Every finding on record at Lauderdale Community Living Center

Based on (Named Glucometer-a device/meter used to check blood sugar levels with the use of a blood sample) User's Guide review, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens for 2 of 2 (Residents #2 and Resident #15) sampled residents reviewed for blood glucose monitoring. Licensed Practical Nurse (LPN) A failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with User's Guide recommendations and facility policy. LPN B failed to perform hand hygiene and glove changes between medication administration of different routes, failed to clean, rinse, and dry a nebulizer mask after use, and failed to perform hand hygiene when changing gloves during resident care for 1 of 4 (Resident #8) residents reviewed for medication administration. LPN B failed to clean soiled items removed from a resident's room prior to storing in a medication cart and failed to clean the medication cart after placing soiled items on it for 1 of 2 (Hall B) medication carts. The facility failed to establish and implement a program to identify, report, investigate, and control infections and communicable diseases when they failed to track infections by organism for 4 of 4 months (April, May, June, and July 2025) reviewed for tracking and trending of infections. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility's policy, placed the residents at risk for potential contamination with bloodborne pathogens and the likelihood to cause serious injury, harm, impairment, and/or death resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately clean and disinfect a multi-use blood glucose meter during medication administration for Resident #2 and #15. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy for F880 on 8/12/2025 at 7:18 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J. The Immediate Jeopardy for F-880 began on 8/12/2025 and continued through 8/13/2025. The Immediate Jeopardy was removed 8/14/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/13/2025 at 4:19 PM, and was validated onsite by the surveyors on 8/14/2025 through review of in-services, audits, and staff interviews conducted on all shifts. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, .Fingerstick Glucose, dated 3/19/2012, revealed .Purpose.To obtain a blood sample to determine the resident's blood glucose level.Preparation.Disinfected blood glucose meter.Ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.Clean and disinfect reusable equipment between uses according to the manufacturer's instructions with an EPA registered disinfectant (follow manufacturers instructions for application) and according to current infection control standards of practice. After cleaning, place on a barrier and/or return to designated storage container. Review of the (Named Glucometer) User's Guide with a revised date of 3/2024, revealed .Cleaning and Disinfecting Your [Named Glucometer].Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface.Cleaning and Disinfecting Your Meter.Wash hands with soap and water and dry thoroughly.Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device.To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port.To disinfect your meter, clean the meter with one of the validated .EPA registered wipes.Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use.Wipe meter dry or allow to air dry.Wash hands with soap and water and dry thoroughly.If the meter or lancing device is being operated by a second person who is providing testing assistance to the use, the meter or lancing device should be disinfected prior to use by the second person. Review of the facility's policy titled, Medications, Nebulizer (Handheld), dated 8/25/2014, revealed .The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.Rinse and disinfect the nebulizer equipment according to facility protocol, or.Wash pieces with warm, soapy water.Rinse with hot water.Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes).Rinse all pieces with sterile water (NOT tap, bottled, or distilled).Allow to air dry on a paper towel.When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Review of the facility's policy titled, Eye Drop Administration, dated 11/1/2008, revealed .To administer ophthalmic solution into and around the eye in a safe and accurate manner.Perform hand hygiene. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 6/2010, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections.Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.After removing gloves.In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol [chemical names for alcohol] for all the following situations.after removing gloves.Washing hands.Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands.Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink.dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel.Discard towels into trash.Using Alcohol-Based Hand Rubs.Apply product to palm of hand and rub hands together.Cover all surfaces of hands and fingers until hands are dry.Follow manufacturers' directions for volume of product to use. Review of the facility policy titled, Infection Prevention Surveillance, dated 10/31/2017, revealed, .Systematically complete surveillance of infections among residents, staff and other personnel routinely in facility.Surveillance of healthcare- associated infections is done by.Review of culture reports and other pertinent lab data. Review of the facility Infection Control job description dated 10/2020, revealed, .Plan, develop, implement, evaluate and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities.Verify that laboratory support is available including microbiological and serological services.Review and analyze infectious disease laboratory reports and consult with the Director of Nursing in developing the care plan for assuring that aseptic techniques are implemented. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with a re-entry date of 10/21/2023, with diagnoses including Hemiplegia, Chronic Right Heart Failure, Diabetes Mellitus (DM), and Chronic Obstructive Pulmonary Disease. Review of the Care Plan with a revised date of 2/7/2024, revealed, .I have a dx [diagnosis] of TYPE 2 DM WITH HYPERGLYCEMIA [high blood glucose level] and am at risk for complications of this disease such as slow / nonhealing wounds, hypo [low]/ hyperglycemia .Fasting Serum Blood Sugar as ordered by doctor. Review of the Physician Order dated 10/20/2023, revealed, .Insulin Aspart Injection Solution [a medication used to treat diabetes] 100 UNIT [the basic measure for the amount of insulin]/ML [milliliter].Inject 5 units subcutaneously [beneath the skin] before meals for diabetes. Review of the Physician's Order dated 11/28/2023, revealed, .NovoLOG Injection Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject as per sliding scale: if 0 - 200 = 0 U [unit]; 201 - 300 = 5 U; 301 - 400 = 8 U; 401 - 500 = 12 U; 501 - 650 = 15 U; 651 - 999 = call MD [Medical Doctor], subcutaneously before meals and at bedtime for diabetes. Review of the Physician Order dated 6/20/2024, revealed, .Lantus Subcutaneous Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject 46 unit subcutaneously two times a day related to.DIABETES MELLITUS. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #2 had moderately impaired cognition. Active diagnoses included Diabetes Mellitus. Review of the Medication Administration Record (MAR) dated 8/12/2025, revealed Resident #2 received insulin before meals. Documentation on Resident #2's MAR revealed blood glucose levels were checked at 7:00 AM and 11:00 AM. During an observation and interview on Hall A on 8/12/2025 at 11:31 AM, revealed LPN A stated, This is my last one [blood glucose check], I saved him [Resident #2] for you to see because he gets scheduled insulin. LPN A then obtained Resident #2's blood glucose reading and returned to the Hall A medication cart with a dirty glucometer. LPN A cleaned the meter using (Named) hand sanitizing wipes, which were 70% ethyl alcohol. LPN A was asked are those (70% ethyl alcohol hand sanitizing wipes) what you use to disinfect the glucometers. LPN A stated, Yes, that's what we use. During an interview on 8/12/2025 at 2:36 PM, LPN A was asked did everyone (residents) have their own glucometer or is the same glucometer used for everyone who is on that medication cart. LPN A stated, Weclean and reuse, we do have extra ones. Each resident has a meter, but we use them as needed. So, we just use one meter, clean it and re-use for everyone until we need a new one. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Polycythemia Vera [a type of blood cancer]. Review of the Care Plan dated 7/26/2025, revealed .I have DIABETES Mellitus with Polyneuropathy [a nerve disorder that impacts nerve functions in the body] and am at risk for complications such as slow / nonhealing wounds, vision impairment, hypo / hyperglycemia.Diabetes medication as ordered by doctor.I have impaired immunity r/t [related to] dx [diagnosis] of POLYCYTHEMIA VERA. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #15 was cognitively intact. Active diagnoses included Diabetes Mellitus. Review of the Physician's Order dated 8/9/2025, revealed .Insulin Lispro Injection Solution.Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 300 = 5 units; 301 - 400 = 8 units; 401 - 500 = 12 units; 501 - 650 = 15 units, subcutaneously with meals related to TYPE 2 DIABETES. Review of the Physician's Order dated 8/9/2025, revealed .Insulin Glargine Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject 40 unit subcutaneously two times a day for diabetes. Review of the MAR dated 8/12/2025, revealed Resident #15 received insulin with meals. Documentation on Resident #15's MAR revealed blood glucose levels were checked at 7:00 AM and 11:00 AM. Observation and interview in Resident #15's room on 8/12/2025 at 4:38 PM, revealed LPN A entered the room, cleaned Resident #15's left hand first finger with an alcohol prep pad and picked up a lancet to obtain the blood specimen. LPN A was stopped by the surveyor and asked if the glucometer had been cleaned. LPN A stated, It was cleaned when I did it last with [named Resident #2]. The surveyor and LPN A exited Resident #15's room and returned to Hall A medication cart. LPN A confirmed the glucometer was last cleaned with (named) hand sanitizing wipe from the following previous blood glucose check on Resident #2. LPN A opened Hall A medication cart, removed a bottle of (named) bleach germicidal wipes, and stated, .They brought me these.The DON asked me what I was using and I told her those other wipes [hand sanitizing wipes] and she said ‘No, don't use those' and gave me these. LPN A again confirmed she had not re-cleaned the glucometer since last using the (named) hand sanitizing wipes. During an interview in the conference room on 8/12/2025 at 7:05 PM, the DON confirmed glucometers should be cleaned with an approved cleaning wipe, that hand sanitizing wipes are not appropriate for cleaning glucometers, and that the inappropriate cleaning of a glucometer can put the residents at risk for infection. The DON was asked if the staff received any in-services or training related to infection control. The DON stated, We had a skills fair in January [2025] .We have in-services quarterly for sure . The DON was unable to provide documentation for infection control training or in-services. During a phone interview on 8/14/2025 at 9:16 AM, the Medical Director confirmed staff should use an EPA approved disinfectant that kills bloodborne pathogens to clean blood glucose monitors, and if the blood glucose monitor is improperly cleaned it can transmit bloodborne diseases like hepatitis and Human Immunodeficiency Virus (HIV). 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including,Chronic Obstructive Pulmonary Disease, Dementia, Retention of Urine, and Solitary Pulmonary Nodule. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 5 which indicated Resident #8 had severely impaired cognition, required assistance with activities of daily living (ADL's), and was noted for an indwelling catheter. Review of the Care Plan dated 7/10/2024, revealed, .ENHANCED BARRIER PRECAUTIONS: I have a [named indwelling catheter] and wound and am at risk for MDRO [multidrug-resistant organisms] transmission.require use of INDWELLING [named] CATHETER r/t [related to] dx of Obstructive Uropathy and chronic urinary retention secondary to hx [history] of trauma to bladder / ureter. I have personal hx of recurrent UTI [urinary tract infection] .at risk for alteration in VISION STATUS r/t need for Rx [prescription] eye drops as ordered. My vision is adequate at baseline.at risk for alteration in RESPIRATORY STATUS r/t dx of COPD, former smoker with current use of Snuff, hx of Pulmonary Nodule. Review of the Physician's Order dated 8/9/2024, revealed .Arnuity Ellipta Inhalation Aerosol Powder Breath Activated [a medication used to control asthma] 100 MCG [microgram]/ACT [actuation].1 inhalation inhale orally in the morning related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD]. Review of the Physician's Order dated 1/29/2025, revealed .Ipratropium-Albuterol Solution [a medication used to control the symptoms of lung diseases] 0.5-2.5 (3) MG [milligram]/3ML 1 vial inhale orally two times a day for COPD. Review of the Physician's Order dated 2/10/2025, revealed .Provide with Enhanced Barrier Precautions during high contact resident care activities r/t Indwelling Foley and Pressure Wound two times a day. Review of the Physician's Order dated 8/7/2025, revealed .Brimonidine Tartrate Ophthalmic Solution [a medication used to lower the pressure in the eye] 0.2 % [percent] .Instill 1 drop in both eyes three times a day related to.DIABETES MELLITUS. Observation in Resident #8's room on 8/12/2025 at 8:47 AM, revealed LPN B pulled Resident #8's left lower eye lid down with a gloved hand, instilled 1 drop of Brimonidine 0.2 % in inner canthus of eye and repeated with right eye, and placed the medication on the resident's over bed table without a clean barrier. Arnuity Ellipta Inhalation 100 mcg was administered with the same gloves and placed on the over bed table without a barrier. Ipratropium/ albuterol 0.5mg -2.5mg per 3 ml nebulizer medication administered via (by way of) a nebulizer mask. LPN B removed her or his gloves and donned new gloves without performing hand hygiene. A nebulizer treatment was completed, the mask was removed from the resident, placed back in plastic bag, and put in the top drawer of Resident #8's nightstand without cleaning, rinsing, or drying the mask. The eye drop bottle and inhaler were removed from the over bed table and placed on top of Hall B medication cart, and then back into the cart. LPN B did not clean the top of the medication cart once the medications where removed. During an interview in the DON's office on 8/13/2025 at 2:38 PM, the DON confirmed staff should perform hand hygiene with glove changes, nebulizers should be cleaned, rinsed, and dried after use prior to being stored, staff should change gloves and perform hand hygiene before administering medications for different routes, soiled items removed from a resident's room should be cleaned/disinfected before being put in a medication cart, and medication carts should be clean/disinfected after soiled items were placed on top of them. 4. Review of the INFECTION CONTROL LOG, monitoring documents dated 4/2025, 5/2025, 6/2025, and 7/2025, revealed .INFECTION RELATED DX [diagnosis].UTI [urinary tract infection] by DX.increased WBC [white blood cells] by DX.cellulitis by DX.PNA [pneumonia] by DX.wound care by DX.Asp. PNA [aspiration pneumonia].abscessed tooth by DX.vag [vaginal] itching by DX.eye infection by DX.skin care under breast (yeast) by DX.poss [possible] cellulitis by DX.URI [upper respiratory infection] by DX.kidney stones by DX.PEG [percutaneous endoscopic gastrostomy tube] (feeding tube inserted through the abdominal wall directly into the stomach) site redness by DX.mouth abscess by DX.yeast by DX.skin cyst by DX.other categories.organism. There was no documentation listed in the Infection Control Log, that named the organism that was being tracked. During an interview on 8/13/2025 at 4:00 PM, the IP/DON confirmed that she does not track the infection by the organisms in the INFECTION CONTROL PROGRAM. The IP/DON was unable to provide any documentation that infection organisms were being tracked to rule out cross contamination or outbreaks of infections. The surveyors verified the Removal plan by: [NAME] Community Living Center Immediate Jeopardy -Summary & Removal Evidence Facility: [NAME] Community Living Center Tag: F-880 - Infection Prevention & Control Date IJ Identified: 08/12/2025 Date of Compliance 08/13/2025 What Happened (Noncompliance) On 08/12/2025, a Licensed Practical Nurse (LPN A) used a blood glucose meter on Resident #2, cleaned it only with a Spectrum Advanced Hand Sanitizing Wipe (not EPA-approved for bloodborne pathogen disinfection), then attempted to use the same glucometer on Resident #15 without re-cleaning with an approved disinfectant. -This failed to follow manufacturer instructions and facility policy, creating the lil<elihood of serious harm through potential transmission of HIV, Hepatitis B, or Hepatitis C. Residents affected were cognitively vulnerable and had comorbidities including diabetes, heart failure, and blood disorders. Infection prevention policy not reinforced consistently; staff competency gaps identified. No consistent real-time monitoring of glucometer cleaning/disinfection practices prior to IJ. Risk for exposure to multiple residents who had blood glucose checks with an Improperly disinfected device. Immediate Corrective Actions Taken (IJ Removal) Ceased use of all glucorneters until disinfected with EPA-registered bleach wipes per manufacturer instructions. Removed all non-approved wipes from medication carts and point-of-care areas; secured approved bleach wipes at all use points.

