and to ensure their needs are met according to the physician's order. Record review of the Face Sheet revealed the facility admitted Resident #54 on 11/15/2019 with a diagnosis of Hemiplegia. Record review of the MDS with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.

Based on observation, interviews, record review and facility policy review the facility failed to provide a privacy bag for a resident with an indwelling catheter for one (1) of five (5) residents with urinary catheters. Resident #235. Findings Include: Record review of the facility's policy titled Catheter Care, undated, revealed Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation .2. Privacy bags will be available and catheter drainage bag will be covered at all times while in use . On 07/17/2023 at 11:00 AM, during an observation, Resident #235 was lying in bed and had an indwelling catheter drainage bag that had yellow urine visible from the doorway and hallway. On 07/19/2023 at 01:15 PM, during an observation, Resident #235 was lying in bed talking to a visitor. The visitor was at the bedside of the resident and the indwelling catheter drainage bag was not covered and urine was visible in his room and hallway. On 07/20/2023 at 08:55 AM, an observation and interview with the Director of Nursing (DON) in Resident #235's room, she confirmed there was no privacy cover on his catheter drainage bag and the urine in the bag was visible. She stated that the drainage bag was not the kind of bag that the facility used, and it should have had a dignity cover over the bag to keep the urine from being seen. She explained that it was the facility policy for the drainage bag to be covered. Record review of the Physician Order Sheet for Foley Catheter dated 7/11/2023, revealed Foley catheter 16 French 10 cc (cubic centimeter) bulb to gravity . Record review of the Face Sheet revealed the facility admitted Resident # 235 on 7/10/23 with diagnoses including Retention of Urine and Acute Kidney Failure.

Based on observation, interviews, record review and facility policy review the facility failed to maintain a clean environment for two (2) of 20 resident rooms. Resident #54 and Resident #76 Findings Include: Review of the facility's policy, Routine Cleaning and Disinfection, dated 5/12/23, revealed, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Policy Explanation and Compliance Guidelines .13. Cleaning of walls .will be conducted when visibly soiled. 14. Privacy curtains in resident rooms will be changed when visibly dirty . Resident #54 On 7/17/23 at 12:20 PM, in an observation and interview with Resident #54, the privacy curtain facing the resident had large visible stains and was soiled. The resident stated that the curtain had been in that condition for a while and no one had said anything to him about replacing it. He said he was sure staff had noticed it but had not done anything about it. On 07/18/23 at 01:53 PM, in an interview and observation with Certified Nurse Aide (CNA) #1, she confirmed that the privacy curtain for Resident #54 was soiled and stained and stated that the privacy curtain was not appropriate. CNA #1 explained that if she saw a privacy curtain that needed to be changed, she would tell housekeeping or maintenance. Then either herself or housekeeping would enter a request for the curtain to be changed in the maintenance log located at the nurse's station. CNA #1 reported that she had not placed a request in the log for the soiled privacy curtain for Resident #54. On 07/18/23 at 02:40 PM, in an interview and observation of the maintenance log with Maintenance #2, he confirmed there had not been a request recorded in the log to change the privacy curtain for Resident #54. He stated that staff added items to the daily log and when the task was completed, it was signed or initialed by the maintenance staff. He confirmed that extra privacy curtains were available for use. On 07/20/23 at 01:42 PM, in an interview with the Director of Nursing (DON) and the Administrator, the Administrator stated that she had been made aware of the soiled privacy curtain. She stated that the facility had ordered new privacy curtains and they were expected to be delivered soon. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Resident #76 On 7/17/23 at 11:20 AM, in an observation of Resident #76's room revealed the wall behind the bed, facing the entrance to the room, had large pieces of missing paint. The wall was soiled and had visible stains. During an interview on 07/19/23 at 10:35 AM, with Maintenance Staff #1, he confirmed that the wall on Resident #76's side of the room nearest the window had peeling paint and was visibly soiled. He said that the reason the wall was missing paint was because the bed was too close to the wall and when the resident raised the bed, it scraped the paint off the wall. He confirmed that though the paint was missing, it did not prevent housekeeping from cleaning the walls. He stated that he had previously repaired the wall, and that he would repair it again. On 07/19/23 at 11:00 AM, an observation and interview with the Director of Nurses (DON) and the Administrator revealed the wall in Resident #76's room had peeling paint and was soiled. She stated that the wall was damaged because the bed was too close to the wall and when staff would raise or lower the bed, it damaged the wall. The DON confirmed the wall was soiled and housekeeping should have cleaned the walls and the room was not conducive to a home-like environment. 47873

Based on observation, interviews, record review and facility policy review the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADLs) for one (1) of (20) sampled residents. Resident #76. Findings include: Record review of the facility's policy, Activities of Daily Living (ADLs), dated 10/28/2021, revealed, .The staff will provide care on a timely basis to promote and prevent avoidable changes in care. This includes the residents ability to: 1. Bathe, dress, and groom .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal oral hygiene as documented in the resident's care plan . During an observation on 07/17/23 at 11:49 AM, Resident # 76 was in bed, and he had fingernails on both hands that were thick, jagged, and had a dark discoloration. The middle three fingernails on both hands were curved beyond the nail bed. During an interview on 7/18/23 at 4:15 PM, with Certified Nurse Aide (CNA) #2, she stated that she cleaned the resident's nails but did not cut his nails because they were thick and jagged. She explained that the nurse performed nail care for that type of nail. An observation and interview on 7/18/23 at 4:25 PM, with Licensed Practical Nurse (LPN) #1, the Director of Nursing (DON), and Registered Nurse (RN) #3, revealed Resident #76 had nails that were thick, discolored, and had been for an undetermined amount of time. LPN #1 explained that she had not provided any care for the nail herself. The DON stated that she was aware that Resident #76 had bilateral long, thick, and discolored nails and there was no Physician Order to perform nail care. Record review of the Face Sheet revealed Resident #76 was admitted by the facility on 10/12/22 with diagnoses that included Cerebral Infarction and Contracture, right hand. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/23 revealed Resident #76 was totally dependent upon staff for bathing and required extensive assistance with personal hygiene.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had been assessed for safe self-administration of medication and failed to ensure a physician's order was transcribed accurately for one (1) of (20) sampled residents. Resident #54 Findings Include: Record review of the facility's policy, Resident Self-Administration of Medication dated 6/23/2023, revealed, Policy .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . Record review of the facility's policy, Medication Orders, undated, revealed, .Policy Explanation and Compliance Guidelines . 4. Documentation of Medication Orders .f. Transcribe newly prescribed medications on the .treatment record . During an observation on 7/17/23 at 12:20 PM, Resident #54, was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and the cream had remained on his overbed table since he received the medication. He said that he used the cream whenever he needed it. Record review of Departmental Notes, dated 1/24/23 at 11:55 PM, revealed Late entry for 1/23/23 Resident returned to facility .with new orders noted from Derm (Dermatology) clinic has bandage noted to left side of face . Record review of a Physician's Order Sheet, dated 1/24/23, revealed a handwritten order Triamcinolone Acetonide 0.1% topical cream. Apply to affected areas on face and scalp twice daily for one-two weeks then as needed for flares. Record review of the Physician Orders For the month of: February 2023, revealed a Physician's Order, with an order date and start date of 1/24/23 for Triamcinolone 0.1% cream .apply to affected areas on face and scalp twice daily for 1-2 weeks then as needed for flares .Stop date: 2/6/23. The interval code on the order was listed as Daily. There was no entry for an interval code to apply the medication as needed. On 07/18/23 at 1:50 PM, during an observation and interview with Licensed Practical Nurse (LPN) #1 in the room of Resident #54, she asked Resident #54 if the nurses were applying the cream and he responded No.He explained that he applied the cream himself. LPN #1 asked Resident #54 where he applied the cream and he stated that he used it on his face whenever he thought he needed it, and he did not tell the nurses whenever he used it. On 07/18/23 at 02:00 PM, in an interview with Registered Nurse (RN) #1, she stated that Resident #54 was very particular and liked things a certain way in his room and on his overbed table. She stated he had a high Brief Inteview for Mental Status (BIMS) score and was able to follow directions, but he had not been assessed to determine if he could safely self-administer the medication. He had not been advised to tell the nurse when he administered the medication so that it could be recorded. On 7/18/23 at 2:30 PM, in an interview with the Director of Nursing (DON), she confirmed there was no Physician's Order in the system for Triamcinolone to be administered as needed. She stated when the nurse entered the Physician's Order into the electronic health record, she should have entered two separate orders, one order for the daily administration of 1-2 weeks with a stop date, and one order to administer as needed without a stop date. She stated the nurse who entered the Physician's Order had not worked at the facility in several months. On 07/20/23 at 08:49 AM, in an interview with the facility's Pharmacist, he confirmed that resident self-administration of medications should be consistent with the facility's policies and regulations for safety and that if a resident self-administers any medication, there should be documentation of the administration. He also confirmed that Physician Orders should be carried out per the facility's policy. On 07/20/23 at 12:20 PM, during an interview with the DON, she stated that it is her expectation that staff inputs Physician's Orders accurately into the electronic medical records. She stated that the nurses are trained upon hire and as needed to input orders. She also confirmed that a resident must be determined to be able to safely administer medications and the physician's order would need to be written for the resident to self-administer. She said that Resident #54 had not been assessed to self-administer medications. The DON explained that the process for ensuring accuracy of physician's orders is for the Quality Assurance (QA) nurse to check behind the nurses and use the yellow copies of the duplicate Physician's Order form to insure orders are entered correctly. She further explained that neither herself nor the current QA nurse was at the facility on 1/24/23 when the transcription error occurred. Record review of the Face Sheet revealed the facility admitted Resident #54 on 11/15/2019 with a diagnosis of Hemiplegia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a BIMS score of 15 which indicated he was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #26 Findings Include: Review of the facility's policy, Oxygen Administration, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use . On 07/17/23 at 11:12 AM, Resident #26 was sitting in a wheelchair next to his bed. There was an oxygen (O2) concentrator in the corner of the room, with a nasal cannula stored on the back of the concentrator. Resident #26 was not wearing the nasal cannula and was unable to communicate if he had removed the cannula himself. There was no cautionary signage on the door of the room indicating that oxygen was being administered. Record review of the Physician's Order Sheet' revealed a Physician's Order dated 7/9/23 for Oxygen at 2L (liters) continuous r/t (related to) hypoxia. Record review of the Departmental Notes for Resident #26, dated 7/17/23 at 4:50 AM, revealed, . SPO2 (Saturation of peripheral oxygen) 94% on 2 lpm (liters per minute) via nasal cannula . On 07/18/23 at 02:00 PM, in an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed there was an O2 concentrator in the room for Resident #26. She also confirmed that there were no cautionary signs on the door indicating use of oxygen. On 07/20/23 at 12:27 PM, in an interview with the Director of Nursing (DON), she stated it was her expectation that all residents receiving oxygen therapy have cautionary signage for safety of the resident. Record review of the Face Sheet revealed the facility admitted Resident #26 on 3/14/23 and he had diagnoses including Obstructive Sleep Apnea and Diabetes Mellitus. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/2023 revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated he had severe cognitive impairment.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 for one (1) of four (4) residents reviewed with wandering and elopement behaviors. Resident #1 exited the facility through a window, unnoticed and unsupervised until License Practical Nurse (LPN) #2 found Resident #1 approximately 500 feet from the facility sitting on a tree stump at the front east side of the property. The facility's failure to provide supervision for Resident #1, with a known elopement risk, put Resident #1 and all other residents with wandering and elopement behaviors, at risk for serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 5/11/23 when Resident #1 exited the facility through a window in her room. The facility Administrator was notified of the IJ on 5/17/23 at 1:00 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 5/11/23, the SA determined the IJ and Substandard Quality of Care (SQC) to be Past Non-Compliance (PNC) and the IJ was removed as of 5/12/23, prior to the SA's first entrance on 5/16/23. Findings include: A review of the facility's Elopement Policy, revised 12/28/20, revealed, .Definition: An Elopement is considered to be when a (cognitively impaired resident, wanders without staff visually monitoring to an unsafe place inside or outside the facility .Facts to Consider .Anytime a resident is successful in exiting the facility unsupervised, this constitutes elopement . On 5/16/23 at 4:00 PM, in an interview with the Administrator, she stated that Resident #1 was admitted by the facility on 2/6/23, had a diagnosis of Alzheimer's disease, and was assessed for wandering and exit seeking behaviors. Resident #1 was deemed to be an elopement risk at that time because she exhibited wandering behaviors and made statements that she wanted to go home. On 5/11/23, the resident exited the facility through her window and was last seen by facility staff at 3:20 PM. At 4:00 PM, a nurse saw that the resident's windows were opened, and the window screens were outside of her windows, as if they had been pushed out. The Administrator confirmed that Resident #1 was located at 4:15 PM, approximately 500 feet from her room on the east side of the facility. Resident #1 was calm and approachable, and she was fully clothed in pants, a top, a jacket, and shoes. She had a skin tear on her wrist. She was transferred to the local Emergency Department (ED) for evaluation and returned to the facility the same day. The Administrator commented that following the incident, all residents were accounted for and were assessed for wandering behaviors. Resident #1 was placed on one-on-one supervision when she returned to the facility from the ED and window screws were installed so the windows would only open to six (6) inches for residents with exit-seeking behaviors. On 5/16/23 at 4:30 PM, during an observation, Resident #1's windows were approximately eight (8) feet from the ground (sidewalk). The outside of the building was brick. The SA walked with the Administrator and Director of Nurses (DON) the route the resident most likely took when she exited the facility. The area was a scattered growth of bushes and trees with a trail, and the ground was flat, with no large holes. On 5/16/23 at 4:40 PM, in an observation and interview with Resident #1, she was resting in her bed and was able to state her name, however, she was unable to recall the current date, time, or her whereabouts. She stated that she just wanted to go home. On 5/17/23 at 9:00 AM, in an interview with LPN #1, she confirmed on 5/11/23 at approximately 3:20 PM, she observed Resident #1 lying on the bed in her room. She stated that at 4:00 PM, while conducting her medication pass, she observed that the resident's door was closed. She entered the resident's room and noticed her windows were open and the window screens were missing. LPN #1 said she looked for the resident in the room and then immediately notified the charge nurse that Resident #1 was missing. She said that prior to the event, Resident #1 was calm and was not exhibiting exiting seeking behaviors. On 5/17/23 at 9:30 AM, an interview with LPN #2, she stated that on 5/11/23 at approximately 4:00 PM, she was informed that Resident #1 was missing from her room, and she began searching for the resident outside. She started walking and calling for the resident and then spotted her at 4:15 PM, sitting on a tree stump. She had stains on her clothing that appeared to be from dirt. On 5/17/23 at 11:00 AM, in an interview with the Maintenance Manager, he stated that following the elopement of Resident #1, he evaluated all resident windows to ensure there were no problems with the windows. He installed window screws so the windows would only open six (6) inches for the residents identified as an elopement risk. Record review of the facility's investigation, dated 5/12/2023, completed by the Administrator revealed, .Incident report date: 05/11/2023 .1520 (3:20 PM) 3-11 (shift) cart nurse observed resident lying in bed 1600 (4:00 PM) 3-11 nurse passed resident room and noticed resident was missing and both windows were open. Nurse searched resident's bathroom and immediately notified charge nurse of resident missing and window open. All staff immediately began looking for resident .1612 (4:12 PM) the administrator was notified .of resident missing. 1613 (4:13 PM) DON was notified .of resident missing .1615 (4:15 PM) resident was located on the front eastside of property sitting on a stump .Resident placed on 1:1 (one on one) staff monitoring . Record review of the weather history for 5/11/23 revealed the weather at 3:53 PM was cloudy and 79 degrees. Record review of the Face Sheet revealed the facility admitted Resident #1 on 2/6/23 with a diagnosis of Alzheimer's disease with late onset. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/23 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated she had severe cognitive impairment. Record review of the Risk Factors For Elopement for Resident #1, dated 2/6/23, revealed, .Elopement Risk Summary .High Risk . The facility implemented the following Corrective Action Plan prior to the SA's entrance on 5/16/23: 1. Brief summary of events: Resident #1 exited the building through her window on 05/11/2023. She was reported missing by Licensed Practical Nurse (LPN) #1 at 4 pm. Resident was located and assessed at 4:15pm by LPN #2 and transferred to the hospital for further assessment on 05/11/2023. Resident returned to the facility at 10:49pm on 05/11/2023 with no major injuries noted. Upon arrival resident #1 was moved to an interior room opening only to the enclosed courtyard and placed on 1:1 supervision. Care Plan was updated by Minimum Data Set (MDS) nurses registered nurse (RN) #1 and LPN 3#. The state agency (SA) presented the administrator with an immediate jeopardy (IJ) template. 2. All residents who are at risk for wandering have the potential to be affected by this same deficient practice. 3. An Emergency Quality Assurance (QA) meeting was held on 05/11/2023 at 4:43pm to include: The Administrator, Director of Nursing, Medical Director, Nurse Practitioner, Infection Preventionist (IP), MDS RN #1, MDS LPN #3, QA RN #2, and QA LPN #4 regarding Resident #1 exiting the building on 05/11/2023. Elopement and Missing Resident policies were discussed and no changes made to policies. 4. All residents were assessed for elopement risk by MDS RN#1, MDS LPN #3 and QA LPN #4 on 05/11/2023 and one additional resident was identified at risk. 5. The resident care plan was updated on 05/11/2023 by MDS RN #1 and Elopement binders at both nurse's stations were updated by QA RN #2 and DON RN #3 to include a picture of resident identified. 6. Wander guard placed by QA RN #2 on 05/11/2023 to resident identified. 7. All windows in residential area were checked by Maintenance and RN#3 on 05/11/2023 at 6:20pm to ensure there were no cracks, to make sure windows locked and that there were screens on windows. Windows of residents who are at risk for wandering were secured to open six inches on 05/11/2023 by maintenance. 8. In-services of elopement and missing person policies were started on 05/11/2023 with present staff. All other staff were in-serviced prior to beginning their next shift. No staff is allowed to work before being in-serviced. 9. All wander guard and security doors were checked by maintenance on 05/11/2023 to make sure all were functioning properly. 10. Monitoring procedures are: Quarterly elopement drills beginning 05/15/2023 Residents at risk for elopement reviewed at weekly Patients at Risk (PAR) meeting on 05/24/2023 for new interventions needed and care plans updated, QA will monitor the resident at risk for elopement procedures in the QA meeting for three months beginning 05/11/2023. 11. The facility alleges all corrective actions were completed on 5/11/23 and the immediate jeopardy was removed on 05/12/2023. The SA validated the facility's corrective action on 5/22/23: The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance and Performance Improvement (QAPI) meeting on 5/11/23. The actions taken to ensure the provision of adequate supervision to meet Resident #1's needs were verified with evidence of verification of the in-services, elopement drills, re-assessments, and wander guard checks. The SA verified that LPN #2 had located Resident #1 on 5/11/23 at 4:15 PM, she was transported to a local hospital and returned to the facility with no adverse findings. The SA verified all residents were assessed for elopement risk by MDS RN#1, MDS LPN #3 and QA LPN #4 on 05/11/2023 and one additional resident was identified at risk. The SA validated through record review and interviews, care plan was updated on 05/11/2023 by MDS RN #1 and Elopement binders at both nurse's stations were updated by QA RN #2 and DON RN #3 to include a picture of resident identified. The SA validated through record review and interviews wander guard placed by QA RN #2 on 05/11/2023 to the resident identified. The SA validated through observation, interviews and record review that all windows in the residential area were checked by Maintenance and RN#3 on 05/11/2023 at 6:20 pm to ensure there were no cracks, to make sure windows were locked, and that there were screens on windows. Windows of residents at risk for wandering were secured to open six inches on 05/11/2023 by maintenance. The SA observed the windows of residents identified as exit seekers to only open six (6) inches. The SA validated through interviews and record reviews in-services of elopement and missing person policies were started on 05/11/2023 with present staff. All other staff were in-serviced prior to beginning their next shift. No staff is allowed to work before being in-serviced. The SA validated through interviews and record reviews, wander guard and security doors were checked by maintenance on 05/11/2023 to make sure all were functioning properly. The SA validated through interviews and record reviews, monitoring procedures are: Quarterly elopement drills beginning 05/15/2023 Residents at risk for elopement reviewed at weekly Patients at Risk (PAR) meeting on 05/24/2023 for new interventions needed and care plans updated, QA will monitor the resident at risk for elopement procedures in the QA meeting for three months beginning 05/11/2023.

Based on record reviews, staff interviews, resident interviews, Resident Representative (RR) interview, job description reviews, and policy and procedure reviews, the facility failed to prevent neglect of a resident (Res) #1 from occurring by neglecting to document/record the treatment and services accessible to five (5) of five sampled residents reviewed for bowel functioning programs. Res. #1, #2, #3, #4 and #5. This failure had the potential to affect all residents in the facility. Resident #1 was admitted to the hospital with vomiting and stomach pain on [DATE] and later died from aspiration due to vomiting as a result of a bowel impaction on [DATE]. Resident #1 had no documented bowel movements (BM's) for 11 days prior to the hospital admission on [DATE]. Res #1 had no bowel programs/interventions documented on the Medication Administration Records (MAR) for January and February 2023, and Res #1 had no bowel programs/interventions nor any care and services rendered to Res #1 documented in the nursing notes for the month of February 2023. The facility's failure to prevent Res #1's constipation resulted in neglect of Res #1. The facility's failure to render the care and services necessary to prevent constipation resulted in the ultimate death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk for serious injury, harm, impairment and possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction. On [DATE] at 5:30 PM, the SA notified the facility Administrator (ADM) and the Director of Nursing (DON) of the IJ and SQC and provided the facility with the IJ template. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. Therefore the scope and severity for CFR 483.12 (a) (1) Freedom from Abuse and Neglect (F600) was lowered from an L to an F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner). Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2. Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADL's (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor . Interviews on [DATE] at 12:00 PM, with the DON and the facility ADM, the DON stated that the Activities of Daily Living (ADL) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The Certified Nursing Assistants ( CNAs) documented the ADL's for each resident at the end of each eight (8) hour shift. The Care Tracker Documentation Record ADL sheets were devised per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if something was not completed or a resident had issues the CNA's report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the ,d+[DATE] and ,d+[DATE] shifts. The DON revealed that for over a year the CNA's charted manually on paper charts and on [DATE] the facility installed computers (Kiosk) systems that now the CNA's digitally chart on each resident at the end of each 8 hour shift. If a resident does not have a bowel movement (BM) during that shift the CNA's report that to the Charge Nurse or to the medication cart nurses. BM's can only be reported once per shift in the digital system. On the manual (paper) system the CNA's can record/documented the number of BM's during the shift, that the resident had. The ADM stated that one (1) Resident #1 (Res #1) had been sent out to the hospital and later passed away. But (Res #1) did not have an infection and did not have a known bowel issue, I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting. Interview on [DATE] at 3:30 PM, with the DON revealed that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the residents care plans. The DON stated, We are not going to be able to provide for you what you are looking for. The CNA's did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The CNA's have been documenting manually on ADL sheets for approximately one (1) year due to no computer/kiosk' system available to CNA's. They had been told to manually document the BM's on the ADL sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse and the med cart nurse was to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were to document in the progress notes what they did and the results of the method for BM's. The DON stated that the nurses had not appropriately documented the BM's in the residents medical records. She stated that the ADL sheets had all been reviewed and an investigation completed by the two Quality Assurance (QA) nurses and there was no documentation of BM's on the ADL sheets and no documentation that the nurses had been notified of no BM's for the residents. The DON stated that they had no nursing notes and no documentation for Res #1 that she had BM's prior to her admission to the hospital on [DATE]. The DON thought that the med cart nurses were supervising the CNA's more closely, but they had not. The DON stated that the Bowel policy and procedure had not been followed and the ADL sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident . She stated the documented information needed for bowel movements on (Res #1) was not in the medical records. Resident #1: Interview with the DON on [DATE] at 9:00 AM, revealed that Res #1 had been admitted to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. The DON stated that Res #1 was diagnosed at the hospital on [DATE] with an impaction and on [DATE] Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. The DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. The facility had not followed the policy and procedure for bowel movement programs. DON stated that she felt responsible because she had assumed that the med cart nurses had been monitoring and supervising the CNA's. She should not have assumed she should have followed up and she should have supervised the nursing staff more closely. DON stated that the Quality Assurance (QA) nurses had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1. DON stated that the CNA's and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to her death from an impaction. Record review of the facility's Care Tracker Documentation Record ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNA's, in accordance to the facility policies and procedures. The CNA's had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM documented on the 7:00 AM-3:00 PM shift; and on [DATE] the CNA's documented one (1) BM during the 7:00 AM -3:00 PM shift. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNA's had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. There were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADL care sheet dated February 1, 2023-February 15, 2023 had documentation that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 had documentation that Res #1 had two (2) BM's during this time period, 1 BM recorded during the 3:00 PM-11:00 PM shift on [DATE], and1 BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no BM's recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023. Record review of the Medication Administration Record (MAR) for the month of February 2023 revealed that Res #1 received no bowel functioning treatment and services. The record review of the Nurse Practitioner's (NP) Progress Note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment. Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Abdominal Computerized Tomography (CT) scan findings were consistent with small bowel obstruction, fecal impaction and stercoral colitis without bowel perforation. Large amounts of stool throughout the rectum. History and Physical Reports revealed positive left-sided abdominal tenderness. The patient was made NPO (nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died . Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE]. Interview on [DATE] at 12:00 PM, with the facility ADM revealed that she never knew that the facility had not monitored the BM's of Res #1 and never was told of the bowel impaction of Res #1. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect. Interview on [DATE] at 2:15 PM, with the DON she stated that they knew on [DATE] when Res #1 died , that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses. Interview on [DATE] at 2:50 PM, with the Assistant Director of Nursing (ADON) stated that no one had ever asked her to monitor the ADL sheets or the charting of nursing staff. She stated that she had been working the unit on [DATE] when the NP had called for her to assess Res #1, who was vomiting. ADON went to Res #1 and found her with coffee ground vomit on her clothing and on the floor. The ADON stated that Res #1 was complaining of stomach pain and her stomach was distended. She called 911 and stayed with Res #1 until the ambulance came to pick up Res #1. The ADON stated that she reported to the NP that Res #1 appeared to possibly have a GI bleed from the looks of the coffee ground vomit. ADON stated that she learned the next day that Res #1 had passed away at the hospital on [DATE] and that the hospital had reported that her death was due to an impaction/bowel obstruction. ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRN's (as needed medications). She stated that there were no documented nursing progress notes for the month of February 2023. ADON stated that no one had asked her to monitor charts. ADON stated that she had assumed that the DON was monitoring the ADL sheets and the nursing progress notes. Interview on [DATE] at 3:00 PM, with the two (2) QA nurses RN#2 and LPN#1 revealed that they were asked by the DON to conduct an investigation of the incident involving Res #1 and they gave a written report to the DON and she gave it to the ADM. Then they had an emergency QA meeting with all the committee members to discuss the findings. They discovered that the CNA's had not documented on the ADL sheets the BM's of the residents and the nursing staff had not documented what actions they took to monitor the ADL's. The QA nurses stated that the BM's of Res #1 had not been recorded on the ADL sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023. Resident #1 was sent out to the hospital on [DATE] for vomiting and then Resident #1 died on [DATE]. Interview on [DATE] at 4:10 PM, with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BM's weren't recorded/documented. No one ever told me that was a problem, I'm not a nurse. I trusted what the nurses said. ADM stated that she had not read the hospital report for Res #1. At 8:20 AM on [DATE] interviews and record reviews were completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADL sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed the facility policy and procedure for bowel programs had not been followed. (ADM#2) stated that she learned a long time ago that if it was not written down in the medical records it did not happen. In an interview on [DATE] at 10:25 AM, with the ADON she confirmed that after the death of Res #1 on [DATE] that the facility had a QA committee meeting to discuss the lack of documentation for the BM's of Res #1 and the lack of nursing progress notes. The facility also discussed the need to return to using the kiosk so the monitoring would be easier to track. The facility reinstated the CNA's kiosk system on [DATE]. The ADON stated that she would be responsible for monitoring the ADL's through the week days and would do chart audits on the day shift 8:00AM-3:00PM Mon-Fri. and the weekend Charge Nurse would monitor the ADL sheets on the weekends. ADON stated that the facility was hiring a new Staff Development nurse and she would also monitor charts. Interview on [DATE] at 1:00 PM, with the Resident Representative (RR) of Resident #1 revealed that she had been at the facility visiting Res #1 on [DATE] or [DATE] when Res #1 told her that her stomach was hurting and that she was in pain. RR stated that (Res #1) had dementia and had some cognitive difficulties but that she would talk and did at times complain of generalized pain, but on this day she was specific with where the pain was located in her stomach. RR stated that Res #1 told her that she had told the nurse and the RR stated that she did not know who the nurse was but the nurse was told by Res #1 that her stomach hurt. I am positive that Res #1 reported not feeling well to the nurse, but I do not know who. RR did not witness the nurse evaluating Res #1. RR stated that the next day early in the morning at approximately 9:00 AM she was contacted by the facility that Res #1 was going to be transferred to the emergency room (ER) due to vomiting and stomach pain. RR met Res #1 at the hospital and stayed with her there. The hospital physician told RR that Res #1 had been vomiting due to a possible GI bleed and that they would run a test to see where the blood was coming from because she had vomit that looked like possible old blood was present somewhere. The hospital did the test and found that there was no GI bleed that Res #1 had a bowel impaction and that was why she was vomiting. The next day on [DATE] Res #1 passed away. RR stated that she had no Death Certificate as of yet but the hospital staff told her that the cause of death was due to an impaction. RR stated that she could not figure out how that could happen. RR stated that Res #1 was incontinent of bowel and bladder but at times she would ask to be assisted to the bathroom. RR stated that she had not obtained copies of the hospital records. RR stated that Res #1 had not received laxatives very much because she never knew of her having constipation issues. Interview on [DATE] at 2:00 PM, with LPN#3 med cart nurse, revealed that she was the nurse for Res #1 everyday that Res #1 was living in the facility. LPN#3 confirmed that she worked days 7:00 AM-7:00 PM and she was never told that Res #1 was not having BM's. The CNA's did not report any negative findings to her for Res #1. LPN#3 also stated that she did not chart in Res #1's nursing notes because she was not aware of any findings that required documentation in the progress notes for Res #1. LPN#3 stated that Res #1 was incontinent of bowel and bladder and that she (LPN#3) was told that Res #1 took herself to the toilet and was independent with toileting. LPN#3 stated that she would have given Res #1 a stool softener and followed the physician's orders had she been told by the CNA's that Res #1 had not had a BM within three (3) days. LPN#3 stated that it was the facility policy that if a resident had not had a BM in three (3) days then the CNA would report it to the med cart nurse. The CNA never reported to me that Res #1 had not had a BM. I was shocked to hear about what happened to Res #1. LPN#3 confirmed that she had never been told to monitor the CNA's ADL sheets. She confirmed that she now knows to monitor the ADL's and bowel movements (BM's) that the CNA's document in the kiosk. LPN#3 stated that the kiosk had been up and running since the middle of March. LPN#3 stated that she had been in-serviced on Abuse/Neglect many times and that she understood that neglect meant not providing services to residents. LPN#3 stated that she believed that Res #1 did not receive the treatments and services that she deserved. Interview on [DATE] at 2:00 PM, with the DON (RN#1) revealed that she had learned in the Attorney General's (AG's) in-service that neglect was defined as when services are not provided to residents that may cause disfavorable out comes. The DON stated that Res #1's death met the definition of neglect. Resident #2: Observation of Res #2 on [DATE] at 12:30 PM, revealed that Res #2 was sitting in a wheelchair outside of her room. Res #2 was not interviewable. Record review of Res #2's Care Tracker Documentation Record ADL sheet dated [DATE] revealed Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE]; and Res #2 had no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE]. Interview on [DATE] at 12:35 PM, with CNA#1 stated that she was the CNA for Res #2 on [DATE]. CNA#1 stated that she would record the bowel movements of the residents she worked with on each of her eight (8) hour shifts. At the end of the eight (8) hour shift if the resident had not had a BM in eight (8) hours the CNA's were to report that to the med cart nurse. Record review of Res #2 revealed a Face Sheet with an admitted [DATE] and diagnosis of Hemiplgia following cerebral infraction affecting right dominant side, among other diagnoses. Record review revealed a MDS dated [DATE] that contained a BIMS score of 3 which indicated that Res #2 was severely cognitively impaired. Resident #3: Observation on [DATE] at 12:20 PM revealed that Res #3, was lying in her bed. Res #3 was not interviewable. Record review of the Care Tracker Documentation Record ADL sheets for January and February 2023 for Res #3 were not documented by the CNA's for every eight (8) hour shift seven (7) days per week as outlined in the CNA's Job Description. Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired. Record review of Res #3's Face Sheet revealed an admitted [DATE] and diagnoses including Constipation, Heart Failure; and Hemiplegia following cerebral infract affecting right dominant side. Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADL's or bowel program. Res #3 had one (1) documented progress note dated [DATE] written by the social worker. No progress notes were documented for [DATE] by nursing staff. Interview on [DATE] at 1:00 PM with CNA #2 stated that she was assigned to work with Res #3 on [DATE] on the first (1st) shift. CNA#2 stated that she documented on the ADL sheets prior to [DATE] the BM's for residents on every shift. She stated that currently when she completed a shift she documented in the kiosk at the end of each eight (8) hour shift the ADL's and the BM's. If a resident does not have a BM on the eight (8) hour shift it is reported to the med cart nurse. The med cart nurse was responsible for checking the resident after the CNA reported to them. Resident #4: Interview and observation on [DATE] at 1:10 PM, with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. I am able to do most things for myself , I just have bad knees and have a need to be assisted with my meds at times. I go to the bathroom by myself, I toilet my self, I bath my self and do most all things for myself. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered a snack or juice of any type. No one had talked to her about her bowel movements. Res #4 stated that she thought that the reason why the staff had never asked her about her bowel movements was because she was cognitive and she was continent and had no bowel issues. Record review of the Care Tracker Documentation Record ADL sheets revealed Res #4's bowel functioning was not addressed by the staff for [DATE] - [DATE]. Interview on [DATE] at 1:40 PM with CNA#3 revealed that they manually recorded the BM's on the ADL sheets for over a year because the kiosk were broken. She stated that if a resident did not have a BM during the 8 hour shift the CNA's reported it to the med nurse. Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Res #4 was cognitively intact. Record review of Res #4's Face Sheet revealed an admitted [DATE] and diagnoses of Chronic Obstructive pulmonary disease; Gastro-escophageal reflux disease; among other diagnoses. Record review revealed that Res #4 had one (1) progress note date [DATE] and one (1) progress note written on [DATE] neither of which addressed her ADL's or bowel functioning. Res #4 had no progress notes documented for [DATE]. Resident #5: On [DATE] at 9:55 AM, during an interview and observation with Res #5 revealed she was lying in bed. She did answer questions asked of her. She stated that she wears briefs and has been incontinent of bowel and bladder. Res #5 stated that she has to have the assistance of staff for all her ADL's. Res #5 stated that the CNA's change her briefs for her on a regular basis. She stated that she had never been offered a stool softener or a laxative. She stated that a very few times she had been constipated and she had asked the nurse for Metamucil. Res #5 was unable to recall when the event occurred for the medication for constipation. Res #5 stated that she had more times that she had diarrhea or loose stools rather than constipation. She stated that she had never been offered Prune Juice and had never asked for Prune Juice. Res #5 stated that she had to have total assistance for all her ADL's. Record review of the Face Sheet for Res #5 revealed a re-admitted [DATE]. Res #5 had diagnoses of Acute heart disease of native coronary artery; Acute systolic (congestive) heart failure; among other diagnoses. Record review of Res #5's MDS dated [DATE] contained a BIMS score of 14 which indicated that she was cognitively intact. Record review of the Care Tracker Documentation Record [DATE] - [DATE] bowel function ADL sheet had Res #5 documented as having no bowel movements from [DATE]-[DATE] (3 consecutive days with no bowel movement) and from [DATE]-[DATE] (3 consecutive days with no bowel movement). There was no documentation in Res #5's medical record to indicate that the CNA's had notified the cart nurse of no BM's for Res #5. Record review of the February 2023 Care Tracker Documentation Record bowel function section of the ADL sheet revealed documentation that Res #5 had no bowel movements (BM's) for February ,d+[DATE], 2023. Res #5 had no bowel movements recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNA's had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation provided by the facility to confirm that the nurses (cart nurses) had been monitoring the BM's of Res #5 during the months of January-[DATE]. Summary: Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNA's and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to Res #1 having un-treated serious constipation which led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The

Based on interviews, record reviews and policy and procedure reviews the facility did develop and/or implement the bowel functioning Care Plans for five (5) of five (5) residents reviewed. Resident (Res) #1, Res #2, Res #3, Res #4, and Res #5 had no implemented bowel functioning programs maintained in the medical records. This failure had the potential to affect all residents in the facility. The facility's failure to implement the bowel functioning/constipation care plan for Res #1 and to render the care and services necessary to prevent constipation resulted in her admission to the hospital on [DATE] and her death on [DATE] from aspiration from vomiting due to small bowel obstruction. The facility's failure develop and implement care plans to provide the care and services necessary to prevent constipation placed all residents in the facility at risk for serious injury, harm, impairment and possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction. On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ template for F656. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. Therefore the scope and severity for CFR 483.21 Develop/Implement Comprehensive Care Plans (F656) was lowered from an L to an F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy and procedure titled: Comprehensive Care Plans undated revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments . Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner). Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2.Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADL's (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor . Interviews on [DATE] at 12:00 PM, with the Director of Nursing (DON (RN#1) revealed that the Certified Nursing Assistants (CNAs') documented the Activities of Daily Living (ADL's) for each resident at the end of each eight (8) hour shift. The ADL sheets were devised per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON stated that the Care Plans for the residents have not been followed and the nursing staff had not documented the bowel functions of each individual resident in accordance with the Care Plans. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if a resident had bowel issues the CNAs' report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse. If a resident does not have a bowel movement (BM) during that shift the CNAs' report that to the Charge Nurse or to the medication cart nurses. The DON stated that the bowel functioning programs for the residents had been reviewed by the Care Plan nurses and the DON and they had not been followed or implemented. Interview on [DATE] at 3:30 PM with the DON revealed the documented information needed for bowel movements on Res #1 was not in the medical records. The DON confirmed that the Care Plans for the residents had not been implemented. Resident #1: Record review of the Care Plan for Res #1 dated [DATE] revealed: Constipation I have constipation risk r/t (in reference to) advanced age, impaired mobility, meds does not take laxative/stool softener regularly Risk for constipation/diarrhea. Goal: Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE] .Interventions: Administer meds as ordered Monitor & record frequency and amount of BM Note any problem with consistency or color of BM Encourage 100% fluid intake pm meal tray check bowel sounds prn (as needed) Administer PRN med a/o (as ordered) Monitor for effectiveness of prn offer Prune Juice prn Notify MD if needed. Record review of the facility's ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNAs', in accordance to the facility policies and procedures. The CNAs' had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM documented on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs' documented one (1) BM during the 7:00 AM -3:00 PM shift. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNAs' had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. There were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADL care sheet dated February 1, 2023-February 15, 2023 had documentation that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 had documentation that Res #1 had two (2) BM's during this time period, 1 BM recorded during the 3:00 PM-11:00 PM shift on [DATE], and 1 BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no BM's recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023. Interview with the DON on [DATE] at 9:00 AM, DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. The DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. DON stated that the QA nurses had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1 as outlined in her care plan. Interview on [DATE] at 2:15 PM with the DON, she stated that they knew on [DATE] when Res #1 died , that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses. Interview on [DATE] at 2:50 PM with the Assistant Director of Nursing (ADON) stated that the Care Plan of Res #1 had not been implemented. Interview on [DATE] at 3:00 PM with the two (2) QA nurses RN#2 and LPN#1 confirmed that the Care Plan of Res #1 had not been followed for Res #1's bowel program. At 8:20 AM on [DATE], interviews and record reviews completed along with the former Administrator (ADM #2) and the current ADM both confirmed that the Care Plan had not been followed for ADL care and Constipation risk and the facility policy and procedure for bowel functioning programs had not been followed. ADM#2 stated that she learned a long time ago that if it was not written down in the medical records it did not happen. Interview on [DATE] at 11:45 AM, with the two (2) care plan/MDS (Minimum Data Set) nurses RN #5 and LPN#2 both confirmed that the care plans for Res #1 had not been followed. Resident #2: Record review of Res #2's Care Plan dated [DATE] revealed there was no Care Plan submitted by the facility that outlined the bowel functioning of Res #2. Record review of the Face Sheet revealed Resident #2 was admitted to the facility with an admitted [DATE]. Diagnoses included Hemiplegia following cerebral infraction affecting right dominant side; Dysphagia; Speech and language deficits; Contracture of muscle, right hand; Dementia; Anxiety disorder; Anorexia. Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired. Record review of Res #2's ADL sheet dated [DATE]-31, 2023 that had many days of missing documentation under the Bowel Function section [DATE] none of the three (3) eight (8) hour shifts had recorded any BM's for Res #2. There were 12 BM's recorded for Res #2 during the three (3) eight (8) hour shifts for the days of [DATE]-[DATE]. Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's recorded/documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE]; no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented/recorded in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE]. Resident #3: Record review of Res #3 revealed a Care Plan dated [DATE] that read: At constipation risk r/t (in reference to) advanced age, impaired mobility, meds. Goal: Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE] .Interventions: Observe & record frequency and amount of BM, Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, check bowel sounds prn, Observe for effectiveness of prn, Offer Prune Juice prn, Notify MD if needed, Administer meds as ordered (See MAR). Record review of the medical record revealed Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADL's or bowel program. No progress notes were documented for [DATE] by nursing staff. The ADL sheets for January and February 2023 for Res #3 were not documented by the CNAs' for every eight (8) hour shift seven (7) days per week. Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired. Record review of the Face Sheet revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia following cerebral infract affecting right dominant side; Constipation, unspecified; Senile degeneration of the brain. Resident #4: Interview with Res #4 on [DATE] at 1:10 PM, revealed that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered a snack or juice of any type. Res #4 stated that she had never been offered a stool softener or a laxative. Res #4 stated that she had more issues with loose stools rather than with constipation. No one had talked to her about her bowel movements. Record review of Res #4's Care Plan dated [DATE] revealed: Constipation has constipation risk r/t (in reference to) diverticulitis of the intestines, side effects of antipsychotic and antidepressant medications. Goal: Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE]. Interventions: Administer meds as ordered, Record any problems with color or consistency of BM, Notify MD as needed, Encourage 100% fluid intake on meal tray, Check bowel sounds prn (as needed) , Encourage fluid intake, Offer Prune juice prn, Observe and record frequency and amount of BM, Observe for effectiveness of prn. Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a BIMS score of 14 which indicated that Res #4 was cognitively intact. Record review of the Face Sheet revealed Res #4 was admitted to the facility on [DATE] with diagnoses that included Bipolar Disorder with mild depression; Chronic Obstructive pulmonary disease. Record review of the medical record revealed there was no documentation submitted by the facility to indicate that the Care Plan of Res #4 had been followed for constipation and/or the bowel functioning of Res #4. Resident #5: In an interview and observation on [DATE] at 9:55 AM, Res #5 she stated that she had never been offered a stool softener or a laxative. She stated that a very few times she had been constipated and she had asked the nurse for Metamucil. Res #5 was unable to recall when the event occurred for the medication for constipation. Res #5 stated that she had more times that she had diarrhea or loose stools rather than constipation. She stated that she had never been offered Prune Juice and had never asked for Prune Juice. Record review of Res #5's Care Plan dated [DATE] revealed: Constipation: I am at risk for constipation related to diuretic use, impaired mobility, medication side effects, opiate use. Goal: Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) by [DATE]. Interventions: Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, Check bowel sounds prn, Offer Prune juice prn (as needed) Administer my medication as per md orders, Observe & record frequency and amount of BM. Record review of the [DATE] - [DATE] bowel function ADL sheet had Res #5 documented/recorded as having no bowel movements from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). The ADL sheet had no BM's documented/recorded for Res #5 from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). Record review of the February 2023 bowel function ADL sheet documented that Res #5 had no bowel movements (BM's) for the first three (3) days of February (February ,d+[DATE], 2023). Res #5 had no bowel movements (BM's) documented/recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNAs' had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation in Res #5's medical record to indicate that the CNAs' had notified the cart nurse of no BM's for Res #5. There was no documentation provided by the facility to confirm that the nurses (cart nurses) had been monitoring the BM's of Res #5 during the months of January-[DATE]. Record review revealed that the Care Plan for Res #5 had not been implemented for Constipation. Record review of the Face Sheet revealed Res #5 was admitted to the facility on [DATE] with diagnoses that included Acute heart disease of native coronary artery and Acute systolic (congestive) heart failure Record review of the MDS dated [DATE] for Res #5 revealed BIMS score of 14 which indicated that she was cognitively intact. Summary: Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNAs' and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to Res #1 having un-treated serious constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not monitored and the CNAs' and licensed nurses had neglected to monitor Res #1 which ultimately resulted in her death at the hospital on [DATE]. The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNAs') were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNAs documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death. The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively. All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE]. Certified Nursing Assistants (CNAs') that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNAs' per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed. CNAs' have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNAs documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP). All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect. CNAs' and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//,d+[DATE] for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place. An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNAs charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse. An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed. We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE]. VALIDATION: On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets. On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified. The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNAs' working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNAs' documentation and to check the kiosk documentation after the CNAs' had documented. On [DATE] the SA confirmed through interviews that the CNAs' (CNAs#1, #2, #3, #4, #5, #6, #7, and CNAs#8) that they had begun digital documentation of the residents ADL's and BM's in the kiosk on [DATE]. Validated through interviews with five (5) LPN's and one (6) RN's that they were instituting the no bowel movement protocol. All interviewed licensed nurses confirmed that they would contact the NP or the MD if the no bowel movement protocol did not produce BM results. The SA confirmed through interviews and record reviews with six (6) Registered Nurses (RN's), eight (8) CNAs', five (5) LPN's, and the facility Administrator that all facility staff had been in-serviced on Abuse and Neglect and all staff knew that any signs and symptoms of abuse would be reported immediately to their supervisors and to the DON and ADM. The ADM and the DON both confirmed and produced the sign in sheets for review for the Abuse and Neglect in-service that was conducted on Friday [DATE] and on Monday [DATE] presented by the AGO. Confirmed through record review of in-services and through interview with RN#1, RN#2 and LPN#1 that they conducted in-service training of all staff that had worked on the importance of reviewing and following the care plans of all residents in order to prevent serious negative outcomes. Confirmed through interview with the two (2) MDS/Care Plan nurses (RN#5 and LPN#2) that all 88 resident care plans have bowel interventions in place. The QA Nurse (RN#2) and (LPN#1) confirmed through interview that the facility conducted an Emergency QA committee meeting on [DATE] to discuss the bowel program and the documentation of BM's and that there would be changes in the documentation by the CNAs' to the new kiosk system rather than the paper documentation. The x 2 QA nurses confirmed through interview that a new Staff Development nurse had been hired and she had begun on [DATE] with in-servicing of facility staff. The ADM confirmed through interview that the QA meeting on [DATE] had all members in attendance except the MD and the ADM confirmed that the DON is the certified (IP). The SA validated through interviews with the ADM that the facility QA committee had held a second QA committee meeting on [DATE] to discuss the deficiencies from the IJ and to discuss the Action Plan for removing the immediacy of the IJ. The ADM confirmed through interview that the QA meeting on [DATE] had all required members present including the MD and the IP. Staff interviewed on [DATE] for Validations of the facility's Removal Plan were: eight (8) CNAs'; six (6) RN's; five (5) LPN's; one (1) Activities Director; one (1) facility ADM; and one (1) DON.