Based on policy review, medical record review, employee timesheets, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being when the facility failed to ensure that a Cardiopulmonary Resuscitation (CPR) certified staff member was working 24 hours per day for 16 of 40 days reviewed. The facility had a census of 35 upon entrance. The findings include: 1. Review of the policy titled, Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 2. Review of the employee timesheets dated [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE], revealed there was not a CPR certified staff member working in the facility for 24 hours for the dates as follows: a. [DATE] b. [DATE] c. [DATE] d. [DATE] e. [DATE] f. [DATE] g. [DATE] h. [DATE] i. [DATE] j. [DATE] Review of the employee timesheets dated [DATE]-[DATE], revealed there was not a CPR certified staff member working in the facility for 24 hours for the dates as follows: a. [DATE] b. [DATE] c. [DATE] d. [DATE] e. [DATE] f. [DATE] Review of the Resident Status List dated [DATE]-[DATE] revealed 30 of 52 residents listed with Full Code status. 3. During an interview on [DATE] at 10:11 AM, the Director of Nursing (DON) confirmed there should be a CPR certified staff member in the facility at all times during each 24-hour day.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when large plastic containers holding dry food items revealed dried substances and loose particles on top of the lids and down the sides of the containers; when stainless steel tables, metal storage racks, and the steam table shelf, were found with dried, splattered substances on their surfaces; and when the walk in dry storage area had a dried white powdery substance on the floor and on top of 2 brown boxes located on a shelf. The outside of the ICE machine contained dried liquid spills down the front and both sides and the inside of the ICE machine contained several white streaks running down the inside walls around the door area. Clean dishes were stored in an area where dirty dishes were being washed. The side-by-side refrigerator contained four opened liquid containers with no open date on the containers. The Facility failed to maintain a complete, 3-day emergency supply of food. Cleaning supplies were stored in the bathroom off of the hallway outside of the entrance to the kitchen, the chemical closet was unlocked, and bathroom door was unlocked. The deep fryer lid and side surfaces were covered in a thick layer of grease and food particles.The microwave oven contained dried substances on the inside. The can opener was covered with a dark brown gummy substance.The double ovens inside surfaces were covered in a black substance that was built up on all walls and doors. The stove's cooking surfaces were covered in a dried/burnt appearing black substance. The facility had a census of 35 with 35 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, FOOD STORAGE, dated 7/11/2024, revealed .Food items should be stored.in accordance with good sanitary practice.All products should be inspected for safety and quality and be dated.when open.Clean and sanitize outside of food bins daily.cleaning supplies must be stored in a separate locked area. Review of the facility policy titled, ICE MACHINE, dated 10/18/2018, revealed .Sanitation of equipment.Frequency: Daily.Wash exterior of machine with hot water and detergent. Rinse with clean water and cloth. Use sanitizing solution and clean cloth to sanitize.Frequency: Weekly. unplug the ice machine. Remove Ice. Wash inside of machine with approved detergent and hot water. Rinse with clean water. Then use sanitizing solution and clean cloth .Allow to air dry.refill ice.Frequency: 2x [times] per year.cleaning and sanitization of internal components usually done by maintenance.Dietary staff can not do actual cleaning of the internal components. Review of the facility policy titled, Cleaning Schedules, dated 8/31/2018, revealed .The Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional .A cleaning schedules shall be posted with tasks designated to specific positions in the department. 2. Observation in the kitchen on 8/11/2025 beginning at 9:15 AM, revealed the following: a. The walk in dry storage area had a dried white powdery substance on the floor and on top of 2 brown boxes located on a shelf. b. Sugar, flour, meal, and thickener were stored in large white plastic storage containers under a stainless-steel table with dried substances and loose particles on top of the lids and down the sides. c. The outside of the ICE machine had dried liquid that had spilled and had run down the front and sides of the ICE machine. The inside of the ICE machine contained several white streaks running down the inside walls around the door area. d. The can opener's surfaces were covered with a dark brown gummy substance. During an observation and interview in the kitchen with the RD on 8/12/2025 at 10:12 AM, revealed the following: a. Utensils were washed and placed to dry on a rack within 2 to 4 feet of dirty dishes and dishwasher area. Clean dishes were being stored in the dirty area by dishwasher. The Registered Dietitian (RD) was asked if this was an appropriate place to store clean dishes. The RD stated, No, they will need to be moved. b.The side-by-side refrigerator contained four opened and undated liquid containers. The RD confirmed an open date should be placed on any container upon initially opening it. c. The Dry storage area still had a white powdery substance spilled on top of the cardboard boxes and on the floor. The large white plastic storage containers containing the sugar, flour, meal, and thickener still had dried substances and loose particles on top of the lids and down the sides of the containers. The RD confirmed that their cleanliness was not acceptable. d. The can opener still had a dark brown gummy substance on it. e. The double ovens inside surfaces were covered in a black substance that is built up on all inside surfaces and doors. f. The stove surfaces were covered in a dried/burnt black substance. g. Chemicals were stored in the bathroom off of the hallway outside of the entrance to the kitchen, the chemical closet was unlocked, and the bathroom door was unlocked. h. The deep [NAME] lid and side surfaces were covered in a thick layer of grease and food particles. i. The microwave contained dried, spilled substances on the inside surfaces. j. The shelf below the steam table, where the cooking trays are stored is covered with dried spilt food. l. Review of 3 Day Emergency Supply list on 8/12/2025 at 9:05 AM, revealed the following items missing, dry milk, dry cereal, jelly, peanut butter with crackers, individually wrapped soft cookies, pasta, marinara sauce, crackers, tuna, chili, mayonnaise, fruit, pudding, juice/punch, green beans, carrots, chicken and dumplings, and baked beans. During an observation and interview outside of the bathroom door in hallway next to kitchen on 8/12/2025 at 10:46 PM, the RD was notified of the unlocked chemical closet and bathroom door. During an interview on 8/13/2025 at 10:45 AM, the RD confirmed that the facility did not have a 3-day emergency supply of food. During an observation and interview outside of the bathroom door in hallway next to kitchen on 8/13/2025 at 2:10 PM, the Administrator confirmed the chemical closet and bathroom doors were unlocked. The Administrator was asked if the chemical closet and the bathroom door should be locked. The Administrator confirmed that they should always be locked. During an interview on 8/13/2025 at 3:08 PM, in the RD office, the RD stated she would ask maintenance to install a key punch locking door.