Based on observations, record review, interviews, and policy and procedure reviews, the facility failed to implement the facility's protocol for monitoring bowel functioning for five (5) of five (5) residents reviewed, Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5, which resulted in Resident #1 becoming ill with vomiting and stomach pain and transferred to the hospital on [DATE]. On [DATE], Resident #1 died at the hospital as a result of a bowel impaction/obstruction. The facility's failure to render the care and services necessary to prevent constipation resulted in the death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk for the likelihood of serious illness and death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Resident #1 began vomiting and complaining of stomach pain. Resident #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction. On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ templates for F 600; F 609; F 656; F 684; and on [DATE] at 1:30 PM the SA provided IJ temple for F 835 to the facility. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE]. The IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. The scope and severity for CFR 483.25 (a) (1) Quality of Care (F 684) was lowered to an F while the facility monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy and procedure titled: Bowel Program Policy, dated [DATE], revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner). Review of the facility's policy and procedure titled: Activities of Daily Living (ADLs') dated ,d+[DATE] Date Reviewed/Revised: [DATE] revealed: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The staff will provide care on a timely basis to promote and prevent avoidable changes in care. Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2. Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADLs' (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor . Interview on [DATE] at 12:00 PM with the Director of Nursing (DON) (RN#1) and the facility Administrator (ADM) revealed that the facility currently had a resident census of 88 residents and was licensed for 105 resident beds. The Certified Nursing Assistants (CNAs) documented the ADLs' for each resident at the end of each eight (8) hour shift. The DON stated that the nurses work 12 hour shifts and the CNAs work 8 hour shifts. The DON stated that the Activities of Daily Living (ADLs) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The ADLs sheets were devised per the individual care plan of each resident. The ADLs sheets were the venue in which the care plans were followed and instituted for each resident. The DON stated that if something was not completed or a resident had issues, the CNAs report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the ,d+[DATE] and ,d+[DATE] shifts. The DON revealed that for over a year the CNAs charted manually on paper charts and on [DATE] the facility installed computers (Kiosk) systems that the CNAs now use to digitally chart on each resident at the end of each 8 hour shift. If a resident does not have a bowel movement (BM) during that shift, the CNAs was supposed to report the lack of BM to the Charge Nurse or to the medication cart nurses. BMs can only be reported once per shift in the digital system. On the manually (paper) system the CNAs documented the number of resident BMs during the shift. The ADM stated that Resident (Res) #1 had been sent out to the hospital and later passed away, but (Res #1) did not have an infection and did not have a known bowel issue; I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting. Interview on [DATE] at 3:30 PM, with the DON (RN#1) revealed that the facility did not have documentation to ensure that Bowel Movement (BM's) the Activities of Daily Living (ADLs) care had been implemented according to the residents care plans. DON stated We are not going to be able to provide for you what you are looking for. The CNAs did not document the Bowel Movements (BM's) on the ADLs sheets for the residents on each shift. The CNAs had been documenting manually on ADLs sheets for approximately one (1) year due to no computer/kiosk' system available to CNAs. They had been told to manually document the BMs on the ADLs sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse. The med cart nurse was supposed to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were supposed to document in the progress notes what they did and the results of the method for BMs. The DON stated that the nurses had not appropriately documented the BMs in the residents medical records. DON stated that the ADLs sheets had all been reviewed and an investigation completed by the facility's Quality Assurance (QA) nurses x 2, and there was no documentation of BMs on the ADLs sheets and no documentation that the nurses had been notified of residents' BMs. DON stated that they had no nursing notes and no documentation for Resident (Res) #1 stating that she had BMs prior to her admission to the hospital on [DATE]. DON said she thought that the med cart nurses were supervising the CNAs more closely, but they had not. DON stated that the Bowel policy and procedure had not been followed and the ADLs sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident. DON stated the documented information needed for bowel movements on (Res #1) was not in the medical records. Resident #1: Interview with the DON (RN#1) on [DATE] at 9:00 AM revealed that (Res #1) had been transferred to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. DON stated that Res #1 was diagnosed at the hospital on [DATE] with an impaction. The DON stated that on [DATE], Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. DON stated that the facility had no documentation that Res #1's BMs were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BMs had been monitored. DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. The DON stated that she had assumed that the med cart nurses had been monitoring and supervising the CNAs. DON stated that she should not have assumed, but she should have followed up and supervised the nursing staff more closely. The DON stated that the QA nurses x 2 had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1. The DON stated that the Quality Assurance (QA) nurses x 2, did all investigations and the written reports were given to the DON and to the facility (ADM). The DON stated that the facility had CNAs began ADLs, including BMs, documentation in the kiosk on [DATE]. DON stated that the CNAs and licensed nurses had failed to document and monitor the input and output of Res #1 which led to her hospital transfer and led to her death from an impaction. Record review of the Care Plan for Res #1 dated [DATE] read: Constipation I have constipation risk r/t (in reference to) advanced age, impaired mobility, meds does not take laxative/stool softener regularly Risk for constipation/diarrhea. Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE] Administer meds as ordered Monitor & record frequency and amount of BM Note any problem with consistency or color of BM Encourage 100% fluid intake pm meal tray check bowel sounds prn (as needed) Administer PRN med a/o (as ordered) Monitor for effectiveness of prn offer Prune Juice prn Notify MD if needed. Record review of the facility's Care Tracker Documentation Record ADLs care sheets for [DATE] through [DATE] for Res #1 revealed the sheets were not appropriately documented for Res #1's BMs on each eight (8) hour shift. The input and output of Res #1 was not documented in accordance to the facility policies and procedures for each eight (8) hour shift by the CNAs, . From [DATE] through [DATE], Res #1 had no (zero) BM's documented/recorded on the ADLs care sheets. There was no documentation in Res #1's medical record to indicate that the CNAs had notified the licensed nurses that Res #1 had no BMs for eight (8) days. The CNAs had documented/recorded that Res #1 had three (3) BMs during the dates of [DATE] through [DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM recorded/documented by the CNAs for Res #1 on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs documented/recorded that Res #1 had one (1) BM during the 7:00 AM -3:00 PM shift. The record review revealed that the progress notes for [DATE] did not contain any documentation of Res #1's lack of BMs or that the licensed nurses had monitored the BMs of Res #1 or that Res #1 had received treatment and services for the lack of BMs during the month of [DATE]. Record review revealed there were four (4) progress notes in [DATE], and there were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADLs care sheet dated February 1, 2023 through February 15, 2023 documented/recorded that Res #1 had no (zero) BMs from February 7, 2023 through February 15, 2023. The ADLs care sheet for Res #1 dated February 16, 2023 through February 28, 2023 documented/recorded that Res #1 had two (2) BMs during this time period one (1) BM recorded/documented during the 3:00 PM-11:00 PM shift on [DATE], and one (1) BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no (zero) BMs documented/recorded on the ADLs care sheets from February 21, 2023 through February 28, 2023. The facility documentation that was provided for Res #1's BMs for February 21, 2023 through February 28, 2023, indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023. The Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023. The record review of the Nurse Practitioner's (NP) progress note, dated [DATE] at 2:39 PM, revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment. Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Patient was made NPO and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. She did have a small bowel movement. Patient found to have urinary tract infection and started on antibiotics. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died . Cause of death Aspiration due to vomiting due to Small bowel obstruction. Time of death 1200 on 3 [DATE]. Interview on [DATE] at 12:00 noon with the facility Administrator (ADM) revealed that she had been the facility ADM for 1 year. The ADM stated that she had not received any reports from the QA nurses that the facility was responsible for the impaction of Res #1. The ADM stated that she had been told by the Nurse Practitioner (NP) that the hospital was to blame for Resident #1's death because they did not place an NG tube that was needed. ADM stated that she never knew that the facility had not monitored the BMs of Res #1 and was never was told of the bowel impaction of Res #1. The ADM stated that she was not a nurse and that she had been licensed as an ADM for approximately one (1) year. The ADM confirmed she was the one that instituted the new kiosk system on [DATE]. ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document. Interview on [DATE] at 2:15 PM with the DON (RN#1) revealed the facility knew on [DATE], when Res #1 died , that there was a problem with the monitoring of the BMs and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses. Interview on [DATE] at 2:50 PM with the Assistant Director of Nursing (ADON-RN#3) revealed that she had been working at the facility since [DATE]. She stated that no one had ever asked her to monitor the ADLs sheets or the charting of nursing staff. She stated that she had been working the unit on [DATE] when the NP had called for her to assess Res #1, who was vomiting. The ADON assessed and found Res #1 with coffee ground vomit on her clothing and on the floor. ADON stated that Res #1 was complaining of stomach pain and her stomach was distended. (ADON-RN#3) called 911 and stayed with the resident until the ambulance arrived to transfer Res #1. The ADON stated that she reported to the NP that Res #1 appeared to possibly have a GI bleed from the looks of the coffee ground vomit. ADON stated that she learned the next day that Res #1 had passed away at the hospital on [DATE], and that the hospital had reported that her death was due to an impaction/bowel obstruction. The ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRN's (as needed medications). The ADON stated that there were no documented nursing progress notes for the month of February 2023. The ADON stated that she did not know why the nurses had not documented progress notes for a month. The ADON stated that no one had asked her to monitor charts, and she had assumed that the DON was monitoring the ADLs sheets and the nursing progress notes. Interview on [DATE] at 3:00 PM with the two (2) QA nurses RN#2 and LPN#1 revealed that they were asked by the DON(RN#1) to conduct an investigation of the incident involving (Res #1) and they gave a written report to the DON and also to the ADM, then they had an emergency QA meeting with all the committee members present to discuss the findings. They discovered that the CNAs had not documented on the ADLs sheets the BMs of the residents and the nursing staff had not documented what actions they took to monitor the ADLs. The QA nurses stated that the BMs of Res #1 had not been recorded on the ADLs sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023. Interview on [DATE] at 4:10 PM with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BMs weren't recorded/documented. No one ever told me that was a problem. I trusted what the nurses said. The ADM stated that she had not read the hospital report for Res #1 and that the family of Res #1 was contacted and they did not raise any questions. The ADM stated that the AG's office came to the facility and in-serviced all staff on Abuse/Neglect. The ADM stated that she had called the Attorney General(AG) to come and in-service the staff because it was time for their annual Abuse/Neglect in-service. At 8:20 AM on [DATE] Interviews and record reviews completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADLs sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed that the Care Plan had not been followed for ADLs care and Constipation risk, and the facility policy and procedure for bowel programs had not been followed. Interview on [DATE] at 10:25 AM, with the ADON-RN#3, revealed that after the death of Res #1 on [DATE] that the facility had a QA committee meeting to discuss the lack of documentation for the BMs of Res #1 and the lack of nursing progress notes. The facility also discussed the need to return to using the kiosk so the monitoring would be easier to track. The facility reinstated the CNA's kiosk system on [DATE]. The ADON-RN#3 stated that she would be responsible for monitoring the ADLs' through the week days and would do chart audits on the day shift 8:00 AM-3:00 PM Monday through Friday, and the weekend Charge Nurse would monitor the ADLs sheets on the weekends. The ADON stated that the facility did not have a Staff Development Nurse but was hiring one and she would also monitor charts. Interviewed on [DATE] at 11:45 AM with Care Plan/MDS nurses, RN #5 and LPN#2, revealed they both confirmed that the care plans for Res #1 had not been followed and that the facility had a QA meeting immediately after Res #1 died on [DATE], and they learned at the QA meeting that Res #1 had died as a result of an impaction. They discussed at the QA meeting on [DATE] that the ADLs sheets had not been documented for bowel movements for Res #1 and that the nurses had not written nursing progress notes for Res #1 for over one (1) month. The Care Plan/MDS Nurses confirmed that the facility hired a new staff development nurse on [DATE] and she began in-services with all staff on [DATE]. Interview on [DATE] at 1:00 PM with the Resident Representative (RR) of Resident #1 revealed that she had been at the facility visiting Res #1 on [DATE] or [DATE] when Res #1 told her that her stomach was hurting. RR stated that (Res #1) had dementia and had some cognitive difficulties. I am positive that Res #1 reported not feeling well to the nurse, but I do not know who. RR did not witness the nurse evaluating Res #1. RR stated that the next day early in the morning at approximately 9:00 AM she was contacted by the facility that Res #1 was going to be transferred to the emergency room (ER) due to vomiting and stomach pain. RR met Res #1 at the hospital and stayed with her there. The hospital physician told RR that Res #1 had been vomiting due to a possible GI bleed and that they would run a test to see where the blood was coming from because she had vomit that looked like possible old blood was present somewhere. The hospital did the test and found that there was no GI bleed but that Res #1 had a bowel impaction and that was why she was vomiting. The next day, on [DATE], Res #1 passed away. RR stated that she had no Death Certificate as of yet but the hospital staff told her that the cause of death was due to an impaction. RR stated that she could not figure out how that could happen. RR stated that Res #1 was incontinent of bowel and bladder but at times she would ask to be assisted to the bathroom. Interview on [DATE] at 2:00 PM with LPN#3 med cart nurse, revealed that she was the nurse for Res #1 everyday that Res #1 was living in the facility. LPN#3 confirmed that she worked days 7:00 AM-7:00 PM and she was never told that Res #1 was not having BMs. The CNAs did not report any negative findings to her for Res #1. LPN #3 also stated that she did not chart in Res #1's nursing notes because she was not aware of any findings that required documentation in the progress notes for Res #1. LPN #3 stated that she documented on the MAR when she gave Res #1 meds. LPN #3 stated that Res #1 was incontinent of bowel and bladder and that she (LPN #3) was told that Res #1 took herself to the toilet and was independent with toileting. LPN #3 stated that she would have given Res #1 a stool softener and followed the physician's orders had she been told by the CNAs that Res #1 had not had a BM within three (3) days. LPN #3 stated that it was the facility policy that if a resident had not had a BM in three (3) days then the CNA would report it to the med cart nurse. The CNA never reported to me that Res #1 had not had a BM. I was shocked to hear about what happened to Res #1. LPN#3 confirmed that she had never been told to monitor the CNA's ADLs sheets. She confirmed that she now knows to monitor the ADLs' and bowel movements (BMs) that the CNAs document in the kiosk. LPN #3 stated that the facility had been using the kiosk since the middle of March. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and The medical record of Res #1 contained no monitoring of her BMs by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BMs of the resident led to Res #1 having untreated constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. Resident #2: Observation of Res #2 on [DATE] at 12:30 PM revealed that Res #2 was sitting in a wheelchair outside of her room. Res #2 was not interviewable. Record review of Res #2's Care Plan dated [DATE] revealed: I am incontinent of bowel and bladder, I have a history of UTI' and E-coli. This is r/t (in reference to) my limited mobility with transfers and toileting and my decreased cognition. Please monitor me for s/s (signs and symptoms) of UTI. Provide me incontinence pads Assess me for symptoms of urinary tract infection. Provide me with good pericare after each incontinent episode Observe me for acute behavioral changes that may indicate UTI Evaluate my fluid intake and hydration status Notify my MD as needed. There was no Care Plan submitted by the facility that outlined the bowel functioning of Res #2. Record review of Res #2 revealed a face sheet with an admitted [DATE] and diagnoses of Hemiplegia following cerebral infraction affecting right dominant side; Dysphagia; Speech and language deficits; Contracture of muscle, right hand; dementia; Anxiety disorder; Anorexia; among other diagnoses. Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired. Record review of Res #2's ADLs sheet, dated [DATE] through [DATE], revealed documentation under the Bowel Function section as follows Res #2 had no BM's recorded for five (5) consecutive days for [DATE] through [DATE]. Res #2 had no BM's recorded/documented on the ADLs sheets for three (3) consecutive days from [DATE]-[DATE]; and Res #2 had no BM's recorded on the ADLs sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented/recorded in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADLs care and services for [DATE]-[DATE]. Interview on [DATE] at 12:35 PM with CNA#1 revealed that she was the CNA for Res #2 on [DATE]. CNA#1 stated that Res #2 was wearing briefs and was incontinent of bowel and bladder. CNA#1 stated that she would record the bowel movements of the residents she worked with on each of her eight (8) hour shifts. At the end of the eight (8) hour shift if the resident had not had a BM in eight (8) hours the CNAs were to report that to the med cart nurse. Resident #3: Observation on [DATE] at 12:20 PM revealed that Res #3, was small and frail and was lying in fetal position on her right side. Res #3 was not interviewable. Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired. Res #3 had a face sheet that contained an admitted [DATE] and diagnoses of Heart Failure; Hemiplegia following cerebral infract affecting right dominant side; Vascular Dementia; Hypertension; Depression; Constipation, unspecified; Senile degeneration of the brain; among other diagnoses. Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADLs' or bowel program. Res #3 had one (1) documented progress note dated [DATE] written by the social worker. No progress notes were documented for [DATE] by nursing staff. The ADLs sheets for January and February 2023 for Res #3 were not documented by the CNAs for every eight (8) hour shift seven (7) days per week. Record review of Res #3 revealed a Care Plan dated [DATE] that read: At constipation risk r/t (in reference to) advanced age, impaired mobility, meds. Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE]. Observe & record frequency and amount of BM, Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, check bowel sounds prn, Observe for effectiveness of prn, Offer Prune Juice prn, Notify MD if needed, Administer meds as ordered (See MAR). Interview on [DATE] at 1:00 PM with CNA #2 she stated that she had been working at the facility as a CNA since [DATE]. She stated that when she completed a shift she documented in the kiosk at the end of each eight (8) hour shift the ADLs and the BMs. CNA #2 stated that she was assigned to work with Res #3 on [DATE] on the first (1st) shift. If a resident does not have a BM on the eight (8) hour shift it is reported to the med cart nurse. The med cart nurse was responsible for checking the resident after the CNA reported to them. CNA#2 stated that she documented on the ADLs sheets prior to [DATE]. CNA#2 stated that they documented on the ADLs sheets the BMs for residents on every shift. CNA #2 did not remember Res #1. Resident #4: Interview and Observation on [DATE] at 1:10 PM with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. Res #4 stated that the facility staff had been talking about the lady that died from an impaction for weeks. Res #4 stated the DON nor the ADM ever walk around and look, and they never go in and out of the residents rooms. Res #4 stated I am able to do most things for myself , I just have bad knees and have a need to be assisted with my meds at times. I go to the bathroom by myself, I toilet myself, I bath myself and do most all things for myself. I am aware that a person died from a bowel obstruction. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered juice of any type. Res #4 stated that she had never been offered a stool softener or a laxative. Res #4 stated that she had more issues with loose stools rather than with constipation. Res #4 stated that she thought that the reason why the staff had never asked her about her bowel movements was because she was cognitive and she was continent and had no bowel issues. Interview on [DATE] at 1:40 PM with CNA #3 revealed that she had worked the third shift 11:00 PM -7:00 AM since 2018 prior to today and yesterday. She stated that the third shift checked the residents every 2 hours and changed those that needed changing. She stated that if a resident did not have a BM during the 8 hour shift the CNAs reported it to the med nurse. CNA #3 stated that they report the BMs on the ADLs sheets in the kiosk since [DATE] and before that they wrote the BMs on the ADLs sheets every 8 hour shift. CNA #3 stated that they manually recorded the BMs on the ADLs sheets for over a year because the kiosk were broken. Record review of Res #4's Care Plan dated [DATE] revealed: Constipation has constipation risk r/t (in reference to) diverticulitis of the intestines, side effects of antipsychotic and antidepressant medications. Will have soft formed stool ,d+[DATE] x week (,d+[DATE] times per week) to next review [DATE]. Administer meds as ordered, Record any problems with color or consistency of BM, Notify MD as needed, Encourage 100% fluid intake on meal tray, Check bowel sounds prn (as needed) , Encourage fluid intake, Offer Prune juice prn, Observe and record frequency and amount of BM, Observe for effectiveness of prn. Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Res #4 was cognitively intact. Res #4 had a facesheet that revealed an admission da [TRUNCATED]

Based on record review, observations, job description reviews, interviews, and policy and procedure reviews, the facility administration failed to identify the staff's failure to monitor residents bowel movements and provide treatment and services to prevent avoidable changes in residents medical conditions as evidenced by the lack of documentation or the inaccurate documentation of five (5) of five (5) sampled residents bowel movement regimens. Resident (Res) #1, #2, #3, #4 and #5. This failure had the potential to affect all residents. The facility's failure to provide administrative oversight and supervision to prevent Res #1's constipation resulted in the ultimate death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk, and in a situation likely to cause serious injury, serious impairment, serious harm or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction. On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and on [DATE] at 1:30 PM the SA provided IJ template for F835 to the facility. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. Therefore the scope and severity for CFR 483.70 (a) (1) Administration (F835) was lowered from an L' to a F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy and procedure titled Reporting Alleged Violations with a revision date of [DATE] revealed, Policy: The purpose of this policy is to ensure that all alleged violations involving . neglect .are reported immediately to the administrator of the facility and to other state officials in accordance with State Law through established procedures (including to the State survey and certification agency) .Compliance Guidelines: 2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation is made . Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner). Record review of a written statement dated [DATE] and signed by the Administrator revealed I, __________(Proper name of Administrator) have not been issued a job description as Administrator at (Proper name of facility). Record review of the Job Description for the Director of Nursing, undated and unsigned revealed the facility job description titled Director of Nursing undated and unsigned revealed Job Summary: Administer all areas in the Nursing Department. This includes patient care, personnel management, and material management. Ensure that license requirements are met. Responsible for: 1. Staff education and performance 2. Staff supervision 3. Setting the standard for patient care. 4. Compliance with state and federal regulations to include . Care Plans, and patient records . Interviews on [DATE] at 12:00 PM, with the Director of Nursing (DON) and the facility Administrator (ADM) revealed that the facility currently had a resident census of 88 residents and was licensed for 105 resident beds. The DON stated that the Care Tracker Documentation Record Activities of Daily Living (ADL) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The Certified Nursing Assistants ( CNAs) documented the ADL's for each resident at the end of each eight (8) hour shift. The ADL sheets were developed per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if something was not completed or a resident had issues the CNAs report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the ,d+[DATE] and ,d+[DATE] shifts. The DON stated that the nurses work 12 hour shifts and the CNAs work 8 hour shifts. The DON revealed that for over a year the CNAs charted manually on paper charts. If a resident does not have a bowel movement (BM) during that shift the CNAs report that to the Charge Nurse or to the medication cart nurses. On the ADL sheets, the CNAs could record the number of BM's during the shift, that the resident had. DON stated that she had not reported any incidents of Neglect/Abuse to the State and that the ADM was responsible for all reporting to the State. The ADM stated that Resident #1 (Res) had been sent out to the hospital and later passed away. But (Res #1) did not have an infection and did not have a known bowel issue, I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting. ADM stated that she had not reported any Neglect/Abuse to the State Agency (SA) in the past three months (Jan-[DATE]). In an interview on [DATE] at 3:30 PM with the DON, she stated that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the residents care plans. The DON stated We are not going to be able to provide for you what you are looking for. The CNAs did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The CNAs have been documenting manually on ADL sheets for approximately one (1) year due to no computer/kiosk' system available to CNAs. They had been told to manually document the BM's on the ADL sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse and the med cart nurse was to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were to document in the progress notes what they did and the results of the method for BM's. She stated that the nurses had not appropriately documented the BM's in the residents medical records. The DON stated that the ADL sheets had all been reviewed and an investigation completed by the Quality Assurance (QA) nurses and there was no documentation of BM's on the ADL sheets and no documentation that the nurses had been notified of no BM's for the residents. DON stated that they had no nursing notes and no documentation for Res #1 that she had BM's prior to her admission to the hospital on [DATE]. DON thought that the med cart nurses were supervising the CNAs more closely, but they had not. DON stated that the Bowel policy and procedure had not been followed and the ADL sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident . She stated the documented information needed for bowel movements on (Res #1) was not in the medical records. During an interview at 9:30 AM on [DATE], the ADM stated that the cooperate office did not have a job description for her as Administrator and she was unable to provide the responsibilities of the ADM. ADM documented on facility letterhead a statement that she was unable to provide a job description for the facility Administrator (ADM). Resident #1: Record review of the Nurse Practitioner's (NP) progress note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chief Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment. Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Abdominal Computerized Tomography (CT) scan findings were consistent with small bowel obstruction, fecal impaction and stercoral colitis without bowel perforation. Large amounts of stool throughout the rectum. History and Physical Reports revealed positive left-sided abdominal tenderness. The patient was made NPO (nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died . Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE]. In an interview with the DON on [DATE] at 9:00 AM, revealed that Res #1 had been admitted to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. Res #1 was diagnosed at the hospital on [DATE] with an impaction and on [DATE] Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. The DON stated that she felt responsible because she had assumed that the med cart nurses had been monitoring and supervising the CNAs. DON stated that she should not have assumed she should have followed up and she should have supervised the nursing staff more closely. DON stated that the Cans and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to her death from an impaction. The DON confirmed that the CNAs' and the licensed nurses had not been adequately supervised and their documentation monitored for implementing the plan of care for each resident. Record review of the facility's Care Tracker Documentation Record ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNAs, in accordance to the facility policies and procedures. From [DATE]-[DATE] Res #1 had no (zero) BM's documented which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNAs had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The CNAs had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM recorded on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs documented (1) BM during the 7:00 AM -3:00 PM shift. The record review revealed that the progress notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's, that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. The ADL care sheet dated February 1, 2023-February 15, 2023 documented/recorded that Res #1 had no (zero) BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 documented/recorded that Res #1 had two (2) BM's during this time period (one (1) BM recorded/documented during the 3:00 PM-11:00 PM shift on [DATE], and one (1) BM on [DATE] during the 7:00 AM-3:00 PM shift). Res #1 had no (zero) BM's documented/recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023. Record review of the Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023. In an interview on [DATE] at 12:00 PM, with the facility Administrator (ADM) revealed that she had been licensed and the facility ADM for 1 year. She stated that she never knew that the facility had not monitored the BM's of Res #1 and never was told of the bowel impaction of Res #1. The ADM stated that she was not a nurse and that she was still learning the ropes. ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document the BM's. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect. In an interview on [DATE] at 2:15 PM, with the DON, she stated that they knew on [DATE] when Res #1 died , that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses. Interview on [DATE] at 2:50 PM, with the Assistant Director of Nursing (ADON-RN#3) revealed that she had been working at the facility since [DATE]. She stated that no one had ever asked her to monitor the ADL sheets or the charting of nursing staff. ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRNs (as needed medications). ADON stated that there were no documented nursing progress notes for the month of February 2023 and that this was not a standard of practice. The ADON stated that she did not know why the nurses had not documented progress notes for a month. She stated that no one had asked her to monitor charts. The ADON stated that she had assumed that the DON was monitoring the ADL sheets and the nursing progress notes. Interview on [DATE] at 3:00 PM, with the two (2) QA nurses, RN#2 and LPN#1, revealed that they were asked by the DON to conduct an investigation of the incident involving (Res #1) and they gave a written report to the DON and she gave it to the ADM. They discovered that the CNAs had not documented on the Care Tracker Documentation Record ADL sheets the BM's of the residents and the nursing staff had not documented what actions they took to monitor the ADL's. The QA nurses stated that the BM's of Res #1 had not been recorded on the ADL sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023. Resident #1 was sent out to the hospital on [DATE] for vomiting and then Resident #1 died on [DATE]. In an interview on [DATE] at 4:10 PM, with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BM's weren't documented. No one ever told me that was a problem, I'm not a nurse. I trusted what the nurses said. ADM stated that she had not read the hospital report for Res #1. ADM stated that the family of Res #1 was contacted and they did not raise any questions. ADM stated that this past Monday and last Friday the Attorney General's office came to the facility and in-serviced all staff on Abuse/Neglect. ADM stated that she had called the Attorney General(AG) to come and in-service the staff because it was time for their annual Abuse/Neglect in-service. ADM stated that she did not ask them to come do the in-service as a result of any incidents at the facility. At 8:20 AM on [DATE], interviews and record reviews were completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADL sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed that the Care Plan had not been followed for ADL care and Constipation risk and the facility policy and procedure for bowel programs had not been followed. (ADM#2) stated that she learned a long time ago that if it was not written down in the medical records it did not happen. Resident #2: Record review of Res #2's Care Tracker Documentation Record ADL sheet dated [DATE]-31, 2023 revealed many days of missing documentation under the Bowel Function section. Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's recorded/documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE], and no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. No progress notes were documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE]. Record review of Res #2 revealed a Face Sheet with an admitted [DATE] and diagnoses of Hemiplegia following cerebral infraction affecting right dominant side, Dysphagia, and dementia, among other diagnoses. Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview for Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired. Resident #3: Record review of the Care Tracker Documentation Record ADL sheets for January and February 2023 for Res #3 were not documented by the CNAs' for every eight (8) hour shift seven (7) days per week as outlined in the CNAs' Job Description. Record review revealed Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. Record review of Res #3 revealed that she had a MDS dated [DATE] that contained a BIMS score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired. Record review of Res #3's Face Sheet revealed an admitted [DATE] and diagnoses of Heart Failure; Hemiplegia following cerebral infract affecting right dominant side; Constipation, unspecified; Senile degeneration of the brain; among other diagnoses. Resident #4: Interview and Observation on [DATE] at 1:10 PM with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. No one had talked to her about her bowel movements. Record review of Res #4's Care Tracker Documentation Record revealed bowel functioning was not addressed by the staff for [DATE] - [DATE]. Record review of Res #4's MDS dated [DATE] contained a BIMS score of 14 which indicated that Res #4 was cognitively intact. Record review revealed Res #4 had a Face Sheet with an admitted [DATE] and diagnoses of Chronic Obstructive pulmonary disease; and Gastro-escophageal reflux disease; among other diagnoses. Resident #5: In an interview and observation on [DATE] at 9:55 AM, with Res #5 revealed that she wears briefs and has been incontinent of bowel and bladder. Res #5 stated that she has to have the assistance of staff for all her ADL's. Res #5 stated that the CNAs' change her briefs for her on a regular basis. Record review of the [DATE] - [DATE] Care Tracker Documentation Record bowel function ADL sheet had Res #5 documented/recorded as having no bowel movements from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). The ADL sheet had no BM's documented for Res #5 from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). There was no documentation in Res #5's medical record to indicate that the CNAs' had notified the med cart nurse of no BM's for Res #5. Record review of the February 2023 Care Tracker Documentation Record bowel function ADL sheet recorded/documented that Res #5 had no bowel movements (BM's) for the first three (3) days of February (February ,d+[DATE], 2023). Res #5 had no bowel movements (BM's) documented/recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNAs' had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation provided by the facility to confirm that the med cart nurses had been monitoring the BM's of Res #5 during the months of January-[DATE]. Record review for Res #5 revealed that she had a Face Sheet revealed a re-admitted [DATE]. Res #5 had diagnoses of Acute heart disease of native coronary artery; Acute systolic (congestive) heart failure; History of falling; among other diagnoses. Record review revealed Res #5's MDS dated [DATE] contained a BIMS score of 14 which indicated that she was cognitively intact. Summary: Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNAs' and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to Res #1 having un-treated serious constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not monitored and the CNAs' and licensed nurses had neglected to monitor Res #1 which ultimately resulted in her death at the hospital on [DATE]. The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNAs') were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNAs documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death. The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively. All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE]. Certified Nursing Assistants (CNAs') that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNAs' per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed. CNAs' have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNAs documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP). All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect. CNAs' and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//,d+[DATE] for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place. An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNAs charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse. An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed. We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE]. VALIDATION: On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets. On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x 2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified. The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNAs' working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNAs' documentation and to check the kiosk documentation after the CNAs' had documented. On [DATE] the SA confirmed through interviews that the CNAs' (CNAs#1, #2, #3, #4, #5, #6, #7, and CNAs#8) that they had begun digital documentation of the residents ADL's and BM's in the kiosk on [DATE].

Based on record review, staff interview, and policy and procedure review the facility failed to report to the proper authorities the neglect of Resident (Res) #1 who was admitted to the hospital on [DATE] from the facility with a bowel impaction that ultimately caused Res #1 to die in the hospital on [DATE] for one (1) of five (5) sampled residents. Resident #1 The facility's failure to report negligence to render the care and services necessary to prevent constipation which resulted in the ultimate death of Resident #1 placed all residents in a situation that caused or was likely to cause serious harm, serious injury, serious impairment or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when the facility failed to report the neglect that resulted in Res #1 being admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction. On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ template for F609. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit. Therefore the scope and severity for CFR 483.12 (a)(1) Reporting (F609) was lowered from an J to a D while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy and procedure titled Reporting Alleged Violations with a revision date of [DATE] revealed, Policy: The purpose of this policy is to ensure that all alleged violations involving . neglect .are reported immediately to the administrator of the facility and to other state officials in accordance with State Law through established procedures (including to the State survey and certification agency) .Compliance Guidelines: 2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation is made . Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care Interview on [DATE] at 12:00 PM, with the Director of Nursing (DON) and the facility Administrator (ADM) revealed the DON stated that she had not reported any incidents of Neglect/Abuse to the State Agencies (SA). The DON stated that the ADM was responsible for all Reporting to (SA). The ADM stated that Res #1 had been sent out to the hospital and later passed away. The ADM stated that she had not reported any Neglect/Abuse to the State Agency (SA) in the past three months (Jan-[DATE]). Interview on [DATE] at 3:30 PM with the DON (RN#1) revealed that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the facility's policies and procedures. The CNA's did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The nurses did not supervise the CNA's documentation of BM's for Res #1. The facility staff did not provide the care and services for Res #1 to prevent a bowel impaction. DON stated the documented information needed for bowel movements on (Res #1) was not in the medical records. The DON confirmed that she had not reported the neglect of Res #1 to any SA. Interview with the DON (RN#1) on [DATE] at 9:00 AM, The DON stated that the facility ADM was responsible for reporting to the State Agencies (SA). DON stated that she did not report to the State Agencies (SA). DON stated that the CNA's and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to Res #1's death from an impaction. DON stated that she had read the hospital report for Res #1's admission and the ER had documented that Res #1's cause of death was aspiration due to vomiting as a result of a bowel impaction. Record review of Res #1's medical records from [DATE] - [DATE] confirmed that the facility had not provided the treatments and services to Res #1 to prevent constipation and/or a bowel impaction. Record review of the facility's ADL care sheets for January -[DATE] were reviewed for Res #1 and was lacking documentation for Res #1's BM's and intake and output on each eight (8) hour shift. The ADL care sheet for [DATE] revealed the CNA's had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNA's had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. The ADL care sheet dated February 1, 2023-February 15, 2023 documented/recorded that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 documented/recorded that Res #1 had two (2) BM's during this time period. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. The Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023. Record review of the NP progress note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment. Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Patient was made NPO (Nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. She did have a small bowel movement. Patient found to have urinary tract infection and started on antibiotics. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died . Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE]. Interview on [DATE] at 12:00 PM, the ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect. The ADM stated that she never told any staff not to report the incident because she did not know neglect was an issue for Res #1. Interview on [DATE] at 2:15 PM, with the DON stated that they knew on [DATE] when Res #1 died , that there was a problem with the monitoring of the BM's and that was why she had asked the QA nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses. Interview on [DATE] at 3:00 PM, with the QA nurses RN#2 and LPN#1 revealed that they were asked by the DON to conduct an investigation of the incident involving Res #1 and they gave a written report to the DON and she gave it to the ADM. The QA nurses both confirmed that they did not report the findings of their investigation to the (SA). Interview at 9:30 AM on [DATE], the ADM confirmed that on [DATE] at 5:00 AM she called the incident of alleged neglect in to the required State Agencies (SA). Summary: Record review of the ADL sheets for (5) of (5) sampled residents Res #1, Res #2, Res #3, and Res #4, revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNA's and there was no MAR documentation of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/measure the BM's of the residents led to Res #1 having un-treated serious constipation which led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not appropriately monitored for BM's by the CNA's, and the licensed nurses had neglected to monitor Res #1's BM's which ultimately resulted in Res #1's death at the hospital on [DATE]. The facility had not reported the incident of neglect to the required SA's. The facility ADM reported the incident of neglect to the SA's on [DATE] at 5:00 AM as per the facility IJ Removal Plan. The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan: On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNA's) were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNA documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death. The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively. All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE]. Certified Nursing Assistants (CNA's) that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNA's per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed. CNA's have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNA documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP). All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect. CNA's and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//,d+[DATE] for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place. An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNA charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse. An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed. We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE]. VALIDATION: On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets. On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified. The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNA's working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNA's documentation and to check the kiosk documentation after the CNA's had documented. On [DATE] the SA confirmed through interviews that the CNA's (CNA#1, #2, #3, #4, #5, #6, #7, and CNA#8) that they had begun digital documentation of the residents ADL's and BM's in the kiosk on [DATE]. Validated through interviews with five (5) LPN's and one (6) RN's that they were instituting the no bowel movement protocol. All interviewed licensed nurses confirmed that they would contact the NP or the MD if the no bowel movement protocol did not produce BM results. The SA confirmed through interviews and record reviews with six (6) Registered Nurses (RN's), eight (8) CNA's, five (5) LPN's, and the facility Administrator that all facility staff had been in-serviced on Abuse and Neglect and all staff knew that any signs and symptoms of abuse would be reported immediately to their supervisors and to the DON and ADM. The ADM and the DON both confirmed and produced the sign in sheets for review for the Abuse and Neglect in-service that was conducted on Friday [DATE] and on Monday [DATE] presented by the AGO. Confirmed through record review of in-services and through interview with RN#1, RN#2 and LPN#1 that they conducted in-service training of all staff that had worked on the importance of reviewing and following the care plans of all residents in order to prevent serious negative outcomes. Confirmed through interview with the two (2) MDS/Care Plan nurses (RN#5 and LPN#2) that all 88 resident care plans have bowel interventions in place. The QA Nurse (RN#2) and (LPN#1) confirmed through interview that the facility conducted an Emergency QA committee meeting on [DATE] to discuss the bowel program and the documentation of BM's and that there would be changes in the documentation by the CNA's to the new kiosk system rather than the paper documentation. The x 2 QA nurses confirmed through interview that a new Staff Development nurse had been hired and she had begun on [DATE] with in-servicing of facility staff. The ADM confirmed through interview that the QA meeting on [DATE] had all members in attendance except the MD and the ADM confirmed that the DON is the certified (IP). The SA validated through interviews with the ADM that the facility QA committee had held a second QA committee meeting on [DATE] to discuss the deficiencies from the IJ and to discuss the Action Plan for removing the immediacy of the IJ. The ADM confirmed through interview that the QA meeting on [DATE] had all required members present including the MD and the IP. Staff interviewed on [DATE] for Validations of the facility's Removal Plan were: eight (8) CNA's; six (6) RN's; five (5) LPN's; one (1) Activities Director; one (1) facility ADM; and one (1) DON.

Based on staff interviews, record reviews, and facility policy review, the facility failed to provide documented evidence that it has, through its Quality Assurance and Performance Improvement (QAPI) Program, failed to call meetings to review and analyze data regarding the three (3) COVID-19 outbreaks within the facility in an effort to prevent the continued spread of COVID-19 prior to the State Agency (SA) entering the facility on 1/19/21, for a COVID-19 survey. This had the potential to affect 75 of 75 residents in the facility. The failure of the facility to utilize the QAPI program to determine the root cause of the COVID-19 outbreaks and identify deficient practices was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 1/19/2021, when the SA entered the facility and identified the failure of the facility's QAPI Committee to meet, review, and analyze data to develop corrective actions to decrease the spread of COVID-19. The facility's Interim Administrator was notified of the IJ on 1/21/2021. An acceptable, credible Removal Plan was provided on 1/22/2021, in which the facility alleged all corrective actions were completed on 1/21/2021, and the IJ was removed on 1/22/2021. The State Agency validated the Removal Plan on 1/23/2021 and determined the IJ was removed on 1/22/2021, prior to exit. Therefore, the scope and severity for 42 CFR §483.75 (a)(1)(b)(1)(2)(3)(f)(1)(2)(3)(4)(5)(6)(i) was lowered from a L to a F, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Quality Assurance and Performance Improvement, dated 02/28/2018, states, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. On 1/21/21, at 9:40 AM, in an interview with the Interim Director of Nursing (IDON), she stated the purpose of a QAPI committee is to provide organization of information and understanding of the situation. She stated that they should have had a QAPI meeting to discuss COVID-19. On 1/21/21, at 9:57 AM, in a phone interview with the Administrator, she stated that a QAPI meeting is on a list of things to do. We have discussed COVID-19, but not held a QAPI meeting. She stated the importance of a QAPI meeting is to get to the root cause of the problem and fix them or correct it to the best of their ability. She stated the facility can benefit from the QAPI meeting by finding out why things keep happening and make them better for the residents. She stated the facility would benefit from having QAPI meetings to discuss COVID-19. On 1/21/21, at 10:23 AM, in an interview with Medical Director, he stated that they have talked about having a QAPI meeting to discuss COVID-19, but they have not had one yet. He stated that he feels that it is important to have QAPI meetings to discuss COVID-19. He further stated they are planning to have a QAPI meeting at the facility soon. On 1/19/2021, at 4:35 PM, in an interview with Licensed Practical Nurse/Quality Assurance Nurse (LPN)#1, she stated that they have not had any Quality Assurance and Improvement (QAPI) committee meetings about COVID-19. She stated, the last QAPI meeting was about admissions and was on 11/19/2020. She stated that she understands the purpose of meetings is to discuss what is working and what is not working. Then the committee should plan ways to monitor identified issues for a certain amount of time to determine if a new policy is needed. She stated she is responsible for organizing the QAPI meetings, but every time that she has tried to plan a meeting to discuss COVID-19, staff were unavailable to attend the meetings. On 1/21/2021, at 4:45 PM, the (IDON) stated we have not done a root cause analysis related to COVID-19. She stated that we monitor situations and identify a problem and then we just try to figure out how to fix it. A record review of the facility's most recent QAPI committee meeting, dated 11/19/2020, revealed that the meeting was held to discuss the facility's admission process. Upon review of the previously held QAPI meetings, there was no mention of COVID-19. The facility provided an acceptable Removal Plan on 1/22/21. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) called on 01/21/2021 at 11:35 AM. The State Agency notified the Interim Administrator that an IJ had been identified. The facility failed to provide a certified Infection Preventionist who had completed specialized training in infection prevention and control to follow infection control guidelines prior to State Agency entering the facility on 01/19/2021. The facility failed to follow infection control guidelines to prevent the spread of COVID-19 due to the failure to don Personal Protective Equipment (PPE) before entering COVID-19 positive and observation resident rooms and proceeding to enter unexposed residents' rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. The facilities Quality Assurance and Performance Improvement (QAPI) Committee failed to put forth good faith attempts to identify the root cause of three different COVID-19 outbreaks and identify corrective actions to prevent further spread of COVID-19 cases and thereby decrease the likelihood for additional COVID-19 cases and deaths. Corrective Action: 1. The facility immediately disinfected the contaminated equipment in addition to all other potentially contaminated equipment in the facility upon notification of deficiency on 1-21-2021. The facility's Infection Preventionist immediately reviewed the documentation of the residents' signs and symptoms log for COVID-19 exhibited over the last 48 hours on 1-21-2021. The facility began receiving the results from Polymerase Chain Reaction (PCR) testing that was conducted on 48 residents on 1-19-2021. Of the 48 residents tested lab results revealed that nine (9) additional residents tested positive and 39 were negative. The facility employees were tested on [DATE] using rapid test and eight (8) staff members tested positive. On 1-20-2021 five (5) staff members were questioned at the screening desk and were tested due to being symptomatic and all five (5) tested positive. All remaining employees were tested on [DATE] with one (1) dietary staff member testing positive. 2. The facility's Infection Preventionist, the acting interim Director of Nursing (DON)/Registered Nurse (RN) #1, completed the required modules and passed the Infection Preventionist specialized training after State Agency had entered the building on January 19, 2021 at 1:00 PM and presented certificate to the State Agency on January 19, 2021 at 1:30 PM. On January 21, 2021, the facility was in possession of the following PPE: 3,035 N-95 masks; 1,840 surgical masks; 1,800 face shields; 2800 gowns; 1,900 bouffant cap; and gloves 8,500. 3. The Infection Preventionist reviewed all testing procedures and the results of the test that had been completed. The facility started in-service training with all employees of the facility that were currently working on January 21, 2021 at 2:00 PM. The training was initiated by the Interim Administrator, Licensed Practical Nurse (LPN) #4, RN #4, and LPN #5. The working staff members were in-serviced on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment and the donning and doffing of Personal Protective Equipment (PPE). A total of 22 employees were in-serviced: two (2) RN's, six (6) LPN's, eight (8) Certified Nursing Assistants (CNA), one (1) maintenance, four (4) housekeeping/laundry agency staff members, and one (1) administrative staff were completed at 3:20 PM. The facility will not allow any employee to work until they have completed all the in-services on the CDC Guidelines of appropriately donning and doffing PPE when entering and exiting isolation and observation rooms, appropriate hand hygiene, appropriate disinfection of medical equipment, and appropriate handling of laundry in the facility to prevent the spread of COVID-19 and other potential infectious diseases. 4. The facility on January 21, 2021 at 12:45 PM, held a QAPI committee meeting. The interim Administrator, RN #1, RN #4, LPN #1, LPN #4, LPN #5 Housekeeping Contractor #3, Dietary #1 and Maintenance #4 were all in attendance. The Medical Director and Administrator attended via telephone conference. The committee discussed the deficient performance in the facility which are the following: failure to provide a certified Infection Preventionist, failure to don PPE before entering COVID-19 positive rooms and observation resident rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. After the information provided by the State Agency was discussed and reviewed, it was determined that the root cause of the facility's deficient practice stemmed from the facility's failure to follow the policies regarding the surveillance and tracking and trending of COVID-19 and other infectious diseases. The QAPI Committee discussed and developed a plan to correct and monitor all deficient practices. Recommendations were made for Quality Assurance (QA) to monitor and implement all CDC approved training to bring into compliance all facility staff and contracted services. It is the responsibility of the QA nurse, administrative nurses, charge nurses, interim DON/ Infection Preventionist and interim Administrator to visually monitor and audit staff every shift daily for three weeks on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment, donning and doffing of personal protective equipment. The QAPI committee will reconvene on January 26, 2021 at 9:30 AM, to further develop the facility's long term plan to improve infection prevention through auditing, staff education, and modifications of policies and procedures to ensure evidence-based practice are followed within the facility. 5. The facility alleges that all corrective actions are completed on 1-21-21 and the IJ was removed on 1-22-21.

Based on observation, staff interviews, record reviews, and policy reviews, the facility failed to follow the guidelines of the Center for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The facility failed to follow infection control guidelines by not donning Personal Protective Equipment (PPE) before entering COVID-19 positive rooms and observation rooms, not wearing face mask correctly, not disinfecting medical equipment before leaving a COVID-19 positive hall, not washing hands in resident rooms, or using hand sanitizer before exiting, laundry on the floor at entrance of laundry room and COVID-19 positive resident room door not being closed. The facility had 97 residents and 68 staff to test positive for COVID-19. The facility had a total of nine (9) deaths related to COVID-19 from [DATE] through [DATE]. These deficient practices had the likelihood to affect 75 of 75 residents who currently reside in the facility. The facility's failure to ensure that the recommended guidelines set by the CDC practices to prepare for COVID-19 for Infection Control were followed placed all residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when observations of non-compliance with Infection Control occurred. The facility's Interim Administrator was notified of the IJ on [DATE], at 11:35 AM. The facility provided an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ on [DATE]. The State Agency (SA) validated the Immediate Jeopardy Removal Plan on [DATE], and determined the IJ was removed on [DATE], prior to exit on [DATE]. Therefore, the scope and severity for 42 CFR(s) 483.80(a)(1)(2)(e)(f)-Infection Control (F880) was lowered from a L to a scope and severity of a F, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Failure to Wear PPE per Guidance: A review of the facility's policy, titled Infection Prevention and Control Program, revised [DATE], revealed, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 4. Standard Precautions: a. All staff should assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. C. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. 5. IsolationTransmission-Based Precautions: a. A resident with an infection or communicable disease shall be placed on isolation/transmission-based precautions as recommended by current CDC guidelines. A review of the facility's policy, Transmission-Based Precautions, revised [DATE], revealed, Policy: It is our policy to take appropriate precautions to prevent transmission of infectious agents, based on the agents' modes of transmission. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on transmission-based upon hire and at least annually.3. Contact Precautions: c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. 4. Droplet Precautions- d. Healthcare personnel wear a mask for close contact with infectious resident. A review of the facility's policy titled, Hand Hygiene Policy, undated, revealed, Purpose: Hand hygiene is the primary means of preventing the transmission of infection. Hand hygiene refers to the use of hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Policy: .Hand washing with soap and water must be performed when: After removing gloves or gowns before and after assisting residents with meals. On [DATE], at 10:51 AM, in an interview with Licensed Practical Nurse (LPN) #1/Quality Assurance (QA) Nurse, her mask came down below her nose twice. LPN #1 continued to talk with SA while her face mask was below her nose. The SA asked her to pull her mask up. On [DATE], at 3:20 PM, in an observation and interview, Health Screener #2 was in the building without a face mask on. She stated she did not have one to put on. Health Screener #1 gave Health Screener #2 a mask to put on. Health Screener #2 stated she knew she was supposed to have a mask on. She stated, I know it causes infection not wearing a mask, but I didn't have one. On [DATE], at 3:29 PM, in an interview with LPN #1/QA Nurse stated the mask is used to prevent transmission of infection. She stated not having a mask on properly or pulling it down can cause infection to spread. It could cause someone get an infection. She stated she had training on the proper way to wear a mask. She stated, I thought the surveyor could not hear me, that is why I pulled it down. On [DATE], at 5:05 PM, an observation of the 300 COVID-19 Hall revealed Certified Nursing Assistant (CNA) #1 assisting Residents #20, #22, and #23 while not wearing PPE. CNA #1 did not have any gloves on, and she did not wash her hands before exiting resident room or use hand sanitizer on the wall in the hallway. Resident #23 tested positive for COVID-19 on [DATE]. Resident # 20 tested positive for COVID-19 on [DATE]. Resident #22 tested positive for COVID-19 on [DATE]. On [DATE], at 5:23 PM, an observation of the COVID-19 hall revealed CNA #2 was feeding Resident #19. The resident was on observation for COVID-19, with the door open. CNA #2 had her face mask pulled down below her nose and mouth. CNA #2 exited the room and did not wash her hands or use hand sanitizer in the hallway. On [DATE], at 12:00 PM, an observation of the 200 Hall revealed RN#3, LPN #2 and CNA #3 were passing out lunch trays to all residents on the 200 Hall without wearing PPE. This included Residents #6, #10, #11, #12, #13, #15, #16, #17, #18, and #19 who were on observation for COVID-19 and Residents #7, #8, #9 and #14 who were all positive for COVID-19. On [DATE] at 3:30PM, an observation of RN #2 entering rooms on the 200 Hall, that she entered two COVID-19 positive rooms (Residents #7 and #8) and one (1) observation room (Resident #16) without donning PPE. On [DATE], at 4:23 PM, in an interview with RN #2, she stated that there are two (2)-three (3) residents on the 200 Hall that are COVID-19 positive. RN#2 was unaware of which residents were positive and which were on observation. She stated that she entered observation rooms without PPE. RN #2 stated she was told that the residents had been tested and did not have COVID-19. She stated that from her knowledge as a nurse, she should have put PPE on. She stated that not putting on PPE and going from room to room can cause cross contamination. She stated the purpose of PPE is to protect herself and other residents. On [DATE], at 4:36 PM, in an interview with CNA #2, she stated that they told me that we have some residents on the 200 Hall that are COVID-19 positive. They did not tell me that the other residents on the hall are on observation. They told me either the residents are positive or not positive. She stated that she should have used precautionary measures with residents on observation, because they could be positive. She stated the purpose of PPE is to protect herself from getting positive and to keep her from passing COVID-19 to residents. She stated that she pulled down her mask so that the resident could hear her, because the resident could not hear well. She stated that the resident was on observation, so by pulling down her mask she could have exposed the resident and herself to COVID-19. On [DATE], at 4:52 PM, in an interview with CNA #1, she stated that all the residents have been positive for COVID-19 at one point. She stated she should have had PPE on because they have not reached their 10 days isolation period. She stated the purpose of PPE is to help prevent the spread of disease. She stated there is a possibility of spreading infection when you go from room to room without wearing PPE. On [DATE], at 8:40 AM, in an interview with RN #3, she stated that she was not paying attention to what rooms she was going in during tray pass on [DATE]. She stated that she was just grabbing trays and going into the resident's rooms to give them their tray. She stated she normally works on the 400 and 500 halls. She stated she had no idea why the other residents are on the 200 Hall. She stated if she knew that the residents were on observation, she would have fully dressed out in PPE. She stated if you do not wear PPE you could spread COVID-19. She stated if an elderly resident gets COVID-19 they could die. On [DATE], at 9:00 AM, in an interview with CNA #3 regarding lunch tray pass on [DATE], she stated the nurses told me that the residents on the 200 Hall were on droplet precautions. She stated that droplet precautions mean, I guess they are under observation for COVID-19. She stated that they are more likely to develop COVID-19 and she should have put on PPE. She stated that by not having PPE on, she could spread COVID-19 from room to room. She stated that the main concern is that residents getting COVID with underlying conditions could die. She stated she was just trying to get the lunch trays passed out. She stated she had to work both 100 and 200 halls today. She stated she knew that some of the residents were COVID-19 positive. She stated that the resident care is more important than getting food out. On [DATE], at 9:15 AM, in an interview with LPN #2 regarding tray pass on [DATE], he stated that he was aware some of the residents had COVID-19. He stated yesterday was his first day working at the facility. He stated RN#3 told me four (4) of the residents were positive on the hall and the rest of the residents were negative. He stated that not putting on PPE was a mistake, and he should have put on PPE. He stated by not putting on PPE and going from room to room could cause cross contamination. He stated RN#3 did not tell him anything else about the other residents on the hall. He stated that resident's immune systems are low, and they could get COVID-19 and die. He stated that he was being oriented by RN #3. Record review of the Residents' Face Sheets revealed the following: Resident #6 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and placed on observation. Resident #7 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #8 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #9 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #10 was admitted to the facility on [DATE]. Resident #10 was exposed to COVID-19 on [DATE] and placed on observation. Resident #11 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and placed on observation. Resident #12 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and placed on observation. Resident #13 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and placed on observation. Resident #14 was admitted to the facility on [DATE]. The resident was exposed on COVID-19 on [DATE] and on [DATE], when tested , the resident was positive for COVID-19. Resident #15 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and was placed on observation. Resident #16 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and was placed on observation. Resident #17 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #18 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] was and placed on observation. Resident #19 was admitted to the facility on [DATE]. The resident was exposed to COVID-19 on [DATE] and was placed on observation. Resident #20 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #22 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #23 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Failure to Follow Infection Control Precautions: A review of the facility's policy titled, Cleaning and Disinfectant of Resident-Care Equipment, revised [DATE], revealed, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. A record review of the facility's policy, titled, Soiled Linen Handling and Storage Policy, revised [DATE], revealed, Policy: It is the policy of this facility that linens will be handled as follows: Never placed on the floor. Clean linen should be kept covered at all times. A review of the facility's policy titled, Coronavirus Surveillance, dated [DATE], revealed, Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness Policy Explanation and Compliance Guidelines: 8. The Infection Preventionist, or designee, will track the following information: d. Employee compliance with hand hygiene. e. Employee compliance with standard and transmission-based precautions. f. Employee compliance with cleaning and disinfection policies and procedures. On [DATE], at 3:00 PM, an observation revealed a large, uncovered laundry cart in the hallway next to the entrance door of the laundry department. The cart was full of clean resident positioning bolsters and heel protectors. There was a pair of blue heel protectors on the floor next to the cart along with a glove and a large amount of dust. In an interview at this time, Housekeeping Supervisor #1 stated the linen in the cart was not being used right now. On [DATE], at 5:10 PM, an observation of the 300 COVID-19 Hall revealed an X-ray Technician came out of Resident #21's room, with an X-ray machine. He did not sanitize the machine before leaving the COVID-19 Hall. He went through the facility without disinfecting the X-ray machine and exited through the facility entrance. Resident #21 tested positive for COVID-19 on [DATE]. On [DATE], at 11:20 AM, in a phone interview with the X-ray Technician #1 stated, he cleans his medical equipment before putting it in the car. He stated that going down the hall without cleaning equipment before exiting the COVID-19 Hall could cause the spread of infection. He stated he should have cleaned the medical equipment before leaving the hall. Record review of the Face Sheet for Resident #21 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Failure to Follow Isolation Precautions: A review of facility's policy titled, Isolation Precautions, revised [DATE], revealed, It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. On [DATE], at 8:45 AM, an observation on the 500-Hall revealed that the door of Resident #24's room was not closed. There was a sign on the door for droplet precautions. Resident #24 tested positive for COVID-19 on [DATE]. On [DATE], at 11:22 AM, an observation of the 500-Hall revealed Resident #25's door was not closed. There was a sign on the door for droplet precautions. Resident #25 tested positive for COVID-19 on [DATE]. At that time, LPN #4 was on the 500-Hall at the medication cart. On [DATE], at 1:23 PM, in an interview, LPN #4 stated the doors needed to be kept closed to the COVID-19 positive resident's rooms under quarantine to keep the infection from spreading in the building. He stated that the doors not being closed can cause the resident's coughed droplets to get into the hallway and could spread. He stated that droplets are anything that be coughed and spread airborne, including sputum. On [DATE], at 5:21 PM, an observation of the COVID-19 hall revealed that the doors of Residents #11, #12, #18, and #19, all of whom were on observation for COVID-19, were open. Record review of the Residents' Face Sheets revealed the following: Resident #24 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Resident #25 was admitted to the facility on [DATE]. The resident was diagnosed with [REDACTED]. On [DATE], at 3:38 PM, in an interview with Interim Director of Nursing (IDON)/Infection Control Preventionist, she stated the resident's doors should be closed when the residents are on droplet precautions. She stated that anyone passing the door can be exposed to COVID-19. She stated when staff masks are down, it defeats the purpose of wearing a mask when you pull it down. She stated you could be asymptomatic and still spread COVID-19. She stated the mask is not only to protect the staff, but it is to prevent from spreading COVID-19. She stated Health Screener #2 should have had a mask on before entering the facility. She stated by her not having a mask on it could cause infection to spread. She stated we had an in-service on PPE. She stated Health Screener #2 has been spoken to about not wearing her mask. This is not Health Screener #2's first time not wearing a mask. She stated that as of [DATE], they have had a total of 89 residents who have tested positive for COVID-19. The first resident tested positive was [DATE]. The first staff tested positive was [DATE]. She stated they have had a total of 63 staff tested positive as of [DATE]. One staff expired due to COVID-19. This prompted us to do facility wide testing in July and we had three (3) staff positive for COVID-19. The IDON stated, that there were two (2) residents on the 200 COVID-19 Hall that were positive for COVID-19, the other residents were left on the 200 Hall due to exposure on [DATE]. On [DATE], at 9:40 AM, in an interview with the IDON, she stated that the staff should not have gone into COVID-19 positive rooms and residents under observation without wearing PPE. She stated that is an issue. She stated when a resident is under observation, the staff should put on PPE before entering resident's room. She stated the staff's actions can cause cross contamination. She stated the elderly have underlying health conditions that increase their chances of dying. She stated when you have COVID-19 positive and pending residents receiving care from a staff member who does not don PPE before giving care, it is an issue. On [DATE], at 9:57 AM, in a phone interview with the Administrator, she stated that the reason for using PPE is to slow down the spread of COVID-19 or Influenza. She stated when a resident is placed on droplet precautions that it means that the staff should wear PPE to prevent the spread of disease. She stated if staff enter a room without PPE on, they can spread infection from room to room. She stated staff should wear a face mask when they enter the facility to prevent spreading the infection. She stated laundry on the floor is cross contamination. On [DATE], at 10:23 AM, in an interview with the Medical Director (MD), he stated that he was aware of all the outbreaks of COVID-19 in the facility and that either myself or the Nurse Practitioner are in the facility daily. He stated he has made changes but it has been a struggle. He stated it is hard to control. Employees have contact with their families and others and bring it in. Resident are isolated and tested if they have signs and symptoms of COVID-19 and staff are tested 2 times a week and screened for signs and symptoms. Some don't have signs and symptoms but have it and bring it in. On [DATE], at 2:30 PM, in an interview with the Administrator stated that he was only able to get three (3) of the eight (8) death certificates that the SA requested. He stated that the remainder of the death certificates were not available as they were not complete at this time. In a record review, of a list provided by the facility revealed that nine (9) residents had expired from COVID-19 between [DATE] and [DATE]. The record review reveals that Residents #26, #27, #28, #29, #30, #31, #32, #33, and #34 expired from COVID-19. A record review of the last in-service revealed that the in-service on [DATE] included COVID, Isolation and Handwashing. The in-service was conducted by the previous DON. Review of the sign-in sheet revealed that CNA #4 attended. The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) called on [DATE] at 11:35 AM. The State Agency notified the interim Administrator that an IJ had been identified. The facility failed to provide a certified Infection Preventionist who had completed specialized training in infection prevention and control to follow infection control guidelines prior to State Agency entering the facility on [DATE]. The facility failed to follow infection control guidelines to prevent the spread of COVID-19 due to the failure to don Personal Protective Equipment (PPE) before entering COVID-19 positive and observation resident rooms and proceeding to enter unexposed residents' rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. The facilities Quality Assurance and Performance Improvement (QAPI) Committee failed to put forth good faith attempts to identify the root cause of three different COVID-19 outbreaks and identify corrective actions to prevent further spread of COVID-19 cases and thereby decrease the likelihood for additional COVID-19 cases and deaths. Corrective Action: 1. The facility immediately disinfected the contaminated equipment in addition to all other potentially contaminated equipment in the facility upon notification of deficiency on [DATE]. The facility's Infection Preventionist immediately reviewed the documentation of the residents' signs and symptoms log for COVID-19 exhibited over the last 48 hours on [DATE]. The facility began receiving the results from Polymerase Chain Reaction (PCR) testing that was conducted on 48 residents on [DATE]. Of the 48 residents tested lab results revealed that nine (9) additional residents tested positive and 39 were negative. The facility employees were tested on [DATE] using rapid test and eight (8) staff members tested positive. On [DATE] five (5) staff members were questioned at the screening desk and were tested due to being symptomatic and all five (5) tested positive. All remaining employees were tested on [DATE] with one (1) dietary staff member testing positive. 2. The facility's Infection Preventionist, the acting interim Director of Nursing (DON)/Registered Nurse (RN) #1, completed the required modules and passed the Infection Preventionist specialized training after State Agency had entered the building on [DATE] at 1:00 PM and presented certificate to the State Agency on [DATE] at 1:30 PM. On [DATE], the facility was in possession of the following PPE: 3,035 N-95 masks; 1,840 surgical masks; 1,800 face shields; 2800 gowns; 1,900 bouffant cap; and gloves 8,500. 3. The Infection Preventionist reviewed all testing procedures and the results of the test that had been completed. The facility started in-service training with all employees of the facility that were currently working on [DATE] at 2:00 PM. The training was initiated by the Interim Administrator, Licensed Practical Nurse (LPN) #4, RN #4, and LPN #5. The working staff members were in-serviced on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment and the donning and doffing of Personal Protective Equipment (PPE). A total of 22 employees were in-serviced: two (2) RN's, six (6) LPN's, eight (8) Certified Nursing Assistants (CNA), one (1) maintenance, four (4) housekeeping/laundry agency staff members, and one (1) administrative staff were completed at 3:20 PM. The facility will not allow any employee to work until they have completed all the in-services on the CDC Guidelines of appropriately donning and doffing PPE when entering and exiting isolation and observation rooms, appropriate hand hygiene, appropriate disinfection of medical equipment, and appropriate handling of laundry in the facility to prevent the spread of COVID-19 and other potential infectious diseases. 4. The facility on [DATE] at 12:45 PM, held a QAPI committee meeting. The interim Administrator, RN #1, RN #4, LPN #1, LPN #4, LPN #5 Housekeeping Contractor #3, Dietary #1 and Maintenance #4 were all in attendance. The Medical Director and Administrator attended via telephone conference. The committee discussed the deficient performance in the facility which are the following: failure to provide a certified Infection Preventionist, failure to don PPE before entering COVID-19 positive rooms and observation resident rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. After the information provided by the State Agency was discussed and reviewed, it was determined that the root cause of the facility's deficient practice stemmed from the facility's failure to follow the policies regarding the surveillance and tracking and trending of COVID-19 and other infectious diseases. The QAPI Committee discussed and developed a plan to correct and monitor all deficient practices. Recommendations were made for Quality Assurance (QA) to monitor and implement all CDC approved training to bring into compliance all facility staff and contracted services. It is the responsibility of the QA nurse, administrative nurses, charge nurses, interim DON/ Infection Preventionist and interim Administrator to visually monitor and audit staff every shift daily for three weeks on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment, donning and doffing of personal protective equipment. The QAPI committee will reconvene on [DATE] at 9:30 AM, to further develop the facility's long term plan to improve infection prevention through auditing, staff education, and modifications of policies and procedures to ensure evidence-based practice are followed within the facility. 5. The facility alleges that all corrective actions are completed on [DATE] and the IJ was removed on [DATE].