Based on facility menu review, observation, and interview, the facility failed to serve food items from the menu posted for 3 out of 3 days reviewed during the recertification survey. The census was 35 with 35 residents receiving meals. The findings include: Review of the facility lunch menu dated 8/11/2025, revealed Beef Ravioli with sauce, seasoned green beans, bread/roll, butter/margarine, and frosted cake. The menu was changed by the Registered Dietitian at 9:15 AM on 8/11/2025, due to lack of food items needed to fill the posted menus for 8/11/2025, 8/12/2025, and 8/13/2025. Observation of the lunch menu on 8/11/2025, revealed meat loaf, sweet potatoes, sugar snap peas, bread/roll, butter/margarine, and frosted white cake. Review of the facility lunch menu dated 8/12/2025, revealed pork riblet with barbeque (BBQ) sauce, savory green rice, seasoned succotash, and creamy raspberry dessert. Observation of the lunch menu on 8/12/2025, revealed roast pork, savory white rice, black eyed peas, bread/roll, butter/margarine, and blue berry dessert. Review of the facility lunch menu dated 8/13/2025, revealed cornmeal crusted chicken, mashed sweet potatoes, sugar snap peas, bread/roll, butter/margarine, and pudding parfait. Observation of the lunch menu on 8/13/2025, revealed the sugar snap peas were substituted with greens. Review of the facility lunch menu dated 8/13/2025, revealed shrimp and smoked sausage sheet pan roast, fried zucchini, corn scone with butter/margarine, and Banana spice cake. Observation of the lunch menu on 8/13/2025, revealed pulled pork, French fries, baked beans, with hamburger as the alternate. During an interview on 8/11/2025 at 9:28 AM, the Registered Dietitian (RD) confirmed that some of the food items needed to complete the menu for the week of 8/10/2028 - 8/16/2025 were not in inventory. The RD confirmed what is posted on the menu is what should be served that day to meet the nutritional needs of the residents.

Based on policy review, employee time sheet review, State of Tennessee Department of Health Division of Health Licensure website review, and interview the facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 of 54 days reviewed and failed to ensure the Director of Nursing (DON) had a current and active nursing license from [DATE]-[DATE]. The findings include: 1. Review of the facility policy titled Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents. 2. Review of the employee time sheets dated [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE], revealed there was no RN on duty for 8 consecutive hours on the following dates : a. [DATE] b. [DATE] c. [DATE] d. [DATE] e. [DATE] f. [DATE] g. [DATE] h. [DATE] i. [DATE] j. [DATE] k. [DATE] l. [DATE] m. [DATE] n. [DATE] o. [DATE] The facility was unable to provide additional employee time sheets for the above dates as requested. 3. Review of the State of Tennessee Department of Health Division of Health Licensure website, last updated on [DATE], revealed the status of the DON's nursing license was lapsed with an expiration date of [DATE]. 4. During an interview on [DATE] at 9:53 AM, the DON confirmed that her license expired on [DATE] and was renewed on [DATE]. During an interview on [DATE] at 10:11 AM, the DON confirmed there should be an RN on duty for 8 consecutive hours, 7 days a week. The DON was asked do you cover as the RN on duty at times. The DON stated, .Yes.we try not to use me unless we have to.on those days my time is manually entered into the system.but I was off the week of [DATE]st.

Based on daily staffing sheet review, observation, and interview, the facility failed to post daily staffing sheets that included the number of actual hours worked by each discipline for 31 of 31 days. The findings include: Review of the facility's posted daily staffing sheets dated 7/12/2025-8/11/2025, revealed the actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) was not included. Observations in the facility's front entrance lobby on 8/11/2025 at 10:30 AM, 8/12/2025 at 7:30 AM, and 8/13/2025 at 7:30 AM, revealed the posted daily staffing sheet did not include the actual number of hours worked by the RN, LPN, and CNA. During an interview on 8/13/2025 at 5:43 PM, the Director of Nursing (DON) confirmed the posted daily staffing sheet should include the actual number of hours worked by the RN, LPN, and CNA. Observation in the facility's front entrance lobby on 8/14/2025 at 7:30 AM, revealed the posted daily staffing sheet did not include the actual number of hours worked by the RN, LPN, and CNA.

Based on policy review, observation, and interview, the facility failed to provide sufficient staff with the competencies and skill sets to carry out the functions of the food and nutrition services when there was not a Dietary Manager employed in the kitchen. The facility had a census of 35 with 35 of those residents receiving a meal tray from the kitchen. The findings include: Review of the facility policy titled, Staffing, with a revision date of 10/22, revealed .Other support services ( .dietary, activities/recreational.staff to ensure resident needs are met. Observations in the Kitchen on 8/11/2025 at 9:15 AM, 8/12/2025 at 10:30 AM, and 8/13/2025 at 2:10PM, revealed the kitchen had no standard cleaning schedules, this was evident by large plastic containers holding dry food items with dried substances and loose particles on top of the lids and down sides of containers; when stainless steel tables, metal storage racks, and the steam table shelf, were found with dried, splattered substances on their surfaces, the walk in dry storage area had a dried white powdery substance on the floor and on top of 2 brown boxes located on a shelf. The outside of the ICE machine had dried liquid spills running down the front and sides. The Inside of the ICE machine has several white streaks running down the inside walls around the door area. During an interview on 8/11/2025 at 9:15 AM, the Registered Dietitian (RD) confirmed that the Dietary Department currently did not have a Dietary Manager. The RD stated, She didn't know how to do her job, she only ordered food supplies one day a week and it was never enough. During an interview on 8/13/2025 at 10:45AM, the RD confirmed that the facility did not have a 3-day emergency supply of food. The RD stated, [The] Dietary Manager would run out of food and pull things from the 3-day emergency supply. During an Interview on 8/13/2025 at 2:10 PM, the Administrator confirmed that the Dietary Manager had been let go on Friday 8/8/2025, due to lack of competencies and skill sets to carry out the functions of Dietary Manager.

Based on review of Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan meeting minutes, policy review, observation and interview, the QAPI Committee failed to recognize ongoing problems of inadequate supervision, failed to provide oversight to ensure an effective Infection Control Program was in place that protected residents from cross contamination and failed to ensure staff were competent in providing resident care. The QAPI committee failed to identify the root cause of the problems identified, failed to develop appropriate plans to correct the identified problems, failed to ensure systems and processes were implemented to address, correct, and maintain acceptable standards of practice, and failed to provide clinical guidance and oversight regarding the implementation of resident care policies and procedures. The QAPI Committee failed to ensure community medical equipment was disinfected to prevent the potential spread of infection when Licensed Practical Nurse (LPN) A failed to clean a multi-use blood glucose meter according to manufacturer's recommendations to prevent cross contamination after performing a blood glucose on Resident #2 which resulted in Immediate Jeopardy. The findings include: Review of the facility policy titled, QAPI Program and QAPI Committee Guideline, dated 4/10/2013, revealed .Each department along with the QAPI committee will identify critical items within that department's area of responsibility that must be monitored and reported. These items are those things most important to the successful functioning of the department, the quality of services provided to the resident, or areas that are inherently high risk .Each department will routinely gather and review data that reflects the current status of the critical items in their area .Once data has been gathered, trended, and compared .Root cause analysis is applied to discover the bottom line cause for system breakdown .Assess staff knowledge and performance . Review of the April 2025 QAPI meeting minutes revealed the Nursing departments review sheet had empty blanks for the month in the following areas: a. any concerns noted, b. body audits completed, c. trends d. Inservice's/skills checkoffs completed this month e. The DON (Director of Nursing) signature. There was no information related to infection control. Review of the May 2025 QAPI meeting minutes revealed all departments review sheets were blank, including Nursing. There was no information related to infection control. Review of the June 2025 QAPI meeting minutes revealed there was no review of the Nursing Department. There was no information related to infection control. During medication administration observations on 8/12/2025 at 11:30 AM, Licensed Practical Nurse (LPN) A performed a blood glucose check on Resident #2 then exited the room, cleaned the blood glucose monitor with a (Named) Hand Sanitizing Wipe which contained 70 percent (%) alcohol, then placed it on a clean barrier to dry. During an observation on 8/12/2025 at 4:38 PM, LPN A entered Resident #15's room with the blood glucose monitor and prepared to perform the Resident's blood glucose check. LPN A was stopped from performing the blood glucose check by the surveyor and asked if the blood glucose monitor had been cleaned. LPN A confirmed the monitor had not been cleaned immediately prior to the procedure and the last time it was cleaned was after monitoring Resident #2's blood glucose (with the hand sanitizing wipes). Refer to F880 Review of the August 2025 Ad/hoc Quality Assurance (QA)/QAPI Meeting review revealed that it was not completed until 8/14/2025, 2 days after the facility was notified of the Immediate Jeopardy at F880. The facility was unable to provide documentation of any education related to blood glucose monitoring or cleaning of blood glucose monitors prior to 8/12/2025. During an interview on 8/12/2025 at 7:05 PM, the DON was asked if anyone ever did medication pass audits and observed blood glucose checks with the floor staff. The DON stated, Yes, I believe at times we have done that. The DON was asked how often (this was done). The DON stated, Well, I think the RN [Registered Nurse] supervisor watches and helps with things like that. The DON was asked if the facility had an RN supervisor. The DON stated, At times there is a RN prn [as needed] and on some weekends. The DON confirmed there was no documentation of audits completed by the RN supervisor. During an interview on 8/14/2025 at 8:01 AM, the Administrator acknowledged the QAPI meeting minutes should not contain blank spaces. The Administrator was asked if after reviewing the minutes from the previous months, she felt the QAPI Program was effective. The Administrator stated, No, I don't. During a telephone interview on 8/14/2025 at 9:16 AM, the Medical Director was asked if he had been involved in a QAPI meeting to discuss the IJ. The Medical Director stated, We were going to do that yesterday [8/13/2025], but they pushed it back and rescheduled it for some time next week. I'm not sure why they changed it.