Based on staff interviews, record reviews and facility policy review, the facility failed to have an Infection Preventionist on staff, that had completed specialized training in Infection Prevention and Control, prior to State Agency (SA) entering the facility on 1/19/21, for a COVID-19 survey. This had the potential to affect 75 of 75 residents in the facility. The failure of the facility to ensure that the facility had an Infection Preventionist who had completed specialized training in Infection Control, prior to SA entering the facility on 1/19/21 caused all residents to be at risk, and in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 1/19/21, when the SA entered the facility. The facility Interim Administrator was notified of the IJ on 1/21/21, at 11:35 AM. An acceptable, credible Removal Plan was provided on 1/22/21 in which the facility alleged all corrective actions were completed 1/21/21 and the IJ was removed on 1/22/21. The SA validated the facility's Immediate Jeopardy Removal Plan on 1/23/21 and determined the IJ was removed on 1/22/21, prior to the exit on 1/23/21. Therefore, the scope and severity 42 CFR(s) §483.80(b)(4)(c)- Infection Preventionist (F882) was lowered from L to a scope and severity of a F, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: The Facility's hiring policy, titled Infection Prevention Nurse, undated, maintain current knowledge of federal, state, and local regulations and ensure that the facility leaders are informed of appropriate issues, understand and comply with infection control, safety and Occupational Safety and Health Administration (OSHA) procedures and regulations. On 1/19/21, at 8:35 AM, in an interview with Interim Director of Nursing (IDON)/ Infection Control Nurse, she stated she has completed the Infection Preventionist training. She stated she would go to the site and print out certificates. On 1/19/21 at 10:00AM, in an interview with the IDON/Infection Control Preventionist, she stated, I did not know there was a final test to take for the certification. I took the test and made 74 percent out of the 100 percent. She stated she had to make 80 percent to pass the test. She stated she was not sure if the current Licensed Practical Nurse (LPN)#3/Infection Control Nurse had completed the certification. On 1/19/21, at 12:58 PM, in an interview with IDON/Infection Control Preventionist, she stated she was the Infection Control Nurse March of 2020 through September 2020. On 1/21/21, at 9:40 AM, in an interview with the IDON/Infection Control Preventionist, she stated the purpose of an Infection Preventionist is to control and prevent infections. She stated the role of the Infection Preventionist is to control the outbreak and identify the cause of the outbreak. She stated a nurse who has not completed all specialized training, does not have all the knowledge needed to do the job. On 1/21/21 at 9:57 AM in a phone interview with the Administrator, she stated it is important for the Infection Control Nurse to have a certification. She stated she was not aware that the nurse had not completed the necessary training. On 1/21/21 at 11:05 AM, in an interview with IDON/Infection Control Preventionist, she stated LPN # 3 is the current Infection Control Nurse. She has not completed the specialized training. She stated that LPN #3 is out due to COVID-19. A record review of LPN #3/ Infection Control Nurse's Certificates of Training revealed certificates for Module one (1), Module two (2) through four (4) dated 9/20/20, Module five (5) through six A (6)dated 9/27/20, Modules 6 B and seven (7) dated 9/28/20, Modules eight (8) through ten (10) dated 10/4/20, Modules 11A through 11 D, dated 10/11/20,and Modules 12 through 15, dated 10/18/20. A record review of IDON Certificates of Training revealed certificates for Module 1 dated 2/17/20, Module 2 dated 2/18/20, Module 3 dated 2/24/20, Module 4 dated 2/24/20, Module 5 dated 2/25/20, Module 6A dated 2/27/20, Module 6 B dated 3/9/20, Module 7 dated 3/12/20, Module 8 dated 3/13/20, Module 9 dated 3/16/20, Module 10A and 10B dated 3/19/20, Module 10C dated 3/20/20, Module 10 D dated 4/8/20, Module 11A,dated 4/23/20, Module11B, dated 4/24/20,Module 11C,dated 5/5/20, Module 11D dated 5/6/20, Module 12A dated 9/21/20, Module 12B,13 and 14, dated 9/23/20 and Module 15, dated 10/02/20. A record review of the IDON/ Infection Preventionist Specialized Training Certification certificate was dated for 1/19/21. The facility provided an acceptable Removal Plan on 1/22/21. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Removal Plan Immediate Jeopardy (IJ) called on 01/21/2021 at 11:35 AM. The State Agency notified the interim Administrator that an IJ had been identified. The facility failed to provide a certified Infection Preventionist who had completed specialized training in infection prevention and control to follow infection control guidelines prior to State Agency entering the facility on 01/19/2021. The facility failed to follow infection control guidelines to prevent the spread of COVID-19 due to the failure to don Personal Protective Equipment (PPE) before entering COVID-19 positive and observation resident rooms and proceeding to enter unexposed residents' rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. The facilities Quality Assurance and Performance Improvement (QAPI) Committee failed to put forth good faith attempts to identify the root cause of three different COVID-19 outbreaks and identify corrective actions to prevent further spread of COVID-19 cases and thereby decrease the likelihood for additional COVID-19 cases and deaths. Corrective Action: 1. The facility immediately disinfected the contaminated equipment in addition to all other potentially contaminated equipment in the facility upon notification of deficiency on 1-21-2021. The facility's Infection Preventionist immediately reviewed the documentation of the residents' signs and symptoms log for COVID-19 exhibited over the last 48 hours on 1-21-2021. The facility began receiving the results from Polymerase Chain Reaction (PCR) testing that was conducted on 48 residents on 1-19-2021. Of the 48 residents tested lab results revealed that nine (9) additional residents tested positive and 39 were negative. The facility employees were tested on [DATE] using rapid test and eight (8) staff members tested positive. On 1-20-2021 five (5) staff members were questioned at the screening desk and were tested due to being symptomatic and all five (5) tested positive. All remaining employees were tested on [DATE] with one (1) dietary staff member testing positive. 2. The facility's Infection Preventionist, the acting interim Director of Nursing (DON)/Registered Nurse (RN) #1, completed the required modules and passed the Infection Preventionist specialized training after State Agency had entered the building on January 19, 2021 at 1:00 PM and presented certificate to the State Agency on January 19, 2021 at 1:30 PM. On January 21, 2021, the facility was in possession of the following PPE: 3,035 N-95 masks; 1,840 surgical masks; 1,800 face shields; 2800 gowns; 1,900 bouffant cap; and gloves 8,500. 3. The Infection Preventionist reviewed all testing procedures and the results of the test that had been completed. The facility started in-service training with all employees of the facility that were currently working on January 21, 2021 at 2:00 PM. The training was initiated by the Interim Administrator, Licensed Practical Nurse (LPN) #4, RN #4, and LPN #5. The working staff members were in-serviced on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment and the donning and doffing of Personal Protective Equipment (PPE). A total of 22 employees were in-serviced: two (2) RN's, six (6) LPN's, eight (8) Certified Nursing Assistants (CNA), one (1) maintenance, four (4) housekeeping/laundry agency staff members, and one (1) administrative staff were completed at 3:20 PM. The facility will not allow any employee to work until they have completed all the in-services on the CDC Guidelines of appropriately donning and doffing PPE when entering and exiting isolation and observation rooms, appropriate hand hygiene, appropriate disinfection of medical equipment, and appropriate handling of laundry in the facility to prevent the spread of COVID-19 and other potential infectious diseases. 4. The facility on January 21, 2021 at 12:45 PM, held a QAPI committee meeting. The interim Administrator, RN #1, RN #4, LPN #1, LPN #4, LPN #5 Housekeeping Contractor #3, Dietary #1 and Maintenance #4 were all in attendance. The Medical Director and Administrator attended via telephone conference. The committee discussed the deficient performance in the facility which are the following: failure to provide a certified Infection Preventionist, failure to don PPE before entering COVID-19 positive rooms and observation resident rooms, performing hand hygiene following resident care, disinfection of medical equipment upon exiting a COVID-19 positive room, and by causing contamination of laundry by allowing it to come in contact with the floor. After the information provided by the State Agency was discussed and reviewed, it was determined that the root cause of the facility's deficient practice stemmed from the facility's failure to follow the policies regarding the surveillance and tracking and trending of COVID-19 and other infectious diseases. The QAPI Committee discussed and developed a plan to correct and monitor all deficient practices. Recommendations were made for Quality Assurance (QA) to monitor and implement all CDC approved training to bring into compliance all facility staff and contracted services. It is the responsibility of the QA nurse, administrative nurses, charge nurses, interim DON/ Infection Preventionist and interim Administrator to visually monitor and audit staff every shift daily for three weeks on the following: hand hygiene, soiled linen handling, storage of soiled linen, cleaning and disinfecting of resident care equipment, donning and doffing of personal protective equipment. The QAPI committee will reconvene on January 26, 2021 at 9:30 AM, to further develop the facility's long term plan to improve infection prevention through auditing, staff education, and modifications of policies and procedures to ensure evidence-based practice are followed within the facility. 5. The facility alleges that all corrective actions are completed on 1-21-21 and the IJ was removed on 1-22-21.

Based on Observation, interview, record review, and facility policy review, the facility failed to follow the Care Plan for pain management during wound care for Resident #4 for one (1) of three (3) wound care observations and failed to supervise Resident #7 for one (1) of four (4) residents reviewed for falls. Findings include: A review of the facility policy, Total Care Plan, dated 2/27/19, revealed that it is the policy of the facility that the Interdisciplinary Care Plan will identify problems that affect the resident and his/her needs and identify the interventions related to the specific problems. Resident #4 During a wound care observation on 12/18/19 at 2:55 PM Licensed practical Nurse (LPN) #1 did not assess Resident #4's pain level before performing wound care. Resident #4 told LPN #1 before she started wound care that his wound was hurting. Resident #4 exhibited facial grimacing as verbally complaining of pain. LPN #1 proceeded with the wound care treatment telling Resident #1 that she would be finished soon, and she would tell the Medication Nurse to give him something for pain. Resident #4 moaned several times during wound care and voiced he was hurting. Resident #4 yelled out and flinched when LPN #1 cleaned the sacral wound. LPN #1 continued wound care without offering Resident #4 and pain medication. In a record review of the Comprehensive Care Plan, dated 11/5/19, revealed the problem of a stage III Pressure Ulcer to Resident #4's sacrum, with an intervention of noting any complaints of pain, location and severity, and the effectiveness of medications. In a record review of the Physician Order's dated, (MONTH) 2019, revealed an order for [REDACTED].#1, stated that by not assessing Resident #4 for pain and administering pain medication as needed, she had not followed the care plan. During an interview, on 12/18/19 at 5:12 PM, Registered Nurse (RN) #2 stated that LPN #1 did not follow the Comprehensive care Plan for wound care by not assessing the pain level of Resident #4 during wound care. During an interview, on 12/18/19 at 5:30 PM, LPN #2 stated that the Comprehensive Care Plan for wound care was not followed by LPN #1 when she did not assess the pain level of Resident #4. The facility admitted Resident #4 on 10/22/19 with the [DIAGNOSES REDACTED]. Resident #7 In a record review of the Physician Order's for Resident #7 dated (MONTH) 2019, revealed orders for a self-release alarm belt while in wheelchair, check every 30 minutes for proper functioning and release every two (2) hours and as needed for toileting and repositioning. In a record review of the Comprehensive Care Plan dated 9/3/18, revealed a problem of Risk for Falls, with the intervention of applying the self-release alarm belt while up in wheelchair and check placement every shift. During an interview on 12/31/19 at 12:21 PM, the Director of Nursing (DON) stated that not following the Comprehensive Care Plan regarding falls and the self-release alarm belt monitoring per Physician Orders could contribute to a fall. The DON verified that the Physician's Order for the self-release seat belt monitoring was not transcribed to the Comprehensive Care Plan or the Treatment Record accurately. The DON stated that the Physician's Order not being transcribed to the Treatment Record accurately and the monitoring not being done as ordered, could have caused the development of a decubitus ulcer, contractures, anxiety, or mental anguish for any resident. During an interview on 12/31/19 at 12:44 PM, LPN #4 revealed that not following the Comprehensive Care Plan regarding falls and the self-release alarm belt monitoring for Resident #7 could have caused an injury to occur as well as skin breakdown and contractures for. LPN #4 stated that not monitoring or releasing the restraints as ordered by the Physician, the same issues could have occurred. LPN #4 verified that the Physician's order for the self-release alarm belt was not transcribed to the Comprehensive Care Plan accurately for Resident #7. During an interview on 12/31/19 at 1:17 PM, LPN #2 stated that the nurses not following the Comprehensive Care Plan for falls and the use and monitoring of a safety belt could cause any resident to get hurt, have skin breakdown in places, as well as to develop contractures. The facility admitted Resident #7 on 3/26/18 with the [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to assess Resident #4's level prior to providing wound care and during the wound care provided by Licensed Practical Nurse (LPN) #1. The failure to assess Resident #4's pain levels resulted in the resident expressing signs of pain during the treatment with facial grimacing, moaning, and verbalization of pain. This was identified for one of three (1 of 3) resident wound care observations. Findings include: A review of the facility policy titled, Clean Dressing Change not dated, revealed the following procedure to perform a clean dressing change included: Explain to Resident that you are about to perform a dressing change on them, explain the procedure and evaluate pain level, administer pain medication if needed. During a wound care observation, on 12/18/19 at 2:55 PM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 entered Resident #4's room to provide wound care to a Stage III pressure ulcer to the Sacrum. Licensed practical Nurse (LPN) #1 did not assess Resident #4's pain level before performing wound care. Resident #4 told LPN #1 before she started the wound care that his wound was hurting. Resident #4 exhibited facial grimacing as well as verbally complaining of pain. LPN #1 proceeded with the wound care treatment telling Resident #1 that she would be finished soon and she would tell the Medication Nurse to give him something for pain. Resident #4 moaned several times during the wound care and voiced he was hurting. Resident #4 yelled out and flinched when LPN #1 cleaned the sacral wound. LPN #1 continued wound care without any pain assessment or pain medication. Review of (MONTH) 2019 Physician's Orders revealed an order, dated 12/13/19, to clean the sacral ulcer with Normal Saline, Pat dry, Apply Hydrogel and Collagen mix to wound bed and cover with silicone foam border every 48 hours and as needed. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The last dose of Tylenol was documented on 12/13/19 at 6:45 AM. Review of the (MONTH) 2019 Physician's Orders revealed an order, dated 11/7/19, for [MEDICATION NAME] (Tylenol) 325 milligrams (mg), two (2) tabs by mouth (po) every four (4) hours as needed (PRN) for pain. During an interview, on 12/18/19 at 3:55 PM, LPN #1 revealed she should have waited to do the wound care and offered him some pain medication. She stated she normally would any other time, but she got nervous. During an interview, on 12/18/19 at 5:12 PM, Registered Nurse (RN) #2/Assistant Director Of Nurses (ADON) stated LPN #1 should have stopped the wound care and offered Resident #4 some pain medication. During an interview, on 12/18/19 at 3:25 PM, LPN #3 revealed she was Resident #4's medication nurse and LPN #1 did not tell her that Resident #4 needed pain medication. During an interview, on 12/18/19 at 5:15 PM, the Medical Director stated Resident #4 had an as needed pain medication available to him when needed. The Medical Director stated the nurses could always call him when needed to address Resident #4's pain level. He stated he was always concerned with controlling the pain level of his residents. Review of the Face Sheet revealed the facility admitted Resident #4 to the facility 10/22/19 with a [DIAGNOSES REDACTED]. Review of Resident #4's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/19, revealed the resident was assessed a high risk for developing pressure ulcers. Resident #4 was admitted with one (1) stage I, two (2) stage II, and two (2) unstagable pressure ulcers. The pain assessment revealed Resident #4 was receiving as needed pain medication. Resident #4's Basic Interview for Mental Status (BIMS) score was 12, which indicated mild cognitive impairment. Review of Resident #4's 5-Day MDS, with an ARD of 11/12/19, revealed the resident was still assessed as high risk for developing pressure ulcers, and was readmitted with a stage III pressure ulcer. Resident #4 received as needed pain medications. The BIMS score was 9, which indicated moderate cognitive impairment.

Based on interview, record review, facility policy review, and the facility investigation review, the facility failed to provide adequate supervision to monitor/check Resident #7's self-release safety belt and as a result Resident #7 fell and sustained a fractured right hip. This concern was identified for for one (1) of four (4) residents with self-release belts observed. Findings include: A review of facility policy titled Accident and Supervision Policy, not dated, revealed that each resident is to receive adequate supervision and assistive devices to prevent accidents which includes implementing interventions to reduce hazards and risks. Specific interventions will be implemented to try and reduce a resident's risk from hazards including documenting interventions and ensuring that the interventions are put into action. A review of facility policy titled Policy for Restraints, not dated, revealed that applying a restraint for patient safety requires additional care, observation and management by the medical staff to ensure patient safety. Resident's with restraints should be checked every 30 minutes and have the restraint removed and the resident repositioned every two (2) hours. Review of the facility's incident Investigation, dated 12/20/19 at 8 AM, revealed resident was observed by Activity Staff pulling on her catheter tubing. Activity Aide stayed with resident and took her to her assigned nurse, who transported the resident to her room, left her in the doorway to go get someone to assist putting the resident to bed. When the nurse returned, the resident was on the floor on her left side in front of the bathroom door with her feet up in the wheelchair. The resident was assisted to bed with the help of the nurse and aide. The Charge Nurse assessed the resident for injuries. The injuries observed were skin tears to the left elbow and hand, and the right knee. The Responsible Representative (RR) and Medical Doctor (MD) were notified. The Assistant Director of Nurses (ADON) was also notified. The resident's catheter was changed. The resident was out of bed and propelling self in wheelchair around the facility the remainder of the day. On 12/11/10 7 on the 7 AM to 3 PM shift, the resident complained of pain in right knee. The Charge Nurse and MD were notified, and a new order was received for an xray of the right knee and hip. Received the xray report stating a fracture to the right hip. Resident was sent to the hospital for further evaluation. Review of the facility's Neurological Flow Sheet revealed neuro checks were started on 12/20/19 at 8:15 AM and completed on 12/11/19 at 3 PM. Review of the hospital's Emergency Department (ED) Physician Note, dated 12/11/19 at 4:46 PM, revealed Resident #7 presented to the emergency room (ER) today after a fall out a wheelchair last night. Patient does not ambulate. The right complete hip xray, on 12/11/19 at 5:39 PM, revealed a Displaced, Angulated Right Femoral Introtrochanteric Fracture. Resident #7 required a Right Open Reduction Internal Fixation surgery to repair the hip during her hospital stay. During an interview, on 12/30/19 at 6:22 AM, Licensed Practical Nurse/LPN #2/Quality Assurance (QA) Nurse stated Resident #7 could not undo her safety belt on command, but she could undo it when she felt like it. LPN #2 stated during their investigation she discovered Registered Nurse (RN) #2/Assistant Director of Nurses (ADON) told her when she got to work at 7AM that morning she checked Resident #7's self-release belt and it was on and functioning properly. LPN #2 stated RN #2 told her Resident #7 was agitated in the dining room and the Activity Director took her to LPN #5 and LPN #5 stated she pushed Resident #7 in her wheelchair just inside the door of her room and left her to go get someone to assist her to place the resident in her bed. When she returned, she found Resident #7 lying on her left side in front of the door. LPN #2 stated LPN #5 revealed to her that she did not check the belt when she placed Resident #7 by the door. During an interview, on 12/30/19 at 7:41 AM, Licensed Practical Nurse (LPN) #5 stated the Activity person brought the Resident #7 to her on the morning she fell stating that Resident #7 seemed agitated and was pulling at her catheter. She stated she pushed Resident #7 down to her room and placed Resident #7 in the doorway of her room. LPN #5 stated she just pushed her inside the doorway of her room and did not check to see if her seat belt was on or even if it was working. LPN #5 stated that she just assumed it was on Resident #7. LPN #5 stated she walked out of the room to go get help to lay Resident #7 down in the bed and when she went back into Resident #7's room, she was lying on the floor on her left side. LPN #5 stated the belt was suppose to alarm if it was unhooked and she didn't hear it alarm. LPN #5 stated the seat belt was not hooked on Resident #7. LPN #5 stated she didn't know Resident #7 well enough to know if she could take the belt off by herself or not. Review of the (MONTH) 2019 physician's orders [REDACTED]. The physician's orders [REDACTED]. Record review of a facility Consent For Use Of Physical Restraints Or Enabling Device, dated 4/23/18, revealed a self-release alarm belt was ordered for confusion, poor safety and hx of falls. Review of the Treatment Administration Record (TAR), dated (MONTH) 2019, revealed self-release alarm belt while in wheelchair, check every 30 minutes for proper functioning and release every two (2) hours and as needed for toileting and repositioning. On 12/9/19 and 12/10/19, the 7 AM to 3 PM shift columns for monitoring/checking the belt every 30 minutes and releasing the belt every two (2) hours was blank. During an interview with RN #2, on 12/31/19 at approximately 10:00 AM, she revealed she checked the resident's seat belt on arrival to work on 12/10/19 at 7AM and it was on and functioning properly. However, she stated she did not document the belt was checked on the Treatment Administration Record (TAR). During an interview, on 12/30/19 on 8:10 AM, LPN #1 revealed she saw the Activities Director coming down the hallway with Resident #7 and the Activity Aide told her that Resident #7 was pulling at her catheter and the resident seemed a little agitated. The Activities Director handed her off to LPN #5 and she took Resident #7 to her room and left her at the door to go look for somebody to help her put Resident #7 in her bed. LPN #1 stated she didn't think to look for the safety belt because she was just passing Resident #7 in the hallway. LPN #1 stated the day Resident #7 fell , she was doing treatments and it would have been her responsibility to sign the TAR off that the self-release alarm belt was checked. LPN #1 stated she didn't remember checking the safety seat belt at all on the morning that Resident #7 fell . During an interview, on 12/30/19 at 10:55 AM, the Activity Director stated to be honest and thinking back on it, she didn't remember seeing the safety belt on Resident #7 that morning. During an interview, on 12/31/19 at 10:39 AM, the Administrator stated the monitoring of the self-release seat belt was not being done correctly according to the physician's orders [REDACTED].#7 and that she was having the monitoring of the belt corrected immediately. During an interview, on 12/31/19 at 12:21 PM, the Director of Nursing (DON) stated the Medication Nurses are responsible for monitoring the self-release alarm belt and documenting that they have been checked according to physician's orders [REDACTED].#7. During an interview, on 12/31/19 at 12:44 PM, LPN #4/Care Plan Nurse revealed the Medication Nurses are responsible to check for the release of the self-release alarm belt and document accordingly. LPN #4 stated after reviewing the TAR, the physician's orders [REDACTED]. During an interview, on 12/31/19 at 1:17 PM, LPN #2 stated the Medication Nurses or Treatment Nurses on the hall are responsible to document and check the self-release alarm belt. LPN #2 verified that according to the TAR, the self-release belt was not being monitored following the physician's orders [REDACTED].>Review of the facility's Incident Log revealed Resident #7 had a fall with injury on 12/10/19 at 8:46 AM. The Type of Injury was a skin tear Review of the Face Sheet revealed Resident #7 was admitted by the facility, on 3/26/18, and discharged on [DATE]. Resident #7 was admitted with the included [DIAGNOSES REDACTED].

Based on interviews, record review and facility policy review, the facility failed to report to the State Agencies (SA)s when Resident #1 exited the facility, unsupervised, on 12/9/18, for one (1) of six (6) residents reviewed for risk of elopement. It is believed Resident #1 exited the building through the 400 hall fire exit door, on 12/9/18, between 8:00 AM and 9:00 AM was found 17 steps from the end of the exit ramp, which was 65 steps down from the top. This exit ramp was greater than six (6) feet tall. Resident #1 was seen from a window by Certified Nursing Assistant (CNA) #1 and immediately went outside and returned Resident #1 into the building. Resident #1 was assessed by Licensed Practical Nurse (LPN) #1 with no injury. There was no documented evidenced that the elopement was reported to the State Agency as required. Resident #1 had a history of [REDACTED].#1 away from the doors. The facility's failure to report the elopement/lack of supervision for Resident #1 to the State Agencies as required, to ensure corrective actions were taken, placed Resident #1 and other residents at risk for elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/9/18, when Resident #1 exited the building from the 400 hall door unsupervised and was found 17 steps from the end of the exit ramp, which was sixty-five steps down from the top of the ramp. On 1/14/19 at 2:20 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 1/22/19, in which the facility alleged all corrective actions were completed on 1/18/19, with removal of the IJ on 1/19/19. The SA validated the A[NAME] on 1/23/19, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.12 (c)(1)(4)-Reporting, F609, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, dated 12/1/18, revealed any complaint must be reported to the Administrator and Director of Nursing (DON), as soon as possible, and then reported to State Agencies by phone within 24 hours and in writing within 72 hours. This policy revealed, the report is to include the name, address and phone number of the person making the report, and the name and address of the believed victim. The incident must include details, any observations, any beliefs, date, time, and place the incident occurred. This incident must include any statements related to the incident, and the name of the individual believed to be responsible for the incident. During an interview and observation, on 1/14/19 at 12:00 PM, Certified Nursing Assistant (CNA) #1 stated on the morning of 12/9/18, she observed Resident #1 through the window blinds of room [ROOM NUMBER], outside and alone in the wheelchair, that was sitting on a grassy area. CNA #1 stated, she immediately went outside and brought Resident #1 inside. CNA #1 used the keypad to unlock the 400 hall fire door exit and walked 65 steps down the ramp and 17 steps from the ramp to where she indicated Resident #1 was located on 12/9/18. CNA #1 stated Resident #1 was still sitting upright in the wheelchair, with the alarm belt in place, when she brought her back into the facility. In an interview on 1/18/19 at 12:30 PM, the Director of Nursing (DON) stated there was no investigation regarding Resident #1 exiting the building, so therefore there was nothing to report. During an interview, on 1/14/19 at 11:18 AM, the facility's Administrator stated Resident #1 was in the sight of staff the whole time while staff was pursuing her on 12/9/18, when she got outside. The Administrator revealed no investigation or reporting was conducted. In a further interview, on 1/14/19 at 11:40 AM, the Administrator stated when talking with Certified Nursing Assistant (CNA) #1 this morning, she learned Resident #1 was outside alone on 12/9/18, and not in sight of employees as previously thought. The Administrator stated, I made a horrible mistake. In an interview, on 1/14/19 at 2:10 PM, the Administrator stated she was told Resident #1 got out of the building, but staff was with her. The Administrator stated had the occurrence been investigated, then she would have known to report it. The Administrator confirmed she had not reported the elopement for Resident #1 and stated, I made a big mistake. The facility provided an Acceptable Allegation of Compliance, which included: Resident #1 was admitted on [DATE]. Resident #1 has the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 has a history of two (2) prior elopements to 12/09/18. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18, at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, seven (7) feet high and five (5) feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 brought Resident #1 back into the facility at approximately 8:30 am with no apparent injuries. Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18, and revealed severe cognitive impairment. The facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. Corrective Actions: 1. LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7 pm on 12/09/18, and was continued on every 30 minute checks until 6:30 am on 12/10/19. 2. LPN #1 reported to the Administrator by phone, on 12/09/18 at 8:55 am, that Resident #1 exited the building and was brought back in by CNA #1. The Administrator was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19 at 11:45 am, revealed that Resident #1 was not in sight at all times. 3. The Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18 at 9:13 am, of Resident #1 exiting the building supervised. No investigation was initiated at this time. There is no documentation that Resident #1 was assessed upon return to the facility. 4. On 12/09/18 at approximately 10 am, LPN #1 put a sign on the Emergency Exit door. The sign stated, This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. 5. The 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm. There were no specific staff assignments made by LPN #1 to monitor the door. 6. The last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18, by Maintenance personnel, and was noted to be working properly. On 12/09/18 at approximately 11:15 am, the door lock was working properly but the sound for the Emergency Exit door alarm was non-functioning, when checked by Maintenance personnel. The Administrator was notified at 11:30 am, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18, by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. On 12/09/18, after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. On 12/10/18 at 7:00 am, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. During further investigation, on 01/14/19 at approximately 11:45 am, it was determined during interview by the Administrator that CNA #1 did not have Resident #1 in sight at all times. 10. On 01/14/19 at approximately 2:00 pm, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at PM, LPN #2, Administrator, Registered Nurse (RN) #1, RN #2, and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. No staff will be allowed to work until they have completed all in-services. 11. Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19 at 8:00 pm, by LPN # 9. Nineteen residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff; staff is aware, and in-services were conducted on 01/16/19 by LPN #2 that residents are on 15 minute checks. 12. The Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19 at approximately 12:30 pm. No discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 at 3:00 pm, and ending 01/17/19 5:30 pm, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19 at 12:30 pm. Resident #1's Responsible Party was notified on 01/16/19, by the DON at 11:50 am. 14. Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19 at 6:20 pm. Care Plans were reviewed and 19 were updated with current intervention for every 15 minute checks. 15. On 01/14/19 at 6:30 pm, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18, with Resident #1, was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. An Emergency QA meeting was held on 01/16/19 at 12:35 pm, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN #2, and the Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. 17. In-service to all staff was initiated by LPN #2 and RN #2 on 01/16/19 at 3:45 pm, regarding changes to daily door checks. 18. On 01/17/19 at 5:30 pm, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. 19. An Emergency QA meeting was held on 01/18/19 at 11:30 am, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator, and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. In-service to all staff was completed by LPN #2 on 01/18/19 at 11:45 am, regarding changes to the Emergency Exit Door Policy. 21. As of 01/18/19 at 5:00 pm, a total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The facility alleges all corrective actions to remove the IJ were completed on 01/18/19, and the IJ removed on 01/19/19. Validation of the Allegation of Compliance included: Based on observation, interviews, record review, the State Agency (SA) validated that Resident #1 was admitted on [DATE]. Resident #1 had the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 had a history of [REDACTED]. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18 at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, 7 feet high and 5 feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 verified by interview that she brought Resident #1 back into the facility at approximately 8:30 am, with no apparent injuries. Record review confirmed Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18 and revealed severe cognitive impairment. Results of record review and interview confirmed the facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. The SA validated the facility's Corrective Actions: 1. The SA validated through interview that LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7:00 pm on 12/09/18, and continued every 30 minute checks until 6:30 am on 12/10/19. 2. The SA validated through interview that LPN #1 reported the elopement of Resident #1 to the Administrator by phone on 12/09/18. Interview with the Administrator confirmed she was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19, revealed that Resident #1 was not in sight at all times. 3. The SA validated through interviews that the Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18, of Resident #1 exiting the building supervised and that no investigation was initiated at this time. 4. The SA validated through observation and interviews that on 12/09/18, LPN #1 put a sign on the Emergency Exit door. The sign stated This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. The sign was observed during survey. 5. The SA validated through staff interviews that the 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm, but no specific staff assignments were made by LPN #1 to monitor the door. 6. The SA validated through interviews and record review that the last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18 by Maintenance personnel and was noted to be working properly, but on 12/09/18, the sound for the Emergency Exit door alarm was non-functioning. Interviews revealed the Administrator was notified, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18 by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. The SA validated through interviews that on 12/09/18 after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. The SA validated through interviews and record review that on 12/10/18, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. The SA validated through interviews that during further investigation on 01/14/19, the Administrator determined that CNA #1 did not have Resident #1 in sight at all times. 10. The SA validated through interviews and record review that on 01/14/19, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at 3:00 pm, LPN #2, Administrator and Registered Nurse (RN) #1, RN #2 and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. The SA validated through interview and staffing records that no staff have been allowed to work until they have completed all in-services. 11. The SA validated through record reviews and interviews that the Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19, by LPN # 9 and that 19 residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff and in-services were conducted on 01/16/19 by LPN #2, that residents are on 15 minute checks. 12. The SA validated through interviews and record review that the Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19, and that no discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 and ending 01/17/19, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The SA validated through interviews and record review the facility Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19. Resident #1's Responsible Party was notified on 01/16/19 by the DON. 14. The SA validated through interviews and record review the Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19. The SA verified Care Plans were updated with current intervention for every 15 minute checks. 15. The SA validated through interviews and record review that on 01/14/19, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18 with Resident #1 was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. The SA validated through interviews and record reviews an Emergency QA meeting was held on 01/16/19, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN# 2 and Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. The SA validated through record review of the documented daily checks. 17. The SA validated through interviews and record review that in-service to all staff was by LPN #2 and RN #2 on 01/16/19, regarding changes to daily door checks. 18. The SA validated through interviews and record reviews that on 01/17/19, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. The SA validated no other concerns were noted. 19. The SA validated through interviews and record review that an Emergency QA meeting was held on 01/18/19, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. The SA validated through interviews and record review that an in-service to all staff was completed by LPN #2 on 01/18/19, regarding changes to the Emergency Exit Door Policy. 21. The SA validated through interviews and record reviews as of 01/18/19, total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The SA validated that all corrective actions were completed on 01/18/19, and the IJ removed on 01/19/19.

Based on interviews and record review the facility failed to investigate when Resident #1 was found outside of the facility, unsupervised on 12/9/19 for one (1) of six (6) residents reviewed at risk for elopement; Resident #1. The facility failed to provide adequate assessment and supervision for a confused, demented resident, with a past history of elopement. It is believed Resident #1 exited the building through the 400 hall fire exit door and on 12/9/18 between 8:00 AM and 9:00 AM was found 17 steps from the end of the exit ramp that was sixty-five steps down from the top. This exit ramp was greater than six (6) feet tall. Resident #1 was seen from a window by Certified Nursing Assistant (CNA) #1 and immediately went outside and returned Resident #1 into the building. Resident #1 was assessed by Licensed Practical Nurse (LPN) #1 with no injury. All staff was responsible to supervise Resident #1 and the other eighteen (18) residents at risk for elopement. Resident #1 was on every 30 minute checks from a fall earlier that morning on 12/9/18 and was documented as being observed on these checks for twenty-four (24) hours. Resident #1 had a history of [REDACTED].#1 away from doors by asking resident to turn around and assist to move away. The failure to investigate the incident when Resident #1, a demented resident with a history of elopement, was found outside and unsupervised on 12/9/18, placed this resident and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/9/18, when Resident #1 exited the building from unsupervised and was found 17 steps from the end of the exit ramp of the 400 Hall, that was 65 steps down from the top of the ramp. CNA #1 returned Resident #1 back into the building. On 1/14/19 at 2:20 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 1/22/19, in which the facility alleged all corrective actions were completed on 1/18/19, and the IJ removed on 1/19/19. The SA validated the A[NAME] on 1/23/19, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.12 (c)(2)-(4), F610, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, dated 12/1/18, revealed any complaint must be reported to the Administrator and Director of Nursing (DON), as soon as possible, and then reported to State Agencies by phone within 24 hours and in writing within 72 hours. Any report of abuse, neglect or exploitation will be investigated by the Administrator/Director of Nursing/Social Services/Quality Assurance (QA) Committee and Facility Security. Investigation shall include but is not limited to questioning the resident involved when appropriate, questioning all staff members, with written statements to be taken as quickly as possible. During an interview and observation, on 1/14/19 at 12:00 PM, Certified Nursing Assistant (CNA) #1 stated on the morning of 12/9/18, she observed Resident #1 through the window blinds of room [ROOM NUMBER], outside in her wheelchair,by herself and immediately went and got her back inside the facility. CNA #1 exited the fire door located on the 400 Hall and walked 65 steps down the ramp and 17 steps from the ramp to where she indicated Resident #1 was located on 12/9/18. CNA #1 stated Resident #1 was still sitting upright in the wheelchair, with the alarm belt in place, when she brought her back into the facility. In an interview, on 1/14/19 at 11:18 AM, the Administrator stated initially it was thought that Resident #1 was in sight of staff the whole time, with staff pursuing her on 12/9/18, when she got outside. The Administrator confirmed, no investigation was conducted for the elopement of Resident #1. In an interview, on 1/14/19 at 11:40 AM, the Administrator stated CNA confirmed in an interview (1/14/19) that Resident #1 was outside alone on 12/9/18, and not in sight of employees as previously thought. The Administrator stated, I made a horrible mistake. During an interview, on 1/14/19 at 2:10 PM, the Administrator stated she was told that Resident #1 got out, but staff was with her. The Administrator stated the occurrence should have been investigated, then she would have known to report it. The Administrator confirmed the elopement of Resident #1 was not investigated or reported and stated, I made a big mistake. Interview with the Director of Nursing (DON), on 1/14/19 at 10:55 AM, revealed an investigation was initiated when Resident #1 eloped in (MONTH) and a head count of all residents were conducted. The DON also stated there was a staff member assigned to each door until the door could be checked after Resident #1 eloped. The DON confirmed the investigation was not documented and was not thorough. Interview on 1/18/19 at 12:30 PM, with the DON, revealed on 12/9/18, she was instructed by the Administrator to go to the facility and conduct a head count and to place staff at all doors, with the focus on the 400 Hall door, because the door wasn't shutting or something, not alarming. On the next day (12/10/18), the DON revealed an investigation was initiated, but was told by the Administrator to stop because Resident #1 was in sight of staff at all times. The DON stated, if an investigation had been completed, it would have revealed Resident #1 had got outside alone and unsupervised. Record review revealed the facility failed to initiated an investigation of Resident #1's elopement on 12/9/18, until 1/14/19, after the Administrator was notified by the State Agency (SA). The facility admitted Resident #1 on 2/7/11, with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/18, revealed Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment identified Resident #1 as severely impaired and never/rarely made decisions. The facility provided an Acceptable Allegation of Compliance, which included: Resident #1 was admitted on [DATE]. Resident #1 has the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 has a history of two (2) prior elopements to 12/09/18. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18, at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, seven (7) feet high and five (5) feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 brought Resident #1 back into the facility at approximately 8:30 am with no apparent injuries. Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18, and revealed severe cognitive impairment. The facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. Corrective Actions: 1. LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7 pm on 12/09/18, and was continued on every 30 minute checks until 6:30 am on 12/10/19. 2. LPN #1 reported to the Administrator by phone, on 12/09/18 at 8:55 am, that Resident #1 exited the building and was brought back in by CNA #1. The Administrator was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19 at 11:45 am, revealed that Resident #1 was not in sight at all times. 3. The Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18 at 9:13 am, of Resident #1 exiting the building supervised. No investigation was initiated at this time. There is no documentation that Resident #1 was assessed upon return to the facility. 4. On 12/09/18 at approximately 10 am, LPN #1 put a sign on the Emergency Exit door. The sign stated, This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. 5. The 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm. There were no specific staff assignments made by LPN #1 to monitor the door. 6. The last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18, by Maintenance personnel, and was noted to be working properly. On 12/09/18 at approximately 11:15 am, the door lock was working properly but the sound for the Emergency Exit door alarm was non-functioning, when checked by Maintenance personnel. The Administrator was notified at 11:30 am, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18, by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. On 12/09/18, after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. On 12/10/18 at 7:00 am, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. During further investigation, on 01/14/19 at approximately 11:45 am, it was determined during interview by the Administrator that CNA #1 did not have Resident #1 in sight at all times. 10. On 01/14/19 at approximately 2:00 pm, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at PM, LPN #2, Administrator, Registered Nurse (RN) #1, RN #2, and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. No staff will be allowed to work until they have completed all in-services. 11. Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19 at 8:00 pm, by LPN # 9. Nineteen residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff; staff is aware, and in-services were conducted on 01/16/19 by LPN #2 that residents are on 15 minute checks. 12. The Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19 at approximately 12:30 pm. No discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 at 3:00 pm, and ending 01/17/19 5:30 pm, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19 at 12:30 pm. Resident #1's Responsible Party was notified on 01/16/19, by the DON at 11:50 am. 14. Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19 at 6:20 pm. Care Plans were reviewed and 19 were updated with current intervention for every 15 minute checks. 15. On 01/14/19 at 6:30 pm, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18, with Resident #1, was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. An Emergency QA meeting was held on 01/16/19 at 12:35 pm, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN #2, and the Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. 17. In-service to all staff was initiated by LPN #2 and RN #2 on 01/16/19 at 3:45 pm, regarding changes to daily door checks. 18. On 01/17/19 at 5:30 pm, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. 19. An Emergency QA meeting was held on 01/18/19 at 11:30 am, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator, and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. In-service to all staff was completed by LPN #2 on 01/18/19 at 11:45 am, regarding changes to the Emergency Exit Door Policy. 21. As of 01/18/19 at 5:00 pm, a total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The facility alleges all corrective actions to remove the IJ were completed on 01/18/19, and the IJ removed on 01/19/19. Validation of the Allegation of Compliance included: Based on observation, interviews, record review, the State Agency (SA) validated that Resident #1 was admitted on [DATE]. Resident #1 had the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 had a history of [REDACTED]. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18 at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, 7 feet high and 5 feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 verified by interview that she brought Resident #1 back into the facility at approximately 8:30 am, with no apparent injuries. Record review confirmed Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18 and revealed severe cognitive impairment. Results of record review and interview confirmed the facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. The SA validated the facility's Corrective Actions: 1. The SA validated through interview that LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7:00 pm on 12/09/18, and continued every 30 minute checks until 6:30 am on 12/10/19. 2. The SA validated through interview that LPN #1 reported the elopement of Resident #1 to the Administrator by phone on 12/09/18. Interview with the Administrator confirmed she was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19, revealed that Resident #1 was not in sight at all times. 3. The SA validated through interviews that the Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18, of Resident #1 exiting the building supervised and that no investigation was initiated at this time. 4. The SA validated through observation and interviews that on 12/09/18, LPN #1 put a sign on the Emergency Exit door. The sign stated This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. The sign was observed during survey. 5. The SA validated through staff interviews that the 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm, but no specific staff assignments were made by LPN #1 to monitor the door. 6. The SA validated through interviews and record review that the last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18 by Maintenance personnel and was noted to be working properly, but on 12/09/18, the sound for the Emergency Exit door alarm was non-functioning. Interviews revealed the Administrator was notified, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18 by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. The SA validated through interviews that on 12/09/18 after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. The SA validated through interviews and record review that on 12/10/18, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. The SA validated through interviews that during further investigation on 01/14/19, the Administrator determined that CNA #1 did not have Resident #1 in sight at all times. 10. The SA validated through interviews and record review that on 01/14/19, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at 3:00 pm, LPN #2, Administrator and Registered Nurse (RN) #1, RN #2 and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. The SA validated through interview and staffing records that no staff have been allowed to work until they have completed all in-services. 11. The SA validated through record reviews and interviews that the Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19, by LPN # 9 and that 19 residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff and in-services were conducted on 01/16/19 by LPN #2, that residents are on 15 minute checks. 12. The SA validated through interviews and record review that the Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19, and that no discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 and ending 01/17/19, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The SA validated through interviews and record review the facility Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19. Resident #1's Responsible Party was notified on 01/16/19 by the DON. 14. The SA validated through interviews and record review the Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19. The SA verified Care Plans were updated with current intervention for every 15 minute checks. 15. The SA validated through interviews and record review that on 01/14/19, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18 with Resident #1 was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. The SA validated through interviews and record reviews an Emergency QA meeting was held on 01/16/19, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN# 2 and Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. The SA validated through record review of the documented daily checks. 17. The SA validated through interviews and record review that in-service to all staff was by LPN #2 and RN #2 on 01/16/19, regarding changes to daily door checks. 18. The SA validated through interviews and record reviews that on 01/17/19, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. The SA validated no other concerns were noted. 19. The SA validated through interviews and record review that an Emergency QA meeting was held on 01/18/19, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. The SA validated through interviews and record review that an in-service to all staff was completed by LPN #2 on 01/18/19, regarding changes to the Emergency Exit Door Policy. 21. The SA validated through interviews and record reviews as of 01/18/19, total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The SA validated that all corrective actions were completed on 01/18/19, and the IJ removed on 01/19/19.

Based on interview, record review, and facility policy review, the facility failed to follow the plan of care for elopement for Resident #1 for one (1) of six (6) residents reviewed for elopement; Resident #1. Resident #1 had been assessed and care planned for the risk of elopement, with a past history of elopement. It is believed Resident #1 exited the building through the 400 hall fire exit door on 12/9/18 between 8:00 AM and 9:00 AM. The resident was found 17 steps from the end of the exit ramp that was 65 steps down from the top. This exit ramp was greater than six (6) feet tall. Resident #1 was seen from a window by Certified Nursing Assistant (CNA) #1 and immediately went outside and returned Resident #1 into the building. Resident #1 was assessed by Licensed Practical Nurse (LPN) #1 with no injury. Due to a history of prior elopement, Resident #1 was care planned to ensure doors are tightly closed and to check doors and systems per protocol, and to direct Resident #1 away from doors by asking the resident to turn around and assist to move away. The failure to implement the care plan to have secured exit doors and supervision for residents with a known history of elopement, placed this and other residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) that began on 12/9/18, when Resident #1, a cognitively impaired resident, exited the building, believed to be from the 400 hall door, unsupervised. Resident #1 and was found at the bottom of the exit ramp, approximately 65 steps from the top of the ramp and approximately 17 steps from the end of the exit ramp. On 1/14/19 at 2:20 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 1/22/19, in which the facility alleged all corrective actions were completed on 1/18/19, and the IJ removed on 1/19/19. The SA validated the A[NAME] on 1/23/19, and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.21 (b)(1)-Develop/Implement Comprehensive Care Plan, F656, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy titled, Elopements and Wandering Residents, modified on 4/20/18, documented the purpose of the policy is to ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of the facility's policy titled, Documentation of Elopement Policy, dated 11/5/09, revealed care planning will be done on the incident and any and all measures/approaches to prevent recurrence. Review of Resident #1's care plan, revealed the resident was at risk for elopement with an onset date of 2/7/11, upon admission. The facility identified Resident #1 as a potential for elopement related to impaired cognition, history of wandering at home and packing up to leave. The listed approaches included to ensure doors are tightly closed and to check doors and systems per protocol. This care plan also listed an approach to direct resident away from doors, and to tell the resident to turn around or assist resident to move away from the door. Review of Resident #1's, Risk Factors for Elopement assessment, dated 11/7/18, documented Resident #1 had a score of 14. This assessment indicated a score above ten (10) was a high risk for elopement. In an interview and observation, with Certified Nursing Assistant (CNA) #1, on 1/14/19 at 12:00 PM, she stated on the morning of 12/9/18, she observed Resident #1 through the window blinds of room [ROOM NUMBER], outside and alone in the wheelchair, which was sitting upright on the grass. The Surveyor and CNA #1 walked 65 steps down the ramp and 17 steps from the ramp to where the CNA indicated Resident #1 was located on 12/9/18. CNA #1 stated Resident #1 was still sitting upright in the wheelchair, with the alarm belt in place, when she brought her back into the facility and reported to the nurse. CNA #1 confirmed Resident #1 did not have enough supervision on 12/9/18, to prevent her from eloping from the facility. CNA #1 stated she was not assigned to Resident #1 on 12/9/18, but stated it was everyone's responsibility to watch all residents at risk for elopement. CNA #1 stated she was aware that Resident #1 was at risk for elopement, and that information is located in the care plan. CNA #1 was asked if the care plan for Resident #1 was followed if she was found outside that far away from the building, and unsupervised, and she responded, I guess not. In an interview, on 1/18/19 at 11:50 AM, Licensed Practical Nurse (LPN) #1 revealed she was on duty 12/9/18, when Resident #1 eloped. LPN #1 stated, she was notified that CNA #1 saw Resident #1 go outside, and she went out and got her. LPN #1 stated, the Administrator was notified, and then was told that CNA #1 did not see Resident #1 go outside, but that Resident #1 was already outside when she was seen out the window. LPN #1 stated she was instructed by the DON not to document the elopement in the Nurses Notes, or to notify the family, or obtain statements. LPN #1 stated the elopement occurred after breakfast between 8:00 AM and 9:00 AM, then stated, Nobody was actually at the Nurses Station when it happened. LPN #1 stated Registered Nurse (RN) #4 was the supervisor that day and checked Resident #1 out for injuries when Resident #1 was returned to the building. In an interview with RN #4, on 1/18/19 at 12:20 PM, she revealed on 12/9/18, she was working as the RN Supervisor, when she heard CNA #1 scream and say that Resident #1 was outside and started running outside. RN #4 reported, that she put the code in the 400 hall door, and exited the building toward where Resident #1 was located outside. RN #4 stated, she observed Resident #1 sitting upright in the wheelchair, stating that she was going home. RN #4 stated, staff assisted Resident #1 inside. RN #4 stated, she received a phone call from the DON to watch the 400 hall door, and to put a note on the door that no staff was allowed to use it. RN #4 stated she had to enter the code to open the 400 hall door, but did not remember hearing an alarm. In an interview, on 1/16/19 at 4:40 PM, LPN #10 stated the purpose of the resident care plan is to have a guide for all resident care and is resident centered. LPN #10 stated if a resident had a care plan for elopement and that resident got outside with no staff present, then the care plan for that resident was not followed. LPN #10 stated there was no documentation of Resident #1's elopement on 12/9/18, so we can't attest the care plan was followed. In an interview, on 1/16/19 at 4:50 PM, LPN # 9 revealed the resident's care plan is an individual working care plan based on the needs, wants and sometimes the [DIAGNOSES REDACTED].#9 stated if a resident is care planned for an elopement risk and they get outside, unsupervised, then somebody was not watching them per the care plan. The facility admitted Resident #1 on 2/7/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/18, revealed Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment identified Resident #1 as severely impaired and never/rarely made decisions.