Based on policy review, medical record review, observation, and interview, the facility failed to implement interventions on the care plan for 1 of 5 (Resident #25) sampled residents reviewed for Hydration and Nutrition. The findings include: 1. Review of the undated facility policy titled Using the Care Plan, revealed .It is the policy of the facility that the care plan be used in developing the resident's daily care routines.Daily care and documentation should be consistent with the resident's care plan . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dysphagia, Need for Assistance with Personal Care, Diabetes, Abnormal Weight Loss, and Congestive Heart Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment and required total assistance with eating. Review of the care plan revised 6/10/2025, revealed .I am at risk for DEHYDRATION / FLUID IMBALANCE.Ensure that I have access to cool, fresh drinking water at bedside whenever possible dated 11/14/2023.I am at risk for alteration in NUTRITIONAL status.Add snack at 10 am [10:00 am] and 2pm [2:00 pm] related to continued weight loss.Revision on: 12/12/2024.I am at risk for impairment to SKIN INTEGRITY including.need for hands on assist with eating. I have an ADL [activities of daily living] self-care performance deficit / FUNCTIONAL MOBILITY LIMITATION r/t [related to] weakness.Eating: Partial/Moderate Assistance - Up to dependent assistance. Observation in Resident #25's room on 8/11/2025 at 9:40 AM, 10:56 AM, 12:42 PM, and 3:02 PM, revealed Resident #25 was in bed and the water pitcher was on the over the bed table out of reach. Observation in Resident #25's room on 8/11/2025 at 12:58 PM revealed Certified Nursing Assistant (CNA) A entered the room, provided tray set up, encouraged Resident #25 to eat then left the room. CNA A did not stay in the room and provide additional encouragement or assistance if needed during the meal. During an interview and observation in the resident's room on 8/11/2025 at 4:05 PM, the Director of Nursing (DON) confirmed that Resident #25 should have fresh water available, and the water pitcher should be in the resident's reach. Observation in Resident #25's room on 8/12/2025 at 7:42 AM, revealed Resident #25 was observed attempting to eat breakfast, without staff in the room to assist. During an interview on 8/12/2025 at 10:12 AM, Licensed Practical Nurse (LPN) B confirmed Resident #25 had orders for snacks to be provided at 10:00 AM and 2:00 PM, and that the resident had not received a snack. During an interview on 8/12/2025 at 3:31 PM, the DON confirmed Resident #25 should have been receiving a snack and staff should follow the plan of care.

Based on policy review, medical record review, observation, and interview the facility failed to provide care and services to assess, treat and prevent the spread of infection for 1 of 2 (Resident #36) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, revised June 2010 .This facility considers hand hygiene the primary means to prevent the spread of infections.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Resident, family members and/or visitors will be encouraged to practice hand hygiene.Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.Before and after changing a dressing.If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations.before and after direct contact with residents.Before handling clean or soiled dressings, gauze pads, etc.After handling used dressings, contaminated equipment, etc.After removing gloves.The use of gloves does not replace handwashing/hand hygiene. Review of the facility policy titled, Skin Care Process, dated January 17, 2018 .It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur.Staff education related to skin care process.Nursing staff should receive training regarding skin and skin care as appropriate upon hire and periodically thereafter.Nurses may need further training in evaluation, assessment, staging and measuring wounds prior to being responsible for wound care.American Medical Technologies provides education materials and guidance.Registered Nurse.Observes wounds weekly. May be responsible for measuring and documenting the progress of the wound.Documentation should include, but is not limited to, regular skin inspections, pressure wound measurements and progress, turning and repositioning, the use of special products or equipment.When documenting, it is important to include the location of the wound, presence of exudate, pain, signs of infections, and the wound bed characteristics.Nurses are encouraged to document descriptions of their observations if in doubt about the specifics of a wound such as the staging a pressure ulcer would or etiology of a wound. 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnosis including Dementia, Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, Pressure Ulcer, and Obesity. Review of quarterly [NAME] Data Set (MDS) dated [DATE], revealed Resident #36 was severely cognitively impaired, was dependent with all Activities of Daily Living (ADLs) and had no pressure ulcers/injuries. Review of the Progress Note dated 6/29/2025 at 12:15 PM, revealed .[Resident #36] has a stage II ulcer to inside of right foot . Review of the Weekly Pressure Injury Record - V 2, dated 6/29/2025, 7/6/2025, 7/13/2025, 7/20/2025 and 7/27/2025, revealed .Wound Origin .Facility acquired .Date first observed 6/29/2025 .Wound location: right inside foot on ankle .Pressure injury stage .[marked as] c. Stage 2 - Partial Thickness loss of dermis presenting as a shallow ulcer with a red pink wound bed, without slough .Wound Bed [marked as] 1. Normal for skin .Surrounding Skin Color [marked as] 1. Normal for skin .Surrounding Tissue/Wound Edge [marked as] 1. Normal for Skin . Review of the Physician's orders dated 7/1/2025, revealed .Wound care to the right medial ankle [the inner side of the right ankle joint] .Alginate calcium with silver [a wound dressing composed of calcium alginate and silver particles designed to promote healing in wounds], silver sulfadiazine [a topical antibiotic cream used to prevent and treat wound infection], ABD pad [absorbent dressing used for wound care], and wrap with gauze roll, (kerlix) once daily or PRN [as needed] if dressing becomes soiled or dislodged one time a day for Wound Care related to PRESSURE ULCER .STAGE 2. Review of the (Named Company) SPECIALTY PHYSICIAN WOUND & [and] MANAGEMENT SUMMARY, dated 7/10/2025, 7/15/2025, 7/17/2025, 7/22/2025, 7/24/2025, revealed .UNSTAGEABLE DTI [Deep Tissue Injury] OF THE RIGHT ANKLE UNDETERMINED THICKNESS .Skin .Intact with purple/maroon discoloration . Review of the quarterly MDS dated [DATE], revealed Resident #36 was severely cognitively impaired, was dependent with all ADLs, and had an unhealed pressure ulcer, unstageable, presenting as a deep tissue injury. Review of the (Named Company) SPECIALTY PHYSICIAN WOUND & [and] MANAGEMENT SUMMARY dated 7/29/2025, 7/31/2025, and 8/5/2025, revealed STAGE 3 PRESSURE WOUND 0F THE RIGHT ANKLE FULL THICKNESS .Slough [dead tissue] .75% [percent] . Review of the Weekly Pressure Injury Record-V 2 dated 8/3/2025, revealed Resident #36 obtained a facility acquired pressure ulcer that was identified on 6/29/2025. The wound was on the inside of the right ankle and documented as a Stage 3 pressure ulcer with full thickness loss of tissue. The wound bed, surrounding skin color, and surrounding tissue/wound edge was documented as Normal for Skin. There was no Weekly Pressure Injury Report for the right ankle after 8/3/2025. The Weekly Pressure Injury reports did not document Slough, eschar (dead tissue), or skin discoloration. Review of the care plan dated 8/4/2025, revealed .PRESSURE ULCER to inside of the right foot .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Observation and interview in the B hallway outside the Resident's room on 8/12/2025 at 12:05 PM, revealed the Physician Assistant (PA) prepared to provide wound care to Resident #36. The PA confirmed she comes to the facility twice a week and provides wound care to Resident #36 when she is here. The PA obtained personal protective equipment (PPE) from a cart in the hallway, dropping an unused isolation gown onto the floor. The PA donned an isolation gown, picked up the gown that had fallen on the floor, put it in a red bag on top of the treatment cart, then without performing hand hygiene, donned a surgical mask and gloves and pushed the treatment cart into Resident #36's room. Resident #36 was up in the wheelchair at the bedside, between her bed and her roommate's bed. The PA closed the door, walked over to the resident, unlocked Resident #36's wheelchair, placed her hands on the arm rests and pulled the wheelchair forward, went behind the wheelchair and pulled the privacy curtain between the beds closed. The PA returned to the front of the wheelchair, pushed it back slightly, and locked the wheelchair. The PA went to the treatment cart, obtained a red bag, placed it on the floor and removed the sock from Resident 36's right foot. Then without changing gloves and performing hand hygiene, the PA obtained scissors from the cart, cut the dressing off of Resident #36's right foot, placed the dressing in the red bag, cleaned the scissors with a bleach wipe, and laid them on the cart to dry. The PA removed her gloves and donned new gloves without performing hand hygiene, picked up a bottle of dermal wound cleanser and a 4 by 4 (4 x 4) gauze, sprayed the gauze and cleaned the wound bed and surrounding tissue. The wound began bleeding, and the PA obtained clean gauze and applying light pressure, cleaned the blood off and covered the wound bed. The PA picked up the red bag from off the floor with her left hand, placed a protective pad on the floor under the Resident's foot and placed the red bag on the pad. The PA removed her left glove and donned a new glove, without performing hand hygiene, turned on her head lamp and looked at the wound, obtained a measuring tape from the cart and showed it to the surveyor, bent down and held the tape up to the wound with her left hand, used her right hand to obtain her glasses from under the isolation gown, and donned her glasses. The PA measured the wound, removed her gloves, documented the measurements, gathered the wound care supplies, then donned gloves without performing hand hygiene, opened and set up the wound care supplies and preformed wound care to Resident #36's right ankle. The PA wrote the date on a piece of tape and used it to secure the dressing, then placed the pen to her right pocket. The PA picked up the items off of the floor, placed the pad and her PPE in the red bag and sealed the bag. The PA then removed the red bag and treatment cart from the room and once in the hallway used hand sanitizer to perform hand hygiene. The PA was asked if she was able to recall the wound when it started and if the wound had been a DTI. The PA confirmed the wound had been unstageable at one time due to having necrotic [dead] tissue over the top of it, but that it had been debrided [removal of dead tissue] and it was improving. The PA confirmed the debridement occurred approximately 2 weeks ago when the stage changed to a Stage 3. The PA was asked is it the policy of the company you work for to do any type of hand hygiene between glove changes. The PA picked up a bottle of hand sanitizer off the treatment cart and stated, I change my gloves, and I sanitize between each patient. During an interview on 8/13/2025 at 2:38 PM, the Director of Nursing (DON) confirmed staff should perform hand hygiene between glove changes. During an interview on 8/13/2025 at 5:05 PM, the DON confirmed the facility should document wound assessments weekly and the wound physician's assessments do not take the place of the facility assessments. The DON confirmed there was no documentation of a wound assessment for Resident #36's right ankle by the facility since 8/3/2025 and that the facility's assessment of the wound did not match the stage or description of the wound physician's assessments between 7/13/2025 and 8/3/2025. The DON confirmed the facility does not provide training related to assessing or staging wounds.