Based on observations, record review, interviews, and policy review, the facility failed to provide adequate assessment and supervision for a confused, demented resident, Resident #1, with a past history of elopement for one (1) of six (6) residents reviewed for risk of elopement; Resident #1. It is believed Resident #1 exited the building through the 400 hall fire exit door on 12/9/18 between 8:00 AM and 9:00 AM. The resident was found 17 steps from the end of the exit ramp that was 65 steps down from the top, and greater than six (6) feet in height. Resident #1 was observed from a window inside the facility, by Certified Nursing Assistant (CNA) #1, who immediately went outside and returned Resident #1 into the building. Resident #1 was assessed by Licensed Practical Nurse (LPN) #1 with no injury. All staff was responsible to supervise Resident #1 and the other 18 residents at risk for elopement. Resident #1 was on every 30 minute checks from a fall earlier that morning on 12/9/18, and was documented as being observed on these checks for twenty-four (24) hours. Resident #1 had a history of [REDACTED].#1 away from doors, by asking resident to turn around and assist to move away. The failure to provide supervision to Resident #1, a demented resident with a history of elopement, resulted in the resident's elopement from the facility and placed this resident and other demented residents with a risk of elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/9/18, when Resident #1 exited the building unsupervised and was found in her wheelchair, 17 steps from the end of the exit ramp that was 65 steps down from the top of the ramp. On 1/14/19 at 2:20 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 1/22/19, in which the facility alleged all corrective actions were completed on 1/18/19, and removal of the IJ on 1/19/19. The SA validated the A[NAME] on 1/23/19, and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.25 (d)(1)(2)-Supervision, F689, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy titled, Elopements and Wandering Residents, modified on 4/20/18, revealed the purpose of the policy is to ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. This policy revealed the facility is equipped with door locks/alarms to help avoid elopements but are not a replacement for necessary supervision. This policy defines elopement to occur when a resident leaves the premises or a safe area without authorization and/or necessary supervision. Review of the facility's policy titled, Documentation of Elopement Policy, dated 11/5/09, revealed an elopement is considered to be when a resident, (confused or alert), wanders past the facility exit without staff knowledge. A review of Resident #1's, Risk Factors for Elopement assessment, dated 11/7/18, documented Resident #1 had a score of 14. This assessment noted a score above ten (10) indicated a high risk for elopement. Review of Resident #1's cumulative physician's orders [REDACTED]. Review of Resident #1's care plan, revealed the resident was at risk for elopement, with an onset date of 2/7/11, upon admission. The facility identified Resident #1 as a potential for elopement related to impaired cognition, history of wandering at home and packing up to leave. A review of the care plan dated for 8/2/18, revealed Resident #1 remained an elopement risk with approaches to ensure doors are tightly closed and to check doors and system per protocol. An additional approach was listed to direct resident away from doors-ask resident to turn around and assist to move away. Interview and observation with Certified Nursing Assistant (CNA) #1, on 1/14/19 at 12:00 PM, revealed on the morning of 12/9/18, she observed Resident #1 through the window blinds of room [ROOM NUMBER]. Resident #1 was outside and alone in the wheelchair, which was sitting on the grass. CNA #1 stated, she immediately went outside and brought Resident #1 inside. CNA #1 and the Surveyor, using the keypad to unlock the 400 hall fire door exit, walked 65 steps down the ramp and 17 steps from the ramp to where she indicated Resident #1 was located on 12/9/18. CNA #1 stated, Resident #1 was still sitting upright in the wheelchair, with the alarm belt in place, when she brought her back into the facility. CNA #1 confirmed, Resident #1 did not have enough supervision on 12/9/18, to prevent her from eloping from the facility. CNA #1 stated, she was not assigned to Resident #1 on 12/9/18, but stated that it was everyone's responsibility to watch all residents at risk for elopement. In an interview, with the Administrator, on 1/14/19 at 11:18 AM, she stated no investigation was conducted because Resident #1 was in sight of staff the whole time with staff pursuing her on 12/9/18, when she got outside. Further interview with the Administrator, on 1/14/19 at 11:40 AM, revealed when she talked to CNA #1 this morning, she learned Resident #1 was outside alone on 12/9/18, and not in sight of employees as previously thought. The Administrator stated, I made a horrible mistake. Interview with the Director of Nursing (DON), on 1/14/19 at 10:55 AM, confirmed Resident #1 did go outside unsupervised on 12/9/18, and an investigation was initiated, but not completed. The DON stated that a head count of all the residents was conducted and staff members were assigned to each door until the doors could be checked after Resident #1 eloped. In an interview, on 1/18/19 at 11:50 AM, Licensed Practical Nurse (LPN) #1 stated that she was on duty 12/9/18, when Resident #1 eloped. LPN #1 stated she was notified that CNA #1 saw Resident #1 go outside and that she went out and got her. LPN #1 stated the Administrator was notified about the elopement and was told that CNA #1 did not see Resident #1 go outside, but that Resident #1 was already outside when the CNA saw her out the window. LPN #1 stated, she was instructed by the DON not to document Resident #1's elopement in the Nurses Notes, not to notify the family, and not to obtain statements. LPN #1 stated the elopement occurred after breakfast, between 8:00 AM and 9:00 AM, and stated, Nobody was actually at the Nurses Station when it happened. LPN #1 stated Registered Nurse (RN) #4 assessed Resident #1 with no injury when CNA #1 returned the resident to the building. An interview with RN #4, on 1/18/19 at 12:20 PM, revealed on 12/9/18, she was working as the RN Supervisor. She stated she heard CNA #1 scream and say that Resident #1 was outside and started running outside the building. RN #4 stated, she put the code in the 400 hall door, and exited the building toward where Resident #1 was outside. RN #4 stated, she observed Resident #1 was sitting upright in the wheelchair, stating that she was going home. RN #4 stated staff got Resident #1 inside and CNA #1 then told her she saw Resident #1 through the blinds of the window from room [ROOM NUMBER]. RN #4 stated she obtained Resident #1's vital signs and checked her over, and didn't see any injuries. RN #4 stated she received a phone call from the DON, to watch the 400 hall door and to put a note on the door that no staff was allowed to use it. RN #4 stated she had to enter the code to open the 400 hall door, but did not remember hearing an alarm. RN #4 stated, she did not remember that Resident #1 had a fall earlier that day, but this event occurred around 8:00 AM to 8:30 AM. RN #4 confirmed a head count of all other residents was completed and everyone was accounted for. Interview on 1/18/19 at 12:30 PM, with the DON, revealed she was called to the facility on [DATE], and was instructed by the Administrator via phone, to conduct a head count and to place staff at all doors, with the focus on the 400 Hall door, because the door wasn't shutting or something not alarming. The next day (12/10/18), the DON stated an investigation was initiated, but was told by the Administrator to stop because Resident #1 was in sight of staff at all times. The DON stated that if an investigation had been completed, it would have revealed Resident #1 had gotten outside alone. During an interview, on 1/18/19 at 11:36 AM, the Maintenance Director stated on 12/9/18, when at the facility fixing a leak in the ceiling, he was notified the back door was not working properly. He stated the alarm was not working and was instructed by the Administrator, by phone, to notify the security company. An interview, on 1/18/19 at 11:40 AM, with Contract Vender #1 of the security company, revealed he was unsure of the exact date in December, but he came and repaired the circuit card for the back door, because it was not working properly at the time. Contract Vender #1 stated, The only reason to replace that card is if the door is not locking properly, the magnetic part and sounding, they both go together. An interview with the Medical Director, on 1/15/19 at 10:55 AM, confirmed he was recently a part of the Quality Assurance (QA) committee meeting, where the elopement, care plan, reporting and investigating policies were discussed, with no changes made at that time. The Medical Director confirmed, the alarm on the 400 hall door was repaired and a sign was posted that employees would no longer be allowed to use the door as an exit. The facility admitted Resident #1, on 2/7/11, with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/10/18, revealed Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment identified Resident #1 as severely impaired and never/rarely made decisions. The facility provided an Acceptable Allegation of Compliance, which included: Resident #1 was admitted on [DATE]. Resident #1 has the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 has a history of two (2) prior elopements to 12/09/18. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18, at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, seven (7) feet high and five (5) feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 brought Resident #1 back into the facility at approximately 8:30 am with no apparent injuries. Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18, and revealed severe cognitive impairment. The facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. Corrective Actions: 1. LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7 pm on 12/09/18, and was continued on every 30 minute checks until 6:30 am on 12/10/19. 2. LPN #1 reported to the Administrator by phone, on 12/09/18 at 8:55 am, that Resident #1 exited the building and was brought back in by CNA #1. The Administrator was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19 at 11:45 am, revealed that Resident #1 was not in sight at all times. 3. The Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18 at 9:13 am, of Resident #1 exiting the building supervised. No investigation was initiated at this time. There is no documentation that Resident #1 was assessed upon return to the facility. 4. On 12/09/18 at approximately 10 am, LPN #1 put a sign on the Emergency Exit door. The sign stated, This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. 5. The 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm. There were no specific staff assignments made by LPN #1 to monitor the door. 6. The last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18, by Maintenance personnel, and was noted to be working properly. On 12/09/18 at approximately 11:15 am, the door lock was working properly but the sound for the Emergency Exit door alarm was non-functioning, when checked by Maintenance personnel. The Administrator was notified at 11:30 am, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18, by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. On 12/09/18, after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. On 12/10/18 at 7:00 am, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. During further investigation, on 01/14/19 at approximately 11:45 am, it was determined during interview by the Administrator that CNA #1 did not have Resident #1 in sight at all times. 10. On 01/14/19 at approximately 2:00 pm, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at PM, LPN #2, Administrator, Registered Nurse (RN) #1, RN #2, and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. No staff will be allowed to work until they have completed all in-services. 11. Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19 at 8:00 pm, by LPN # 9. Nineteen residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff; staff is aware, and in-services were conducted on 01/16/19 by LPN #2 that residents are on 15 minute checks. 12. The Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19 at approximately 12:30 pm. No discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 at 3:00 pm, and ending 01/17/19 5:30 pm, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19 at 12:30 pm. Resident #1's Responsible Party was notified on 01/16/19, by the DON at 11:50 am. 14. Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19 at 6:20 pm. Care Plans were reviewed and 19 were updated with current intervention for every 15 minute checks. 15. On 01/14/19 at 6:30 pm, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18, with Resident #1, was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. An Emergency QA meeting was held on 01/16/19 at 12:35 pm, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN #2, and the Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. 17. In-service to all staff was initiated by LPN #2 and RN #2 on 01/16/19 at 3:45 pm, regarding changes to daily door checks. 18. On 01/17/19 at 5:30 pm, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. 19. An Emergency QA meeting was held on 01/18/19 at 11:30 am, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator, and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. In-service to all staff was completed by LPN #2 on 01/18/19 at 11:45 am, regarding changes to the Emergency Exit Door Policy. 21. As of 01/18/19 at 5:00 pm, a total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff, and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The facility alleges all corrective actions to remove the IJ were completed on 01/18/19, and the IJ removed on 01/19/19. Validation of the Allegation of Compliance included: Based on observation, interviews, record review, the State Agency (SA) validated that Resident #1 was admitted on [DATE]. Resident #1 had the following Diagnoses: [REDACTED]. On 02/07/11, Resident #1 was originally care planned for Elopement risk. Resident #1 had a history of [REDACTED]. The Elopement care plan was revised on 05/06/16, to include Resident #1's continued risk for elopement. On 12/09/18 at approximately 8:00 am, Resident #1, who is cognitively impaired and wheelchair bound, exited the building unsupervised. Resident #1 was located approximately 17 walking steps from the end of the ramp in a grassy area located outside the 400 hall emergency exit. Due to the location of Resident #1, it is believed that Resident #1 exited through the 400 Hall Emergency Exit door. The exit ramp measures 153 feet long, 7 feet high and 5 feet wide with a handrail the entire way (approximately 65 steps). Certified Nursing Assistant (CNA) #1 verified by interview that she brought Resident #1 back into the facility at approximately 8:30 am, with no apparent injuries. Record review confirmed Resident #1's last Brief Interview for Mental Status (BIMS) was conducted on 10/10/18 and revealed severe cognitive impairment. Results of record review and interview confirmed the facility failed to investigate Resident #1's elopement and failed to document an assessment and interventions after Resident #1 exited the building unsupervised on 12/09/18. The facility failed to report Resident #1's elopement to the required State Agencies. The SA validated the facility's Corrective Actions: 1. The SA validated through interview that LPN #1 kept Resident #1 in her line of sight for the remainder of her shift which ended at 7:00 pm on 12/09/18, and continued every 30 minute checks until 6:30 am on 12/10/19. 2. The SA validated through interview that LPN #1 reported the elopement of Resident #1 to the Administrator by phone on 12/09/18. Interview with the Administrator confirmed she was told that Resident #1 was in line of sight at all times, but further investigation on 01/14/19, revealed that Resident #1 was not in sight at all times. 3. The SA validated through interviews that the Administrator notified the Corporate Nurse and the Director of Nursing (DON) on 12/09/18, of Resident #1 exiting the building supervised and that no investigation was initiated at this time. 4. The SA validated through observation and interviews that on 12/09/18, LPN #1 put a sign on the Emergency Exit door. The sign stated This is an Emergency Exit Only. Employees must use Employee Exit at the rear of the building. The sign was observed during survey. 5. The SA validated through staff interviews that the 400 Hall Emergency Exit door was visually monitored from approximately 10:00 am on 12/09/18, by nursing staff, until repairs were made on 12/10/18 at 12:00 pm, but no specific staff assignments were made by LPN #1 to monitor the door. 6. The SA validated through interviews and record review that the last check of the Emergency Exit door alarm system prior to Resident #1's elopement was on 12/07/18 by Maintenance personnel and was noted to be working properly, but on 12/09/18, the sound for the Emergency Exit door alarm was non-functioning. Interviews revealed the Administrator was notified, and a repair call was placed to the alarm company at this time. The Emergency Exit door alarm was repaired on 12/10/18 by the alarm company (Proper Name), and all Emergency Exit doors were checked by the alarm company and found to be working properly. 7. The SA validated through interviews that on 12/09/18 after Resident #1 was returned to the building, LPN #1 initiated a resident head count. The census was 92. The head count revealed all 92 residents were in the building. 8. The SA validated through interviews and record review that on 12/10/18, 400 and 500 hall nursing staff were in-serviced by the Assistant Director of Nursing (ADON) on the 400 hall Emergency Exit Door; the employees must use employee entrance, not the 400 hall Emergency Exit. 9. The SA validated through interviews that during further investigation on 01/14/19, the Administrator determined that CNA #1 did not have Resident #1 in sight at all times. 10. The SA validated through interviews and record review that on 01/14/19, the Corporate Nurse educated the Administrator and DON on proper investigating and reporting. Beginning on 01/14/19 at 3:00 pm, LPN #2, Administrator and Registered Nurse (RN) #1, RN #2 and RN #3 began in-servicing all staff on the following policies: Abuse/Neglect and Exploitation, Reporting incidents, Emergency Exit Door Alarm System, to include alarm checks that are done Monday through Friday by Maintenance personnel, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. A total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel. This was completed by 6:00 pm on 01/15/19. The SA validated through interview and staffing records that no staff have been allowed to work until they have completed all in-services. 11. The SA validated through record reviews and interviews that the Elopement Risk Factors, which are used for assessments, were completed on all 98 residents in the facility on 01/14/19, by LPN # 9 and that 19 residents were identified as being at risk for elopement: Resident #1, and Resident #3 through Resident #20. All 19 residents were placed on every 15 minute checks by nursing staff and in-services were conducted on 01/16/19 by LPN #2, that residents are on 15 minute checks. 12. The SA validated through interviews and record review that the Elopement risk book was reviewed for accuracy by LPN #2 on 1/14/19, and that no discrepancies were noted. All staff were in-serviced on the Elopement Book beginning on 01/16/19 and ending 01/17/19, by LPN #2 and RN #2 to ensure they are aware of the Elopement book, where it is located and what residents are at risk for elopement. 13. The SA validated through interviews and record review the facility Administrator notified the Attorney General's office of Resident #1's elopement and the DON called Resident #1's elopement in to the State Department of Health on 01/15/19. Resident #1's Responsible Party was notified on 01/16/19 by the DON. 14. The SA validated through interviews and record review the Care Plans for residents at risk for elopement were reviewed and updated as necessary by LPN #9 on 01/14/19. The SA verified Care Plans were updated with current intervention for every 15 minute checks. 15. The SA validated through interviews and record review that on 01/14/19, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, DON, Administrator, QA Nurse, and Minimum Data Set(MDS) Nurse in attendance. Medical Director attended by phone. The elopement that occurred on Sunday, 12/09/18 with Resident #1 was discussed. Policies and procedures were reviewed: Abuse/Neglect and Exploitation, Investigating and Reporting policy, Emergency Exit Door Alarm System, Elopement and Wandering Resident, Following Care Plan and the non-use of the Emergency Exit by the 400 hall Nurse's Station. No revisions were made. 16. The SA validated through interviews and record reviews an Emergency QA meeting was held on 01/16/19, regarding door alarm checks. In attendance were the Medical Director, Administrator, DON, Maintenance Supervisor, LPN# 2 and Assistant Administrator. A change was made to the Emergency Exit Door Alarm System Policy to include the doors will be checked on a daily basis by Maintenance personnel. The SA validated through record review of the documented daily checks. 17. The SA validated through interviews and record review that in-service to all staff was by LPN #2 and RN #2 on 01/16/19, regarding changes to daily door checks. 18. The SA validated through interviews and record reviews that on 01/17/19, LPN #2 reviewed 82 incident reports from 12/01/18 to 01/17/19, to ensure thorough investigation and reporting requirements were met, and brought her findings to the QA interdisciplinary team. There were no other concerns for reporting or investigating identified. The SA validated no other concerns were noted. 19. The SA validated through interviews and record review that an Emergency QA meeting was held on 01/18/19, regarding Emergency Exit Door Policy. In attendance were the Medical Director, Administrator, DON, LPN# 2, Assistant Administrator and Corporate Nurse. A change was made to the Emergency Exit Door Alarm System Policy. The doors now have a five (5) second delay in locking instead of a 15 second delay. Codes have been changed and only the following staff has access: The Administrator, Assistant Administrator, Corporate Nurse, DON, ADON and Maintenance Supervisor. Changes included the Emergency Exit doors are checked and documented daily by Maintenance personnel. 20. The SA validated through interviews and record review that an in-service to all staff was completed by LPN #2 on 01/18/19, regarding changes to the Emergency Exit Door Policy. 21. The SA validated through interviews and record reviews as of 01/18/19, total of 155 employees: 15 RN's, 36 LPN's, 54 CNA's, seven (7) Activity Aides, Activity Director, 14 dietary staff, three (3) Maintenance, five (5) Administrative staff, 13 Housekeeping/Laundry Contract Staff and seven (7) contract therapy personnel were in-serviced on the policy and or policy changes made by the facility. 22. The SA validated that all corrective actions were completed on 01/18/19, and the IJ removed on 01/19/19.

Based on observation, record review, staff interview and facility policy review, the facility failed to follow the Care Plan for exit seeking behaviors for one (1) of six (6) residents reviewed at risk for wandering/elopement, for Resident #1. Following an assessment on 12/03/14, the facility identified Resident #1 at risk for elopement and developed an elopement care plan dated 12/03/14. Resident #1 had a history of [REDACTED]. Resident #1 wore a wander guard alarm bracelet. According to the facility's documentation, on 05/02/16 at 5:15 PM, the facility became aware that Resident #1 had eloped from the facility when a visitor brought the resident back into the building. Resident #1 had exited the main entrance to the facility, traveled down the wheelchair ramp to the right of the main entrance in her wheelchair, turned left and was at a speed bump at the entrance to the parking area. The distance was approximately 68 steps from the main entrance to the speed bump in the parking lot. Due to Resident #1 not being able to propel her wheelchair over the speed bump, a visitor observed Resident #1 in her wheelchair in the parking lot and returned the resident to the facility. The facility's failure to implement interventions listed in the resident's elopement risk care plan placed Resident #1 in a situation that was likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 05/02/16 when Resident #1 left the facility without supervision of staff. The State Agency notified the facility on 05/06/16 of the Immediate Jeopardy (IJ) at 42 CFR 43.20 (k) (3) (ii) Services per Qualified Person per Care Plan (F282). The facility submitted an acceptable Allegation of Compliance (AOC) on 05/09/16. The State Agency surveyor validated the facility's AOC and determined the IJ was removed on 05/11/16 prior to exit. Therefore, the scope and severity for the IJ at 42 CFR 483.20 (K) (3) (ii) Services per Qualified Person per Care Plan (F282) was lowered to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of systemic change. Findings include: Review of the Total Care Plan Policy, effective 01/01/07, revealed, It is the policy of this facility that the Interdisciplinary care plan will be done as follows: Identify the interventions related to the specific problems. Review of Resident #1's comprehensive care plan revealed a problem, dated 12/03/14, for Elope (Elopement) Risk, Resident has potential for elopement r/t (related to) propels self in w/c (wheelchair), delusions at times believes she has to get home to the children. The approaches included to, Direct resident away from doors - ask resident to turn around and assist to move away and Respond promptly to alarms and remove resident from the area. Review of the facility's elopement investigation revealed on 05/02/16 at 5:40 PM Resident #1 was observed by a visitor outside of facility doors unaccompanied by staff. Resident was brought back inside to nurse's station. The facility investigation documented that the nurse (who was not identified) did not check the main entrance door where the alarm sounded and Resident #1 exited the building. Certified Nursing Assistant (CNA) #2 confirmed in an interview, on 05/06/16 at 3:45 PM, that she had seen Resident #1 attempting to exit the facility in the past. CNA #2 also stated staff would try to redirect the resident unsuccessfully. On 05/09/16 at 11:00 AM, an interview with Licensed Practical Nurse (LPN) #2 revealed he had spoken to Resident #1 on 05/02/16 prior to her elopement, and the resident had talked about her family and her babies. On 05/09/16 at 12:15, an interview with LPN #3 revealed she had observed Resident #1, circling (inside) the building in her wheelchair prior to the resident's elopement from the facility. On 05/06/16 at 9:10 AM, an interview with Registered Nurse (RN) #1 revealed Resident #1 was circling (inside) the building in her wheelchair. RN #1 stated the facility staff did not initiate any behavioral interventions at that time. Interview, on 05/05/16 at 1:40 PM, with the facility's Administrator revealed the Wander Guard door alarm sounded when Resident #1 exited the building. The Administrator said the nurse should have checked the front entrance door to determine if a resident had exited the facility, but failed to check. Licensed Practical Nurse (LPN) #1 confirmed in an interview, on 05/06/16 at 3:35 PM, that he was in the activity dining room with other residents when a visiting family member took another resident out to the smoking area multiple times. LPN #1 stated the alarm sounded, and he saw an activity aide turn off the Wander Guard alarm. During this time, Resident #1 eloped from the facility. During an interview, on 05/06/16 at 11:10 AM, with the visitor who returned Resident #1 to the facility confirmed when Resident #1 was propelled back into the facility through the main entrance door, the Wander Guard alarm sounded. Observation, on 05/05/16 at 2:10 PM, revealed Resident #1 seated in her wheel chair in the activity dining room during a party with a Wander Guard bracelet on her right wrist. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/07/11 with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/16, revealed Resident #1 scored eight (08) of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The facility submitted an acceptable Allegation of Compliance (AoC) on 05/09/16 for the Immediate Jeopardy (IJ). Review of the facility's AoC revealed the facility took the following action to remove the Immediate Jeopardy. 1) 05/02/2016 5:10 pm, Resident #1 who was moderately cognitively impaired exited through the front entrance of the facility in a self-propelled wheel chair causing the wander guard system to alarm. Facility staff did not check the front door alarm. Resident #1 was observed by a visitor unsupervised by staff approximately 68 ft outside of the facility doors. Resident #1 was brought back inside to nurse's station by a visitor. This is when the staff became aware of the unsupervised elopement by resident #1. 2) 05/02/2016 5:15 pm, Once resident #1 was returned to nurse's station, the Registered Nurse (RN) charge nurse notified the ADON of the elopement. 3) 05/02/2016 5:22 pm, The Director of Nurses (DON) was notified of elopement by the Assistant Director of Nurses (ADON). 4) 05/02/2016 5:25 pm, DON directed one on one direct observation by CNA who sat at arm's length of the resident until 10:00 pm. Thirty-minute visual checks were implemented by Nurse #1 beginning at 6:00 pm and continued with Nurse #2, Nurse #3, Nurse #4 and Nurse #5 until 7:00 pm on 05/04/2016 to ensure Resident #1's safety. 5) 05/02/2016 5:29 pm, the ADON notified the Administrator of the elopement. 6) 05/02/2016 6:55 pm, Body audit of visible skin, ROM and vital signs were completed for Resident #1 by RN charge nurse and was documented in the incident report. Vital signs were as follows: Temp 98.4, Pulse 67, Respirations 18 and Blood Pressure 152/70. No signs of physical harm were revealed in skin check. 7) 05/03/2016 8:00 am, A complete body audit was completed on Resident #1 by RN charge nurse with no physical injuries to Resident #1. This was documented on body audit sheet. 8) 05/03/2016 8:15 am, Wander guard alarm system checked by facility environmental services supervisor and found to be working properly. 9) 05/03/2106 8:36 am, Responsible Party (RP) notified of Resident #1's elopement. 10) 05/04/2016 10:45 am, Health Facilities Licensure & Certification and State Attorney General's Office were notified by the Administrator as required. 11) 05/06/2016-3:00 pm QA committee meeting was held to discuss the elopement with QA Nurse, Physician, DON, ADON, Administrator, MDS Nurse and Social Services. The QA Committee recommended: Elopement drills to be done once on each shift for 3 pm-11 pm, 11 pm-7 am and 7 am-3 pm shifts. DON and ADON to in-service that all staff are to supervise residents on exit seeking behaviors. Update Elopement Policy to include wander guard manufacturing guidelines. Perform a care plan review of all 16-elopement risk residents to update behavioral interventions specific to residents. Physician to complete medication review for Resident #1. DON, QA Nurse, and RN charge nurse to in-service all staff members prior to shift on updated Elopement Policies. Social services to perform psychosocial evaluation on Resident #1. Speech Therapist to perform a cognitive linguistics evaluation on Resident #1. 12) 05/06/ :30 pm, DON and Human Resources Manager reviewed and revised the orientation process for all new hired employees to include Elopement Policy and Procedures and added responding to alarms and the explanation of the wander guard system. 13) 05/06/2016 4:45 pm, Physician reviewed and evaluated medications of resident #1. He discontinued calcium/vitamin D and made no other medication changes. He also ordered the following test Complete Metabolic Panel, Para [MEDICAL CONDITION] Hormone (PTH), [MEDICAL CONDITION] Stimulating Hormone (TSH), Vitamin B12 level, free T4 ([MEDICATION NAME]) and UA (Urinalysis) with culture and sensitivity. 14) 05/06/2016 5:00 pm, Resident #1 care plan was updated to offer Resident #1 a baby doll when resident is looking for her children and/or exhibiting exit-seeking behavior. 15) 05/06/2016 5:30 pm, Social Services completed a psychosocial evaluation and determined that there was no psychosocial harm to Resident #1. 16) 05/06/2106 5:45 pm, Speech Therapist conducted a cognitive linguistic evaluation and determined that Resident #1 has a moderate cognitive impairment. The Speech Therapist recommendations to reduce communications breakdown and provide simple cognitive linguistic stimulation are as follows: Pick up on key words to address needs. Redirect frequently back to task in gentle manner. Validate emotions and feeling to encourage more appropriate interactive skills and confidence. Paraphrase information and repeat it back to allow increased processing time. Use face-to-face communication, slow the rate of speech, breaking down units of information. Provide appropriate word as needed if frustration occurs. Appropriately agree with misinformation unless frustration occurs. Use gentle correction as much as needed such as I think you told me . Never present with bad or disturbing news. Direct supervision of all ADLS, monitor hydration/nutrition. Provide objects as distractions as needed. Instead of open-ended questions, give a choice with visual cues. 17) 05/06/2016 6:15 pm, QA nurse conducted an audit of all photos of the 16 residents who are at risk of elopement. The wander guard expiration dates were added to the elopement binders and placed at nurses' station. 18) 05/06/2016 6:30 pm, Administrator reviewed facilities policy and procedures as well as manufacturers recommendations for usage of the Wander Guard system to ensure that they were properly being used by staff. Elopement Policy was revised to include: -Behavior interventions will be placed on care plans for all elopement risk residents. -Residents at risk for elopement will have a wander guard placed on their wrist. -Test each signaling device before using. -Do not use the device past the expiration date on the side of device. -Do not place wander guard on or near metal surfaces. Because metal could interfere with the signal sent to the door modules. -Do not use more than one wander guard per resident. If more than one device is brought too close together, it may not be received by door monitor and alarm will not sound. -Wander guard device is to be tested every night by assigned nurse. 19) 05/06/2016 7:00 pm, Elopement drill was implemented for evening shift staff by DON and all staff who participated signed in-service sheet that they participated. All staff were interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 20) 05/06/2016 8:00 pm, Care plans for all 16 residents at risk of Elopement were updated and reviewed to include behavior interventions. 21) 05/06/2016 11:00 pm, Elopement drill was implemented for night shift staff by RN charge nurse and all staff who participated signed in- service sheet that they participated. All staff were interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 22) 05/07/2016 7:30 am, All employees were in-serviced prior to working scheduled shifts about Elopement Policies, procedures, supervision of residents on exit seeking behaviors and responding to wander guard alarms. Training was conducted by DON, ADON, QA Nurse and RN Charge nurse for all employees prior to their next scheduled shift. No employees will be allowed to work prior to completion of the training. 23) 05/07/2016 8:00 am, Elopement drill was implemented for day shift staff employees by DON and all staff who participated signed in-service sheet that they participated. All staff interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 24) 05/08/2016 8:00 am, the DON, QA nurse and RN charge nurse in-serviced all staff on updated care plans of elopement risk residents and Speech Therapist recommendations for Resident #1. On 05/11/16, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. On 05/11/16, the State Agency (SA) surveyor validated Resident #1 exited through the front entrance of the facility in a self-propelled wheel chair causing the Wander Guard system to alarm and the facility staff did not check the front door alarm. Resident #1 was observed by a visitor unsupervised by staff approximately 68 feet outside of the facility doors. A visitor brought Resident #1 back inside to the nurse's station, and this was when the staff became aware of the unsupervised elopement by Resident #1 on 05/02/16 at 5:10 PM. 2. On 05/11/16, the State Agency (SA) surveyor validated the RN (Registered Nurse) charge nurse notified the ADON (Assistant Director of Nursing) of the elopement on 05/02/16 at 5:15 PM. 3. On 05/11/16, the SA surveyor validated the ADON (Assistant Director of Nursing) notified the DON (Director of Nursing) of Resident #1's elopement on 05/02/16 at 5:22 PM. 4. On 05/11/16, the SA surveyor validated the DON ordered one on one direct observation by a CNA (Certified Nursing Assistant) who sat at arm's length of Resident #1 until 10:00 PM. Thirty-minute visual checks were implemented by Nurse #1 beginning at 6:00 PM and continued with Nurses #2, #3, #4 and #5 until 7:00 PM on 05/04/16 to ensure Resident #1's safety on 05/02/16 at 5:25 PM. 5. On 05/11/16, the SA surveyor validated the ADON notified the administrator of (Resident #1's) elopement on 05/02/16 at 5:29 PM. 6. On 05/11/16, the SA surveyor validated Resident #1 would not allow a complete body audit at that (time of the elopement). A body audit of visible skin, ROM (Range of Motion) and vital signs were completed for Resident #1 by the RN charge nurse and was documented in the Incident Report. The vital signs were as follows: 98.4 temperature, 67 pulse, 18 respirations and 152/70 blood pressure. No signs of physical harm were revealed in the skin check on 05/02/16 at 6:55 PM. 7. On 05/11/16, the SA surveyor validated a complete body audit was documented on a Nurses Body Audit Sheet on 05/03/16 at 8:00 AM for Resident #1 by the RN charge nurse with no physical injuries noted. 8. On 05/11/16, the SA surveyor validated the Wander Guard alarm system was checked by the facility Environmental Services Supervisor and found to be working properly on 05/03/16 at 8:15 AM. 9. On 05/11/16, the SA surveyor validated the RP (Responsible Party) was notified of Resident #1's elopement on 05/03/16 at 8:36 AM 10. On 05/11/16, the SA surveyor validated the Administrator notified Health Facilities Licensure and Certification and the State Attorney General's office on 05/04/16 at 10:45 AM. 11. On 05/11/16, the SA surveyor validated the QA (Quality Assurance) committee met on 05/06/16 at 3:00 PM to discuss elopement with the QA Nurse, Physician, DON, ADON, administrator, MDS (Minimum Data Set) Nurse and Social Services in attendance. The QA committee recommended: -Elopement drill will be done once on each shift for 3:00 PM - 11:00 PM, 11:00 PM - 7:00 AM and 7:00 AM - 3:00 PM shifts. - The DON and ADON were to in-service all staff are to supervise residents on exit-seeking behaviors. - Update Elopement Policy to include Wander Guard manufacturing guidelines. - Perform a Care Plan review of all 16-elopement risk residents to update behavioral interventions specific to residents. - The Physician was to complete a medication review for Resident #1. -The DON, QA Nurse and RN charge Nurse to in-service all staff members prior to shift on updated Elopement Policies. - Social Services were to perform psychosocial evaluation on Resident #1. 12. On 05/11/16, the SA surveyor validated that on 05/06/16 at 4:30 PM, the DON and Human Resources Manager reviewed and revised the orientation process for all newly hired employees to include the Elopement Policy and Procedures and added responding to alarms and the explanation of the Wander Guard system. 13. On 05/11/16, the SA surveyor validated the Physician reviewed and evaluated medications and ordered a CMP, PTH, TSH, B 12 level, free T4, and UA with culture and sensitivity on 05/06/15 at 4:45 PM. 14. On 05/11/16, the SA surveyor validated the facility updated Resident #1's Care Plan on 05/06/16 at 5:30 PM to offer Resident #1 a baby doll when the resident is looking for her children and/or exhibiting exit-seeking behavior. 15. On 05/11/16, the SA surveyor validated Social Services completed a Psychosocial evaluation on 05/06/16 at 5:30 PM and determined there was no psychological harm to Resident #1. 16. On 05/11/16, the SA surveyor validated the Speech Therapist (ST) conducted a cognitive linguistic evaluation on 05/06/16 at 5:45 PM and determined Resident #1 had a moderate cognitive impairment. The ST recommended the following: - Pick up on key words to address (the Resident's) needs. - Redirect frequently back to task in a gentle manner. - Validate emotions and feelings to encourage more appropriate interactive skills and confidence. - Paraphrase information and repeat it back to allow increased processing time. - Use face-to-face communication, slow the rate of speech, and break down units of information - Provide appropriate words as needed if frustration occurs. - Appropriately agree with misinformation unless frustration occurs. - Use gentle correction as much as needed, such as, I think you told me . - Never present with bad or disturbing news. - Direct supervision of all ADLs (Activities of Daily Living), monitor hydration/nutrition. - Provide objects as distractions as needed. - Instead of open-ended questions, give a choice with visual cues. 17. On 05/11/16, the SA validated the QA nurse conducted an audit of photos of the 16 residents at risk of elopement. The Wander Guard expiration dates were added to the elopement binders and placed at the nurses' station. 18. On 05/11/16, the SA validated the administrator reviewed the facility's policies and procedures as well as manufacturers recommendations for the usage of the Wander Guard system on 05/06/16 at 6:30 PM. The Elopement Policy was revised to include: - Behavior interventions will be placed on Care Plans for all elopement risk residents. - Residents at risk for elopement will have a Wander Guard placed on their wrists. - Each signaling device would be tested before using. - Do not use the device past the expiration date on the side of the device. - Do not place the Wander Guard on or near metal surfaces, because metal could interfere with the signal sent to the door modules. - Do not use more than one (1) Wander Guard per resident. If more than one (1) device is brought too close together, it may not be received by the door monitor and the alarm will not sound. - The Wander Guard device is to be tested every night by the assigned nurse. 19. On 05/11/16, the SA validated an Elopement drill was implemented for the evening shift (3:00 PM - 11:00 PM) by the DON, and all staff who participated signed an in-service sheet that they participated on 05/06/16 at 7:00 PM. 20. On 05/11/16, the SA validated care plans for all 16 residents at risk of elopement were updated and reviewed to include behavior interventions on 05/06/16 at 8:00 PM. 21. On 05/11/16, the SA validated an Elopement drill was implemented for the night shift (11:00 PM - 7:00 AM) staff by the Charge Nurse and all staff who participated signed in-service sheet that they participated on 05/06/16 at 11:00 PM. 22. On 05/11/16, the SA validated all employees were in-serviced prior to working scheduled shifts about the Elopement Policies, procedures, supervision of residents with exit seeking behaviors and responding to the Wander Guard alarms by the DON, ADON, QA Nurse and the RN Charge Nurse on 05/07/16 at 7:30 AM. 23. On 05/11/16, the SA validated the Elopement drill was implemented for the day shift staff (7:00 AM - 3:00 PM) employees by the DON and all staff who participated signed the in-service sheet that they participated on 05/07/16 at 8:00 AM. 24. On 05/11/16, the SA validated the DON, QA Nurse and RN Charge Nurse in-serviced all staff on updated care plans of the elopement risk residents and Speech Therapist recommendations for Resident #1 on 05/08/16 at 8:00 AM. 25. On 05/11/16, the SA surveyor determined based on schedule and sign in sheets that no staff were allowed to work until inserviced. The SA determined the IJ was removed on 05/11/16.

Based on observation, record review, staff interview and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 for one (1) of six (6) residents reviewed. The facility identified Resident #1 as a risk for Elopement on 12/03/14. Resident #1 had a history of [REDACTED]. On 05/02/16 at 5:15 PM, the facility became aware of Resident #1's elopement after a visitor brought the Resident back into the building. Resident #1 had exited the main entrance to the facility, traveled down the wheelchair ramp to the right of the main entrance in her wheelchair, turned left and was at a speed bump at the entrance to the parking area. It was approximately 68 steps from the main entrance to the speed bump in the parking lot. Resident #1 had not been able to propel her wheelchair over the speed bump when a visitor observed Resident #1 in his/her wheelchair in the parking lot and returned the Resident to the facility. The facility's failure to supervise a resident with exit seeking behaviors placed Resident #1 in a situation that was likely to cause serious harm, impairment, or death. This was determined to be an Immediate Jeopardy (IJ) that began on 05/02/16 when Resident #1 eloped. The State Agency notified the facility on 05/06/16 of the Immediate Jeopardy (IJ) and Substandard Quality of Quality of Care at 42 CFR 483.25 (h) Accident Hazards (F323). The facility submitted an acceptable Allegation of Compliance (AOC) on 05/09/16. The State Agency surveyor validated the facility's AOC and determined the IJ was removed on 05/11/16 prior to exit. The scope and severity for the IJ at 42CFR 483.25 (h) Accident Hazards (F323) was lowered to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of systemic change. Findings include: Review of the policy for In the Event of an Elopement, dated 11/05/09, revealed, In the event of a resident elopement the following procedures will take place: The alarms will be re-checked during normal business hours by the Housekeeping Supervisor and by the Charge nurse after normal working hours. The resident's alarm bracelet will be checked and replaced if found to be non-functioning. Review of the Documentation of Elopement Policy, dated 11/05/09, revealed, Purpose: Elopement is considered to be when a resident (confused or alert), wanders past the Facility exits without staff knowledge. Review of the facility's Departmental Notes, dated 05/02/16 at 5:49 PM, revealed, an entry by Registered Nurse (RN) #2 that read, Was told that resident (#1) was spotted going out the front doors by (visitor). Review of the facility's Departmental Notes, dated 05/02/16 at 6:55 PM, revealed an entry by RN #1 that read CNA (Certified Nursing Assistant) from LTC (Long Term Care) side brought res (resident) to me. The note also stated a visitor saw Resident #1 outside by the offices. It was reported the visitor observed Resident #1 while returning another resident to the facility. Review of the facility's elopement investigation of Resident #1 revealed the facility documented that on 05/02/16 at 5:40 pm Resident #1 was observed by a visitor outside of facility doors unaccompanied by staff and the resident was brought back inside to nurses' station. Elopement protocol was initiated by staff. The investigation also revealed on 05/03/16 at 8:30 am the Quality Assurance (QA) nurse, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator met to discuss elopement protocol and investigation. According to the report, the investigation found the nurse (who was not identified) did not proceed to check the main entrance door where (Resident #1) was trying to exit the building when the alarm sounded. Interview, on 05/05/16 at 5:50 PM, with Certified Nursing Assistant (CNA) #1 revealed prior to Resident #1's elopement on 05/02/16, the resident was looking for her children and stated she needed to go to Gulfport. Interview, on 05/06/16 at 9:10 AM, with Registered Nurse (RN) #1 revealed Resident #1 was just circling (inside) the building in her wheelchair. Interview, on 05/06/16 at 3:45 PM, with CNA #2 confirmed the employee had seen Resident #1 attempting to exit the facility in the past. CNA #2 also stated staff would try to redirect the resident but was unsuccessful. Interview, on 05/09/16 at 11:00 AM, with LPN #2 revealed he had spoken to Resident #1 on 05/02/16 prior to her elopement. LPN #2 stated the resident had talked about her family and her babies. Interview, on 05/09/16 at 12:15, with LPN #3 revealed she had observed Resident #1 circling (inside) the building in her wheelchair prior to the elopement. Review of a statement, dated 05/02/16 and signed by Certified Nursing Assistant (CNA) #4 revealed, I was feeding a resident. When I came out, I heard the alarms so I went to see what was going on! That's when I saw (visitor) with resident (#1). I then got (Resident #1) and took her to Station II. Interview, on 05/05/16 at 6:10 PM, with CNA #4 revealed she heard the alarm sounding when she exited the room where she was providing care on 05/02/16 when Resident #1 eloped. CNA #4 saw Resident #1 after she was brought inside the building by the visitor. Review of a statement, dated 05/02/16 and signed by Licensed Practical Nurse (LPN) #1 revealed, (I) heard the alarms go off. The statement also revealed a family member of another resident was taking the other resident back out to smoking area causing alarm to go off again. Notice (noticed) activity aid turn alarm off. Interview, on 05/06/16 at 3:35 PM, with LPN #1 confirmed the statement and added he was in the activity dining room when a family member took another resident out to the smoking area multiple times during the time Resident #1 eloped. LPN #1 stated he saw an activity aide had turned off the Wander Guard alarm once. Review of a statement, dated 05/03/16 and signed by the visitor who found Resident #1 in the parking lot, revealed, After (bringing) a new admit inside the building I (noticed) the alarm going off at in front door. I got back in the van and (noticed) (Resident #1) at the speed bump in the parking lot (sitting) in the wheel chair with the seat (belt) holding (Resident #1) in. I brought (Resident #1) back to the building to a nurse. Interview with the visitor who returned Resident #1 to the facility, on 05/06/16 at 11:10 AM, revealed he confirmed the written statement and added, I don't know how far she would have gotten if it hadn't been for the speed bump. The visitor also stated, I did not see her until I turned around to leave (the parking lot. The visitor explained the Wander Guard alarm sounded when he re-entered the building with Resident #1. The visitor said Resident #1 stated she needed to get her grandchildren when he brought her inside. Review of a statement, dated 05/03/16 and signed by the Housekeeping Supervisor revealed, I checked the wander guard alarm on (Resident #1's) arm and the alarm to the front entrance door near the dining area and the alarm did sound. Interview, on 05/06/16 at 8:50 AM, with the Housekeeping Supervisor revealed he took Resident #1 to all doors equipped with a Wander Guard alarm system on 05/03/16, which was the day after Resident #1 eloped, to ensure they worked. The Housekeeping Supervisor explained some days the resident would circle inside the building looking for a way out. The Housekeeping Supervisor also stated Resident #1 was on a tear the day of the elopement, and wanted to go to 33rd street. The Housekeeping Supervisor stated CNA #1 assisted with the door alarm checks. Interview, on 05/05/16 at 5:50 PM, with CNA #1 revealed, I did not check (Resident #1's) alarm or the door alarm (when the Resident eloped on 05/02/16). We checked it on May 3 (2016). Review of a statement from the Assistant Director of Nurses (ADON), dated 05/03/16 revealed, I checked the wander guard alarm on (Resident #1's) arm and the alarm to the front entrance door near the dining area and the alarm did sound. Interview, on 05/05/16 at 3:00 PM, with the ADON revealed she was not at the facility when Resident #1 eloped on 05/02/16. The ADON stated she checked (Resident #1's) Wander Guard after 11:00 PM, but she did not check the front entrance door alarm because that was the responsibility of Maintenance and she would have had to bring Resident #1 to the front of the building in the middle of the night to have checked the proper function of the Wander Guard at the front door exit. The ADON stated on 05/03/16, he/she had observed the green lights on the Wander Guard alarm box, which indicated the alarm was functioning. Observation and interview, on 05/07/16 at 11:25 AM, with Maintenance Employee #1 revealed the alarm panel for the Wander Guard system was at the LTC nursing station. When an exit door with the Wander Guard system was opened, an alarm sounded and a red light flashed. Maintenance Employee #1 stated, The only way to silence the alarm is to punch in codes at the Wander Guard box. Maintenance Employee #1 also stated the exit doors will lock if a resident with a Wander Guard is between two (2) to three (3) feet from the door. Maintenance Employee #1 then added the lock on the exit door would release if the bar on the door was pushed continuously for approximately 15 seconds. There were two (2) Wander Guard alarm boxes on the wall. The alarm boxes were high on the wall, and were labeled for each exit door. The bottom of the box was six (6) feet and six (6) inches from the floor. The top of the box was seven (7) feet and five (5) inches from the floor. Each alarm light was labeled with the exit door connected to the alarm. Interview, on 05/09/16 at 11:00 AM with Resident #1's Responsible Party (RP) revealed the facility contacted her on 05/03/16 and told her at that time the elopement was under investigation. Observation of Resident #1, on 05/05/16 at 2:10 PM, revealed the resident was seated in her wheel chair in the activity dining room. The Wander Guard was noted on her right wrist, and a wheel chair alarm was also in place. Observation of Resident #1, on 05/05/16 at 5:25 PM, revealed the resident lying in bed. Observation of Resident #1, on 05/06/16 at 2:20 PM, revealed the resident lying in bed asleep and the room light was turned off. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/07/11 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/16, revealed Resident #1 scored eight (08) of 16 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The facility submitted an acceptable Allegation of Compliance (AoC) on 05/09/16 for the Immediate Jeopardy (IJ). Review of the facility's AoC revealed the facility took the following action to remove the Immediate Jeopardy. 1) 05/02/2016 5:10 pm, Resident #1 who was moderately cognitively impaired exited through the front entrance of the facility in a self-propelled wheel chair causing the wander guard system to alarm. Facility staff did not check the front door alarm. Resident #1 was observed by a visitor unsupervised by staff approximately 68 ft outside of the facility doors. Resident #1 was brought back inside to nurse's station by a visitor. This is when the staff became aware of the unsupervised elopement by resident #1. 2) 05/02/2016 5:15 pm, Once resident #1 was returned to nurse's station, the Registered Nurse (RN) charge nurse notified the ADON of the elopement. 3) 05/02/2016 5:22 pm, The Director of Nurses (DON) was notified of elopement by the Assistant Director of Nurses (ADON). 4) 05/02/2016 5:25 pm, DON directed one on one direct observation by CNA who sat at arm's length of the resident until 10:00 pm. Thirty-minute visual checks were implemented by Nurse #1 beginning at 6:00 pm and continued with Nurse #2, Nurse #3, Nurse #4 and Nurse #5 until 7:00 pm on 05/04/2016 to ensure Resident #1's safety. 5) 05/02/2016 5:29 pm, the ADON notified the Administrator of the elopement. 6) 05/02/2016 6:55 pm, Body audit of visible skin, ROM and vital signs were completed for Resident #1 by RN charge nurse and was documented in the incident report. Vital signs were as follows: Temp 98.4, Pulse 67, Respirations 18 and Blood Pressure 152/70. No signs of physical harm were revealed in skin check. 7) 05/03/2016 8:00 am, A complete body audit was completed on Resident #1 by RN charge nurse with no physical injuries to Resident #1. This was documented on body audit sheet. 8) 05/03/2016 8:15 am, Wander guard alarm system checked by facility environmental services supervisor and found to be working properly. 9) 05/03/2106 8:36 am, Responsible Party (RP) notified of Resident #1's elopement. 10) 05/04/2016 10:45 am, Health Facilities Licensure & Certification and State Attorney General's Office were notified by the Administrator as required. 11) 05/06/2016-3:00 pm QA committee meeting was held to discuss the elopement with QA Nurse, Physician, DON, ADON, Administrator, MDS Nurse and Social Services. The QA Committee recommended: Elopement drills to be done once on each shift for 3 pm-11 pm, 11 pm-7 am and 7 am-3 pm shifts. DON and ADON to in-service that all staff are to supervise residents on exit seeking behaviors. Update Elopement Policy to include wander guard manufacturing guidelines. Perform a care plan review of all 16-elopement risk residents to update behavioral interventions specific to residents. Physician to complete medication review for Resident #1. DON, QA Nurse, and RN charge nurse to in-service all staff members prior to shift on updated Elopement Policies. Social services to perform psychosocial evaluation on Resident #1. Speech Therapist to perform a cognitive linguistics evaluation on Resident #1. 12) 05/06/ :30 pm, DON and Human Resources Manager reviewed and revised the orientation process for all new hired employees to include Elopement Policy and Procedures and added responding to alarms and the explanation of the wander guard system. 13) 05/06/2016 4:45 pm, Physician reviewed and evaluated medications of resident #1. He discontinued calcium/vitamin D and made no other medication changes. He also ordered the following test Complete Metabolic Panel, Para [DIAGNOSES REDACTED] (PTH), Thyroid Stimulating Hormone (TSH), Vitamin B12 level, free T4 (Thyroxine) and UA (Urinalysis) with culture and sensitivity. 14) 05/06/2016 5:00 pm, Resident #1 care plan was updated to offer Resident #1 a baby doll when resident is looking for her children and/or exhibiting exit-seeking behavior. 15) 05/06/2016 5:30 pm, Social Services completed a psychosocial evaluation and determined that there was no psychosocial harm to Resident #1. 16) 05/06/2106 5:45 pm, Speech Therapist conducted a cognitive linguistic evaluation and determined that Resident #1 has a moderate cognitive impairment. The Speech Therapist recommendations to reduce communications breakdown and provide simple cognitive linguistic stimulation are as follows: Pick up on key words to address needs. Redirect frequently back to task in gentle manner. Validate emotions and feeling to encourage more appropriate interactive skills and confidence. Paraphrase information and repeat it back to allow increased processing time. Use face-to-face communication, slow the rate of speech, breaking down units of information. Provide appropriate word as needed if frustration occurs. Appropriately agree with misinformation unless frustration occurs. Use gentle correction as much as needed such as I think you told me . Never present with bad or disturbing news. Direct supervision of all ADLS, monitor hydration/nutrition. Provide objects as distractions as needed. Instead of open-ended questions, give a choice with visual cues. 17) 05/06/2016 6:15 pm, QA nurse conducted an audit of all photos of the 16 residents who are at risk of elopement. The wander guard expiration dates were added to the elopement binders and placed at nurses' station. 18) 05/06/2016 6:30 pm, Administrator reviewed facilities policy and procedures as well as manufacturers recommendations for usage of the Wander Guard system to ensure that they were properly being used by staff. Elopement Policy was revised to include: -Behavior interventions will be placed on care plans for all elopement risk residents. -Residents at risk for elopement will have a wander guard placed on their wrist. -Test each signaling device before using. -Do not use the device past the expiration date on the side of device. -Do not place wander guard on or near metal surfaces. Because metal could interfere with the signal sent to the door modules. -Do not use more than one wander guard per resident. If more than one device is brought too close together, it may not be received by door monitor and alarm will not sound. -Wander guard device is to be tested every night by assigned nurse. 19) 05/06/2016 7:00 pm, Elopement drill was implemented for evening shift staff by DON and all staff who participated signed in-service sheet that they participated. All staff were interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 20) 05/06/2016 8:00 pm, Care plans for all 16 residents at risk of Elopement were updated and reviewed to include behavior interventions. 21) 05/06/2016 11:00 pm, Elopement drill was implemented for night shift staff by RN charge nurse and all staff who participated signed in- service sheet that they participated. All staff were interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 22) 05/07/2016 7:30 am, All employees were in-serviced prior to working scheduled shifts about Elopement Policies, procedures, supervision of residents on exit seeking behaviors and responding to wander guard alarms. Training was conducted by DON, ADON, QA Nurse and RN Charge nurse for all employees prior to their next scheduled shift. No employees will be allowed to work prior to completion of the training. 23) 05/07/2016 8:00 am, Elopement drill was implemented for day shift staff employees by DON and all staff who participated signed in-service sheet that they participated. All staff interviewed to determine if they understood Elopement Policy. All staff voiced understanding. 24) 05/08/2016 8:00 am, the DON, QA nurse and RN charge nurse in-serviced all staff on updated care plans of elopement risk residents and Speech Therapist recommendations for Resident #1. On 05/11/16, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. 1. On 05/11/16, the State Agency (SA) surveyor validated Resident #1 exited through the front entrance of the facility in a self-propelled wheel chair causing the Wander Guard system to alarm and the facility staff did not check the front door alarm. Resident #1 was observed by a visitor unsupervised by staff approximately 68 feet outside of the facility doors. A visitor brought Resident #1 back inside to the nurse's station, and this was when the staff became aware of the unsupervised elopement by Resident #1 on 05/02/16 at 5:10 PM. 2. On 05/11/16, the State Agency (SA) surveyor validated the RN (Registered Nurse) charge nurse notified the ADON (Assistant Director of Nursing) of the elopement on 05/02/16 at 5:15 PM. 3. On 05/11/16, the SA surveyor validated the ADON (Assistant Director of Nursing) notified the DON (Director of Nursing) of Resident #1's elopement on 05/02/16 at 5:22 PM. 4. On 05/11/16, the SA surveyor validated the DON ordered one on one direct observation by a CNA (Certified Nursing Assistant) who sat at arm's length of Resident #1 until 10:00 PM. Thirty-minute visual checks were implemented by Nurse #1 beginning at 6:00 PM and continued with Nurses #2, #3, #4 and #5 until 7:00 PM on 05/04/16 to ensure Resident #1's safety on 05/02/16 at 5:25 PM. 5. On 05/11/16, the SA surveyor validated the ADON notified the administrator of (Resident #1's) elopement on 05/02/16 at 5:29 PM. 6. On 05/11/16, the SA surveyor validated Resident #1 would not allow a complete body audit at that (time of the elopement). A body audit of visible skin, ROM (Range of Motion) and vital signs were completed for Resident #1 by the RN charge nurse and was documented in the Incident Report. The vital signs were as follows: 98.4 temperature, 67 pulse, 18 respirations and 152/70 blood pressure. No signs of physical harm were revealed in the skin check on 05/02/16 at 6:55 PM. 7. On 05/11/16, the SA surveyor validated a complete body audit was documented on a Nurses Body Audit Sheet on 05/03/16 at 8:00 AM for Resident #1 by the RN charge nurse with no physical injuries noted. 8. On 05/11/16, the SA surveyor validated the Wander Guard alarm system was checked by the facility Environmental Services Supervisor and found to be working properly on 05/03/16 at 8:15 AM. 9. On 05/11/16, the SA surveyor validated the RP (Responsible Party) was notified of Resident #1's elopement on 05/03/16 at 8:36 AM 10. On 05/11/16, the SA surveyor validated the Administrator notified Health Facilities Licensure and Certification and the State Attorney General's office on 05/04/16 at 10:45 AM. 11. On 05/11/16, the SA surveyor validated the QA (Quality Assurance) committee met on 05/06/16 at 3:00 PM to discuss elopement with the QA Nurse, Physician, DON, ADON, administrator, MDS (Minimum Data Set) Nurse and Social Services in attendance. The QA committee recommended: -Elopement drill will be done once on each shift for 3:00 PM - 11:00 PM, 11:00 PM - 7:00 AM and 7:00 AM - 3:00 PM shifts. - The DON and ADON were to in-service all staff are to supervise residents on exit-seeking behaviors. - Update Elopement Policy to include Wander Guard manufacturing guidelines. - Perform a Care Plan review of all 16-elopement risk residents to update behavioral interventions specific to residents. - The Physician was to complete a medication review for Resident #1. -The DON, QA Nurse and RN charge Nurse to in-service all staff members prior to shift on updated Elopement Policies. - Social Services were to perform psychosocial evaluation on Resident #1. 12. On 05/11/16, the SA surveyor validated that on 05/06/16 at 4:30 PM, the DON and Human Resources Manager reviewed and revised the orientation process for all newly hired employees to include the Elopement Policy and Procedures and added responding to alarms and the explanation of the Wander Guard system. 13. On 05/11/16, the SA surveyor validated the Physician reviewed and evaluated medications and ordered a CMP, PTH, TSH, B 12 level, free T4, and UA with culture and sensitivity on 05/06/15 at 4:45 PM. 14. On 05/11/16, the SA surveyor validated the facility updated Resident #1's Care Plan on 05/06/16 at 5:30 PM to offer Resident #1 a baby doll when the resident is looking for her children and/or exhibiting exit-seeking behavior. 15. On 05/11/16, the SA surveyor validated Social Services completed a Psychosocial evaluation on 05/06/16 at 5:30 PM and determined there was no psychological harm to Resident #1. 16. On 05/11/16, the SA surveyor validated the Speech Therapist (ST) conducted a cognitive linguistic evaluation on 05/06/16 at 5:45 PM and determined Resident #1 had a moderate cognitive impairment. The ST recommended the following: - Pick up on key words to address (the Resident's) needs. - Redirect frequently back to task in a gentle manner. - Validate emotions and feelings to encourage more appropriate interactive skills and confidence. - Paraphrase information and repeat it back to allow increased processing time. - Use face-to-face communication, slow the rate of speech, and break down units of information - Provide appropriate words as needed if frustration occurs. - Appropriately agree with misinformation unless frustration occurs. - Use gentle correction as much as needed, such as, I think you told me . - Never present with bad or disturbing news. - Direct supervision of all ADLs (Activities of Daily Living), monitor hydration/nutrition. - Provide objects as distractions as needed. - Instead of open-ended questions, give a choice with visual cues. 17. On 05/11/16, the SA validated the QA nurse conducted an audit of photos of the 16 residents at risk of elopement. The Wander Guard expiration dates were added to the elopement binders and placed at the nurses' station. 18. On 05/11/16, the SA validated the administrator reviewed the facility's policies and procedures as well as manufacturers recommendations for the usage of the Wander Guard system on 05/06/16 at 6:30 PM. The Elopement Policy was revised to include: - Behavior interventions will be placed on Care Plans for all elopement risk residents. - Residents at risk for elopement will have a Wander Guard placed on their wrists. - Each signaling device would be tested before using. - Do not use the device past the expiration date on the side of the device. - Do not place the Wander Guard on or near metal surfaces, because metal could interfere with the signal sent to the door modules. - Do not use more than one (1) Wander Guard per resident. If more than one (1) device is brought too close together, it may not be received by the door monitor and the alarm will not sound. - The Wander Guard device is to be tested every night by the assigned nurse. 19. On 05/11/16, the SA validated an Elopement drill was implemented for the evening shift (3:00 PM - 11:00 PM) by the DON, and all staff who participated signed an in-service sheet that they participated on 05/06/16 at 7:00 PM. 20. On 05/11/16, the SA validated care plans for all 16 residents at risk of elopement were updated and reviewed to include behavior interventions on 05/06/16 at 8:00 PM. 21. On 05/11/16, the SA validated an Elopement drill was implemented for the night shift (11:00 PM - 7:00 AM) staff by the Charge Nurse and all staff who participated signed in-service sheet that they participated on 05/06/16 at 11:00 PM. 22. On 05/11/16, the SA validated all employees were in-serviced prior to working scheduled shifts about the Elopement Policies, procedures, supervision of residents with exit seeking behaviors and responding to the Wander Guard alarms by the DON, ADON, QA Nurse and the RN Charge Nurse on 05/07/16 at 7:30 AM. 23. On 05/11/16, the SA validated the Elopement drill was implemented for the day shift staff (7:00 AM - 3:00 PM) employees by the DON and all staff who participated signed the in-service sheet that they participated on 05/07/16 at 8:00 AM. 24. On 05/11/16, the SA validated the DON, QA Nurse and RN Charge Nurse in-serviced all staff on updated care plans of the elopement risk residents and Speech Therapist recommendations for Resident #1 on 05/08/16 at 8:00 AM. 25. On 05/11/16, the SA surveyor determined based on schedule and sign in sheets that no staff were allowed to work until inserviced. The SA determined the IJ was removed on 05/11/16.