Based on medical record review and interview, the facility failed to provide Behavioral Health Training to staff caring for 3 of 3 (Resident #8, #25, and #30) sampled residents reviewed for Dementia. The findings include: 1. Review of medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Statue (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired. 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Dementia, Unspecified Mood (Affective) Disorder, Diabetes, and Epilepsy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. 3. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Dementia, Hemiplegia, Cerebral Infarction, Diabetes, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #30 was severely cognitively impaired. The facility was unable to provide documentation of Behavioral Health Training for staff. During an interview on 8/12/2025 at 3:05 PM, the Regional Nurse confirmed that the facility had no Dementia management training. The Regional Nurse was asked if the facility utilized a computerized system that provides in-service trainings to the staff. The Regional Nurse confirmed the facility uses a (named) computer system to provide staff training, but it does not include training related to Dementia care. During an interview on 8/13/2025 at 9:22 AM, Certified Nursing Assistant (CNA) Dconfirmed that she did not receive training on how to care for residents with Dementia. During an interview on 8/13/2025 at 10:03 AM, CNA F confirmed that another CNA had spoken with her about care of Dementia residents during orientation, but that she had not had formal training provided by the facility related to caring for residents with Dementia or behavior management. During an interview on 8/13/2025 at 9:59 AM, CNA D stated .today is my 4th day here .no [dementia] training when [I] hired in . During an interview on 8/13/2025 at 10:03 AM, CNA F stated that she had worked in the facility about 2 weeks. CNA F was asked if she had Dementia training on hire. CNA F stated, .yes .they talked to me about it . CNA F was asked who talked with her about it (Dementia training). CNA F stated, .another aide when I got on the floor . During an interview on 8/13/2025 at 10:07 AM, Housekeeper H stated she will have worked at the facility .2 years next month . Housekeeper H was asked if she had received Dementia training. Housekeeper H stated, .No ma'am .

Based on policy review, Pharmacy Executive Summary review, observation, and interview, the facility failed to ensure medications were properly stored and secured when refrigerated medications were stored outside of the recommended temperature range for 1 of 1 medication refrigerator observed, when 2 nurses (Licensed Practical Nurse (LPN) A and LPN E) left medications unattended in 1 of 1 medication room, and when one of two (B Hall Medication Cart) medication carts was left unsecured and unattended. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, revised 2/2023, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Review of the (Named Pharmacy) Executive Summary Comments form dated 5/29/2025, revealed .Refrigerated Medications.should be between 36 degrees and 46 degrees. Observation in the A/B Hall Medication Room on 8/12/2025 beginning at 3:11 PM, revealed LPN A unlocked the medication room, left the door open, and walked away leaving the surveyor alone and medications in the medication room out of sight of staff for 9 minutes.The medication refrigerator was 65 degrees Fahrenheit (F), and the door was ajar due to ice buildup in freezer section preventing the door from closing. Water was noted in the refrigerator, on the floor and on the medications contained in the refrigerator. The medication refrigerator contained the following medications: a. a box of five 3 milliliter (ml) Lantus (a medication used to treat Diabetes)100 unit (a basic measurement for an amount of insulin)/ml pens. b. a box of five 3 ml Insulin Lispro (a medication used to treat Diabetes) 100unit/ml pens, six 3ml Lantus 100 unit/ml pens, one 10 ml bottle of Insulin Lispro 100 unit/ml. c. an opened bottle of Tuberculin (a combination of proteins used to diagnose tuberculosis) Serum. d. an emergency supply box containing one 10 ml vial of Novolog 70/30 (a medication used to treat Diabetes), one 10 ml vial of Novolin N (a medication used to treat Diabetes), one 10 ml vial of Novolin R (a medication used to treat Diabetes) and, four Promethazine [a medication used to treat nausea and vomiting] 25 milligram (mg) suppository. Review of the Medication Refrigerator Temperature Log for 5/2025, revealed no temperature was logged on the following days: 5/1/2025-5/5/2025, 5/7/2025-5/8/2025, 5/15/2025-5/18/2025, 5/28/2025-5/29/2025. Review of the Medication Refrigerator Temperature Log for 6/2025, revealed no temperature was logged on the following days: 6/1/2025-6/6/2025, 6/9/2025-6/10/2025, 6/13/2025-6/30/2025. Review of the Medication Refrigerator Temperature Log for 7/2025, revealed no temperature on the following days: 7/20/2025 and 7/22/2025-7/31/2025. Review of the Medication Refrigerator Temperature Log for 8/2025, revealed no temperature on 8/11/2025 and 8/12/2025. During an observation and interview in the A/B Hall Medication Room on8/12/2025 at 3:20 PM, the Regional Consultant confirmed that the medications contained in the medication refrigerator were stored at an incorrect temperature and were no longer safe for use. Observation in the A/B Hall Medication Room on 08/13/2025 at 10:13 AM, revealed LPN E unlocked the door to the medication room, left the door open, and exited leaving the surveyor alone and medications in the medication room out of sight of staff for 6 minutes. The medication refrigerator showed a temperature of 32 degrees F and the freezer area showed a temperature of 30 degrees. During an interview on 8/13/2025 at 2:38 PM, the Director of Nursing (DON) confirmed that storing medications outside of the manufacturers recommended temperature range could alter the medications effectiveness, that the medication refrigerator's temperature should be checked daily and maintained in a log book, that the temperature should be maintained between 36 degrees F and 46 degrees F, that the medication refrigerator's log book was inconsistent and incomplete for the months of May, June, July, and August 2025, and that no one should be in the medication room without licensed nursing staff present. Observation at the nurse's station on 8/14/2025 at 11:25 AM, revealed the B Hall medication cart was unlocked, unattended, and parked beside the nurses' station. During an interview on 8/14/2025 at 11:27 AM, LPN I was asked if the medication cart was unlocked. LPN I confirmed the cart was unlocked and should have been locked.

Based on policy review, medical record review, and interview, the facility failed to conduct a care plan conference with the family representative for 1 of 7 (Resident #8) sampled residents reviewed. The findings include: The facility policy titled, Resident/Family Participation, dated 12/12/2017, revealed .It is the policy of this facility that each resident and his-her family members be encouraged to participate in the development of the resident's comprehensive assessment and care plan .Resident's representative are invited to attend and participate in the resident's assessment and care planning conference . Review of medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Statue (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired. Review of the Care Plan revision dated 7/8/2025, revealed .Resident #8 had a BIMs of 5, that indicated severe cognitive impairment . During a phone interview with Resident #8's grandson on 8/11/2025 at 11:19 AM, Resident #8's grandson stated that he had never been invited to a care plan meeting. During an interview on 08/13/2025 at 8:30 AM, the Social Service Director (SSD) stated, Resident #8 is his own Responsible Party, and he was invited to the care plan meetings. The SSD was asked if Resident #8's BIMs score was a 5. The SSD stated, Yes. During an interview on 8/13/2025 at 9:29 AM, the Director of Nursing (DON) was asked who should be invited to a care plan meeting. The DON stated the resident and their representative. The DON was asked if a resident has a BIMS score of 5, should they be their own responsible party. The DON stated, No. The DON was asked if a resident has a BIMS score of 5 should they be the only party invited to the care plan meeting or should family member be invited too. The DON stated, No, the family should be invited also.

Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of accident hazards when nursing staff left a razor open and unattended on a bedside table for 1 of 35 (Resident #2) residents reviewed. The findings include: 1. Review of the facility policy titled, Sharps Disposal dated 8/2009, revealed .This facility shall discard contaminated sharps into designated containers.Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnosis including Cerebral Infarction (a condition where brain tissue dies due to lack of blood supply), Post-Traumatic Stress Disorder, Anxiety, Diabetes, Depression, and Seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated that Resident #2 was cognitively intact and was dependent with personal hygiene including shaving. Review of the care plan dated 7/25/2025, revealed .I have an ADL [Activities of Daily Limit] self-care performance deficit .I will receive adequate level of assistance with daily care tasks through next review date .Personal Hygiene.Dependent .I am at risk for BEHAVIORS r/t [related to] hx [history] of using forks to scratch my skin causing skin compromise .I have a hx of using objects other than my fingernails to scratch myself . Observation in Resident #2's room on 8/11/2025 at 4:12 PM, revealed an open and unattended razor lying on a bedside table positioned beside Resident #2's bed. During an observation and interview in Resident #2's room on 8/11/2025 at 4:17 PM, Licensed Practical Nurse (LPN) E confirmed that an open and unattended razor should not be at Resident #2's bedside. During an interview on 8/13/2025 at 12:37 PM, the Director of Nursing (DON) confirmed that razors should not be left open and unattended.

Based on facility policy review, Centers for Medicare and Medicaid (CMS) Payroll-Based Journal (PBJ) Staffing Data Report, employee timesheet review, and interview the facility failed to ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the 2nd quarter (1/1/2025-3/31/2025) for 8 of 26 days reviewed. The facility census upon entrance was 35. The findings include: 1. Review of the facility policy titled, Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 2. Review of the CMS 2nd Quarter 2025 PBJ Staffing Data Report for the facility revealed a concern for low weekend staffing and a 1star staffing rating. 3. Review of the employee time sheets dated 1/11/2025, revealed 33.68 total staffing hours for Certified Nursing Assistants (CNAs), 22.54 for Licensed Practical Nurses (LPNs), and 0 for Registered Nurses (RNs) with a census of 32. The Per Patient Day (PPD- refers to nursing hours allocated to each resident per day) was 1.76. The facility failed to provide 24 hours of nursing on 1/11/2025. Review of the employee time sheets dated 1/25/2025, revealed 40.6 total staffing hours for CNAs, 0 for LPNs, and 11.87 for RNs with a census of 32. The PPD was 1.64. The facility failed to provide 24 hours of nursing on 1/25/2025. Review of the employee time sheets dated 1/26/2025, revealed the total staffing hours of 53.74 for CNAs, 0 for LPNs, and 11.67 for RNs with a census of 32. The facility failed to provide 24 hours of nursing on 1/26/2025. Review of the employee time sheets dated 3/1/2025, revealed 4 total staffing hours for CNAs, 0 for LPNs, and 11.93 for RNs with a census of 32. The PPD was 0.5. The facility failed to provide 24 hours of nursing on 3/1/2025. Review of the employee time sheets dated 3/2/2025, revealed 42.4 total staffing hours for CNAs, 0 for LPNs, and 13.12 for RNs with a census of 32. The PPD was 1.74. The facility failed to provide 24 hours of nursing on 3/2/2025. Review of the employee time sheets dated 3/22/2025, revealed 42.4 total staffing hours for CNAs, 5 for LPNs, and 0 for RNs with a census of 39. The PPD was 1.22. The facility failed to provide 24 hours of nursing on 3/22/2025. Review of the employee time sheets dated 3/23/2025, revealed 56.35 total staffing hours for CNAs, 16 for LPNs, and 0 for RNs with a census of 38. The PPD was 1.9. The facility failed to provide 24 hours of nursing on 3/23/2025. Review of the employee time sheets dated 3/30/2025, revealed 56.79 total staffing hours for CNAs, 15.87 for LPNs, and 0 for RNs with a census of 36. The facility failed to provide 24 hours of nursing on 3/30/2025. The facility was unable to provide additional printed off employee time sheets for 1/11/2025, 1/25/2025, 1/26/2025, 3/1/2025, 3/2/2025, 3/22/2025, 3/23/2025, and 3/30/2025 as requested. 4. During an interview on 8/14/2025 at 10:11 AM the Director of Nursing (DON) confirmed there should always be a nurse in the facility.

Based on policy review, medical record review, facility investigation review, timeanddate.com weather website review, police report review, observation, and interview, the facility failed to provide adequate supervision to ensure the resident environment was free of accident hazards for 1 of 3 (Resident #1) residents reviewed with wandering/exit seeking behaviors. On 2/9/2025 between 7:00 PM and 7:20 PM, Resident #1, a vulnerable resident with Dementia, who experienced hallucinations, exit seeking behaviors and was cognitively impaired, eloped through an unlocked and unsecured door that malfunctioned on C Hall. Resident #1 exited the facility, left his wheelchair at the door, went down a steep embankment, and was found on the ground at the driveway entrance, beside a two-way street, and sustained head injuries that required hospital transfer and evaluation in the local Emergency Department (ED). The temperature outside on 2/9/2025, between 7:00 PM and 7:20 PM, was 37 degrees Fahrenheit. Resident #1 was observed, lying on the ground beside the road by an unknown passerby who called 911. The facility staff was not aware Resident #1 had exited the building. The police department contacted the facility and reported Resident #1 was lying on the ground, down a steep embankment at the end of the facility drive (that was approximately 110 yards from the facility), by the roadside. The facility's failure resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A partial extended survey was conducted on 4/29/2025 through 4/30/2025. The Administrator was notified of the Immediate Jeopardy (IJ) on 4/29/2025 at 10:20 AM, in the private dining room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began 2/9/2025 through 4/29/2025. The Immediate Jeopardy was removed on 4/30/2025 when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 4/30/2025. The facility is required to submit a plan of correction. The findings include: 1. Review of the undated facility policy titled, Emergency Procedure-Missing Resident, revealed .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety . Review of the undated facility policy titled, Accidents and Incidents-Investigating and Reporting, revealed .Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Hallucinations, Depression, and Anxiety. Review of the Comprehensive Care Plan dated 9/23/2024, revealed Resident #1 was at risk for elopement related to severe confusion, was mobile with a wheelchair and able to walk, and had a history of trying to open exit doors to facility, especially when looking for spouse. The goal listed for Resident #1 was will not leave facility unattended. Review of the Wander Evaluation assessment dated [DATE], revealed Resident #1 was a wandering/elopement risk as a result of being cognitively impaired, had poor decision-making skills, could ambulate with and without assistive device (wheelchair), and frequently looked for his spouse. Review of a Progress Note dated 12/28/2024 at 5:29 AM, revealed . [Resident #1] has been up all night, actively attempting to open doors .voices concerns about his wife's illness .resident also told this nurse that someone came into his room and put glue on his head . Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score of 7 indicated severe cognitive impairment. Further review of the MDS revealed Resident #1 experienced hallucinations and delusions, independently propelled a wheelchair for mobility, and required supervision and/or assistance with all aspects of personal care. Wandering behavior was not identified on the MDS assessment, although the medical record revealed Resident #1 exhibited wandering and exit seeking behavior. Review of a progress note dated 2/9/2025 at 10:13 PM, revealed .At 1925 [7:25 PM] a .police officer alerted the 6p-6a [6:00 PM - 6:00 AM] staff that they had observed [Resident #1] at the entrance drive at the front of the facility and that he [Resident #1] had fallen and injured the back of his head, this resident eloped from facility through the exit door at the end of C-Hall, staff was unaware that this client was missing from the facility due to clinical staff observing him wandering on A-Hall and ambulating without his w/c [wheelchair], it was noted that the door alarm did not function properly at the time of this [resident]'s elopement therefore clinical staff was not alerted to resident elopement from the facility . Review of a body audit assessment dated [DATE] at 11:55 PM, revealed an abrasion to back of head with small amount of blood oozing (bleeding). 3. Review of the weather history for [NAME], TN on 2/9/2025 at approximately 7:20 PM, according to timeanddate.com weather website, the temperature outside was 37 degrees Fahrenheit. 4. Review of the facility investigation dated 2/9/2025, revealed the following: a. Review of the facility incident report dated 2/9/2025 at 7:30 PM, by LPN A revealed .Police notified clinical staff .[Resident #1] lying on the ground at the entrance driveway, at the front of the facility and he [Resident #1] had fallen and injured the back of his head, this nurse observed .police, fire and rescue, and ambulance .[Resident #1] was .transferred to the hospital .after checking all the doors and windows in the facility, staff had found that [Resident #1] had eloped out of the exit door on C-Hall and through the gate leading to the property at the front of the facility, the alarm for the exit door on the C-Hall was not functioning and gave no alert to staff that the exit door had been breached .Injuries observed at time of incident . b. A signed, written statement dated 2/9/2025, by Certified Nursing Assistant (CNA) B revealed, .Me [CNA B] and [named CNA C] found that [Named Resident #1] got out on C Hall. The doors on C Hall was [were] open and the [door] codes was [were] not working we went out the doors to find that the gate was wide open and that's how he [Resident #1] got out. No alarm went off to let us know the door had came [come] open . c. A signed, written statement dated 2/9/2025, by CNA C revealed, .I heard a knock on the front door it was the police they asked me do we [facility] have a [named Resident #1], I say [said] yes, [police officer] told me that [Resident #1] had fell [fallen] outside and he finna [fixing to] go to the hospital so I ran and found [named Licensed Practical Nurse (LPN) A]. d. A signed, written statement dated 2/9/2025, by LPN A revealed, .At 1930 [7:30 PM], [named CNA C] alerted this nurse that the police need to speak [with] this nurse regarding a [Resident #1]. Upon speaking [with] the police officer it was apparent that [named Resident #1] had somehow eloped from the facility with his w/c [wheelchair] and made it to the end of the facility driveway in front of the building before falling and injuring himself .This nurse observed police, fire and rescue, and EMT[Emergency Medical Technician]/ambulance on [named street] in front of the facility. The police officer stated that [Resident #1] was being .transferred to the hospital in [relation to] .striking and injuring the back of his head upon falling to the ground .[Resident #1] had pushed the Exit Doors open at the end of C-Hall, pushed the double gate open at the front of the facility, and made his way down the hill to the parking lot entrance . e. A signed, written statement dated 2/9/2025, by the former Maintenance Director revealed, .I got here at 8:00 PM [on 2/9/2025]. I checked the door on C Hall and one door was open so I shut the door . f. Review of the hospital medical record dated 2/9/2025 at 8:00 PM, revealed Resident #1 was evaluated in the ED for head injuries sustained during the fall. A Computerized Tomography Scan report (CT scan/CAT scan provides detailed images inside of the body) of the head dated 2/9/2025 at 10:12 PM, revealed posterior scalp (back of the head) swelling and a laceration (open area of the skin). The hospital Discharge summary dated [DATE], revealed Resident #1 was diagnosed with head trauma, contusions (bruising) and abrasions (scrape, graze or superficial injury) sustained during the fall. g. Review of an e-mail correspondence dated 2/10/2025 at 9:07 AM, written by the Administrator to the Ombudsmen revealed, .I wanted to inform you that [Resident #1] exited the facility and made it to the end of the driveway. [Resident #1] was taken to the hospital . h. Review of the Ad Hoc (special) QAPI (Quality Assurance and Performance Improvement) meeting minutes dated 2/10/2025, revealed .Maintenance has identified a defect in door closure . 5. Review of the local Police Department report dated 2/9/2025 at 7:32 PM, revealed .E [Emergency] 911 call stating [caller] found a male laying in the roadway unconscious, caller's husband did stop and has the male sitting up now .EMS [Emergency Management Service] in route .Nursing Home .was notified .and they [nursing home staff] advised he [Resident #1] is a patient there [at nursing home]. [Nursing home staff] advised the male will be transported to the ER [Emergency Room] due to injuries . 6. Observations during a facility tour with the Administrator on 4/28/2025 beginning at 12:30 PM, revealed the following: a. The Exterior C Hall door was locked and unable to be opened by pressing on the lever. The doors were not equipped with delayed egress (a door locking system that temporarily prevents a door from opening immediately after an exit attempt, providing a short delay for a security response). A keypad was observed on the wall adjacent to the door. The Administrator made multiple unsuccessful attempts to open the exterior door entering a code into the keypad. The Administrator was unable to unlock/open the C Hall door. The Administrator stated the door would open if the fire alarm sounded. b. A resident room at the end of C Hall beside the C Hall exterior door was inspected. The resident room had two windows, each window was unlocked and opened by the surveyor. The alarm attached to each window failed to alarm when the window was opened. The Administrator stated the alarm should sound when the window is opened but the batteries in the window alarms must not be working. c. The Exterior A Hall doors were locked, unable to be opened by pressing on the lever, and were not equipped with delayed egress. A keypad was observed on the wall adjacent to the door. The Administrator made multiple unsuccessful attempts to open the exterior door entering a code into the keypad. The Administrator was unable to unlock/open the door. d. The Laundry Room exterior door was inspected. The doorknob fell off of the door during the surveyor's attempt to open the exterior door. The laundry room staff member stated, .The maintenance person was made aware of the broken doorknob a long time ago . e. The interior service hall door leading from the front lobby to the back service hall was open. The Administrator stated the service hall door should not be left ajar and should be closed and locked at all times. During an interview on 4/28/2025 at 1:05 PM, the Administrator was asked if the facility doors were a resident safety concern. The Administrator stated, Yes, they are . During an interview on 4/28/2025 at 1:13 PM, the former Maintenance Director stated the Administrator notified him of Resident #1's elopement from the facility on 2/9/2025, .when I got to the facility, I noticed [Resident #1]'s wheelchair was at the end of C-Hall by the double door going outside. One of the doors had malfunctioned, the magnets that hold the doors closed had to be replaced. The C-Hall doors had not been closing properly for close to a year . Observation on 4/29/2025 at 1:20 PM, revealed Resident #1 sitting in a wheelchair near the nurse's station. Resident #1 was awake, confused, and unable to answer questions. During an observation and interview on 4/29/2025 beginning at 1:45 PM, the Regional Director of Maintenance (RDM) measured the distance from the exterior C Hall door, down a steep embankment to the estimated location Resident #1 was found on the ground at the end of the drive near the two-way street. The distance was approximately 110 yards (330 feet). The RDM stated the keypad code to all exterior doors had been reset. During an interview on 4/30/2025 at 3:04 PM, CNA C verified his/her signed written statement dated 2/9/2025. CNA C stated Resident #1 would sometimes leave the facility with family members and would frequently be difficult to redirect upon return to the facility. CNA C stated the C Hall door was open and no alarm had sounded when Resident #1 exited the facility on 2/9/2025. Attempts to interview LPN A and CNA B by phone during the survey were unsuccessful. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F689 was received on 4/29/2025 and validated onsite by the surveyor on 4/30/2025 through observation of exterior doors including keypad enabling exterior doors to open and staff interview. The Removal Plan included the following: On April 29, 2025, at 10:30 PM, the State Agency informed the Administrator that the facility had failed to provide adequate supervision to prevent the elopement of Resident#1, a vulnerable individual who exited the facility unnoticed and without supervision. On February 9, 2025, at 7:30 PM, facility staff were notified by local law enforcement that the residents (resident) were (was) not present in the building. The resident had been transported to the emergency room. 1. On February 9, 2025, at 7:28 PM, missing resident procedures were initiated, and all residents were accounted for. 2. On February 9, 2025, the LPN notified both the Director of Nursing and the Administrator. The Administrator instructed the LPN to contact the Maintenance Supervisor and directed that a CNA be stationed at the door until maintenance arrived. The LPN also attempted to contact the resident's next of kin; however, the call went to voicemail. The resident had a BIMS score of 0, indicating severe cognitive impairment. 3. On February 9, 2025, at 7:50 PM, the Maintenance Supervisor arrived at the facility. He inspected all exit doors to ensure proper functionality. A CNA remained Stationed at the door until the necessary repairs were completed. 4. On February 9, 2025, the Director of Nursing informed the resident's physician to provide an update on the status of the missing resident. The Administrator also sent an email to the Ombudsman regarding the situation. 5. An in-service training on elopement procedures was conducted. The elopement book and care plans were audited and reviewed. Additionally, a visual check every hour was implemented for all residents identified as at risk for elopement. 6. A Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the incident involving Resident #1. QAPI minutes included: The QAPI committee reviewed the incident, the actions taken, and the existing policy. After careful consideration, no recommendations for changes were made. The care team conducted a 100% (percent) audit of the care plans for all residents identified as being at risk for elopement. The Maintenance Supervisor conducted elopement drills across all shifts on 2-9-25 (2025). Correction: This practice of elopement drills will continue under the oversight of the Director of Nursing or Administrator for the next four weeks, with the results presented at each monthly QAPI committee meeting for review and recommendations. Any identified issues will be promptly addressed by the Administrator. The Maintenance Supervisor has contacted the State system regarding concerns with the exit doors, and the necessary repairs have been completed. All doors will be logged daily, including documentation of door openings and alarm activity, for a period of four weeks. The logging frequency will then transition to twice weekly for two weeks, and subsequently to once monthly for three months. If any additional issues are identified during this period, the matter will be brought to the QAPI committee for review, and daily checks will be reinstated as necessary. Maintenance has begun replacing all window alarms. A log will be maintained and reviewed weekly for four weeks, then biweekly for two weeks, and subsequently monthly for three months to ensure proper functionality. If any additional issues are identified during this period, the matter will be brought to the QAPI committee for review, and daily checks will be reinstated as necessary. In-service training has been initiated to address procedures for emergencies and resident relocations. The training emphasizes that, in the event of a fire, all emergency exit doors will be released and opened to ensure the safety of both residents and staff. Subject: Plan of Correction and Follow-Up Regarding Immediate Jeopardy Removal and Elopement Incident 1. Date of Immediacy Removal The facility alleges that the immediacy has been removed as of April 29, 2025, 2. Door Codes and Keypads Audit An audit of all door codes and keypad systems was completed on April 29, 2025, by the current Maintenance Director. All keypads were reset to factory default, recommended with a new master code, and assigned a universal code. The Maintenance Director tested each keypad multiple times to confirm full operability. 3. Staff Inservice Training Inservice's were conducted for all facility staff by the Director of Nursing and the Regional Nurse Consultant, training included all departments and all shifts, including evening staff. Staff verbalized understanding and demonstrated competence in the major use of secured (security) systems and elopement prevention protocols. An elopement drill was conducted on April 29, 2025, at 6:00 PM. 4. Regional Oversight and Audit On April 29, 2025, Regional Oversight performed a comprehensive follow-up audit of the facility's doors and windows, including a walkthrough with the Life Safety Surveyor. The audit confirmed that all systems were compliant and functioning properly. 5. Emergency Egress Protocol Education Staff education on emergency egress protocols was conducted by the Maintenance Director and Regional Nurse Consultant on April 29, 2025. All staff, including those on the evening shift, were trained. Understanding was verified through staff verbal feedback and real-time demonstration. 6.Window Alarms System Audit A full audit of window alarms was conducted on April 29, 2025, by the Maintenance Director and Regional Maintenance Director. The audit included testing each alarm to confirm activation when windows were raised, replacing batteries as necessary, and ensuring all units were in the on position. 7. Ongoing Compliance Monitoring Daily monitoring is now in place for all residents identified as being at risk for elopement. Clinical staff are responsible for daily risk assessments and documentation. Additionally, all secured doors will be inspected daily, with any discrepancies reported and addressed through the facility's QA PI (Quality Assurance Performance Improvement) process. 8. Third-Party Verification and Resident Care Plan Review Third-party verification was completed on April 29, 2025, by the Life Safely Surveyor. The fire monitoring service has been contacted for an additional full-door inspection. All residents with known elopement or wandering behaviors are undergoing additional nursing assessments. 100 (percent) of their care plans have been reviewed, with no new interventions noted at this time. We trust these comprehensive actions demonstrate our commitment to resident safety and regulatory compliance. Please do not hesitate to contact us with any further questions or requests for documentation. Following the February incident, immediate corrective actions were implemented, including verification of door functionality and the establishment of a comprehensive monitoring process. Since that time, the doors have been functioning properly, and a procedure has been in place to ensure safe evacuation in the event of an emergency. During the revisit on 4/28/2025, it was noted that the doors required a system reset. This was addressed immediately, and the doors resumed properly functioning without delay. Additional measures have since been incorporated into the ongoing monitoring process to ensure sustained functionality and resident safety. The revised Removal Plan reflects both the original and updated interventions.

Based on policy review, observation, and interview, the facility failed to ensure that food was prepared, and served under sanitary conditions when the oven door had a brown dried liquid on the glass, on the top of the oven door, carbon build up on the frying pans, a rusted mesh skimmer, steam table pans wet nesting on top of other table pans, and top of the convection oven and doors had a shiny film. The facility had a census of 34 with 34 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility's policy titled, CLEANING SCHEDULES, dated 8/31/2018, revealed .The Food and Nutrition services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional . 2. During an observation on 6/10/2024 at 8:35 AM, revealed the oven had dried brown liquid on the inside and top of the door. During an observation on 6/10/2024 at 8:40 AM, revealed 3 frying pans with dark thick carbon buildup. During an observation on 6/10/2024 at 8:45 AM, revealed a rusted mesh skimmer hanging with the frying pans. During an observation on 6/11/2024 at 8:46 AM, revealed a wet nesting of a steam table pan on top of another pans. During an interview on 6/10/2024 at 8:42 AM, the DM confirmed that there was a carbon build up on the frying pans. The DM stated, .they needed to be replaced . The DM also took the mesh skimmer down and threw it out and stated, I need to order a new one . During an interview on 6/10/2024 at 8:48 AM, the DM confirmed the brown dried liquid needed to be cleaned off oven. During an interview on 6/11/2024 at 8:50 AM, the DM confirmed the pans should not be stacked while wet. During an observation and interview on 6/11/2024 at 10:45 AM, revealed the convection oven had a shiny substance on the top. The DM stated, .It needed to be cleaned.

Based on policy review, observation and interview, revealed the facility failed to ensure infection control practices were followed for 2 of 6 sampled residents (Resident #9 and #27) during medication administration when 2 of 5 nurses Licensed Practical Nurse (LPN) D and Registered Nurse (RN) C) failed to perform hand hygiene during administration of medications, and when RN C failed to sanitize reusable equipment after exiting a residents room with enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Administering Medications dated 4/2019, revealed . Staff follows established infection control procedures for the administration of medication as applicable . Review of the facility's policy titled, Handwashing/Hand Hygiene dated 8/2019, revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Wash hands .after contact with a resident .Use an alcohol based hand rub .before and after direct contact with residents .before preparing and handling medications .after contact with resident's intact skin .after contact with objects .after removing gloves .before and after entering isolation precaution settings .Washing hands .wet hands first with water, then apply an amount of product recommended . rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers .rinse hands with water and dry thoroughly with a disposable towel .Use a towel to turn the faucet off . 2. Review of medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Polyneuropathy, Anxiety, and Depression. During observation of medication administration on 6/12/2024 at 8:49 AM, revealed LPN D entered Resident #9's room to administer medications and did not perform hand hygiene prior to donning gloves 3. Review of the medical record revealed Resident #27 admitted to the facility on [DATE], with the diagnoses including Stroke, Anemia, Coronary Artery Disease, Heart Failure, Hypertension, Diabetes, Hemiplegia, and Seizure. Review of the Physician's Orders dated 6/11/24 revealed , .May cocktail medications together for medication administration via PEG tube . During observation and interview during medication administration on 6/11/2024 at 4:00 PM, revealed RN C failed to perform hand hygiene at the completion of medication administration via peg tube on Resident #27 and failed to clean the stethoscope after checking peg tube placement. RN C placed the stethoscope around her neck after use and exited Resident #27's room. When RN C was asked if she had completed all tasks related to care, RN C stated, Yes. RN C was asked about if she should clean the stethoscope. RN C confirmed that she should and proceeded to clean the stethoscope, then placed the stethoscope back around her neck after she cleaned it. During an interview on 6/12/2024 at 3:42 PM the Director of Nursing (DON) confirmed nurses should perform proper hand hygiene with medication administration. The DON was asked the process of cleaning of reusable equipment after each use. The DON confirmed that reusable equipment should be cleaned with a bleach wipe and allowed to dry on a clean surface.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when medications were left in residents' rooms for 4 of 34 (Resident #9, #19, #28, and #30 ) sampled residents, and 1 of 4 medication storage areas were left unlocked and unattended by (Licensed Practical Nurse (LPN) B), and when opened, undated, and expired medications were noted in 1 of 1 medication storage rooms. The findings include: 1. Review of the facility's policy titled, Self-Administration of Medications dated 11/18/2016 revealed .self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be clinically appropriate for the resident .Prescription medication of the residents permitted to self-administer are stored in central medication cart or medication room .The nurse then records such self-administration on the MAR [Medication Administration Record] . Review of the facility's policy titled, Administering Medications dated 4/2019, revealed .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely . Review of the facility's policy titled, Storage of Medications dated of 11/2020, revealed .Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to locked medications .The nursing staff is responsible for maintaining medication storage .Drug containers that have missing, incomplete, improper, incorrect labels are returned to the pharmacy for proper labeling before storing .Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended . 2. During an observation of medication administration on 6/12/2024 at 8:49 AM, revealed LPN D gathered medications for administration to Resident #9's room. LPN D placed medication cup of 13 meds and 2 eye drop medications on the resident's over the bed table. LPN D then exited resident's room to perform hand hygiene, leaving the medications unattended and out of sight on the over the bed table. 3. During a random observation in Resident #19's room on 6/10/2024 at 9:05 AM, revealed Resident #19 was lying in bed with a medication cup on the over the bed table with approximately 15 pills in it. Resident #19 sat up on side of bed and self-administered the medication. During an interview on 6/11/2024 at 3:21 PM, the DON confirmed that medications should not be left at residents' bedside. The DON was asked if a resident should have an order and an assessment completed to self-administer medications. The DON stated, Yes. The DON confirmed that the facility does have wanderers in the building. 4. During a random observation in Resident #28's room on 6/10/2024 at 2:22 PM, revealed approximately 10 medications in a medication cup on the resident's over the bed table. Resident #28 confirmed that the medications were brought into his room and left at bedside after breakfast. During an observation and interview in Resident #28's room [ROOM NUMBER]/10/2024 at 2:27 PM, LPN E was asked if the medication cup should be left at the resident's bedside. LPN E confirmed that medications should not be left at bedside and removed the medications from Resident #28's room. 5. During a random observation in Resident #30's room on 6/10/2024 at 9:37 AM, revealed Silver Sulfadiazine Cream (cream used to prevent wound infections) and wound cleanser on Resident #30's nightstand. During an interview on 6/10/2024 at 10:19 AM, LPN F was asked if the Silver Sulfadiazine Cream and wound cleanser should be left at the bedside. LPN F confirmed that it should not be left at the bedside. 6. During an observation of medication administration on 6/11/2024 at 10:53 AM, revealed LPN B gathered medications, placed the medications in a medication cup, knocked and entered Resident #24's room, leaving the medication cart unlocked and out of sight on the 100 Hall. During an interview on 6/12/2024 at 3:42 PM, the DON was asked if medications should be left at the resident's bedside. The DON confirmed that medications should not be left at bedside. The DON was asked if the medication cart should be left unlocked during medication administration. The DON confirmed that the medication cart should not be left unlocked or unattended. 7. During a random observation and interview in the Medication Storage Room on 6/12/2024 at 2:21 PM, revealed a vial of Tuberculin (A TB skin test solution) opened and undated, Osmolite 1.5 (nutritional liquid supplement) opened and dated on 5/31/2024 in the medication refrigerator, and Osmolite 1.5 opened and dated 6/1/2024 in the nourishment refrigerator. RN C was asked if the Tuberculin should be dated when opened, and if the Osmolite should be discarded within a certain timeframe. RN C confirmed that all opened medications should be dated when opened and that the Osmolite should have been discarded after 24 hours of being opened.

Based on policy review, medical record review, observation and interview, the facility failed to accurately assess residents with wandering for 1 of 12 residents (Resident #32) reviewed for accuracy of assessments. The findings include: 1. Review of the facility's policy titled, Elopement/Unsafe Wandering Plan dated 2/7/2012 revealed, .Wandering is a random or repetitive locomotion. This movement may be goal directed or may be non goal directed or aimless .residents shall be evaluated for unsafe wandering or elopement potential during each care planning review . 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Cognitive, Social, or Emotional Deficit following Cerebrovascular Disease, Vascular Dementia Severe with Agitation, Diabetes, Chronic Kidney Disease, and Alzheimer's Disease. Review of the Care Plan dated 5/1/2024, revealed Resident #32 was an Elopement risk/wanderer and wandered aimlessly. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed .Section E- Behavior .E0900 .Wandering .Behavior not exhibited . Review of the quarterly MDS dated [DATE], revealed .Section E- Behavior .E0900 .Wandering .Behavior not exhibited . During observations on 6/10/2024 at 10:09 AM and 12:06 PM, on 6/11/2024 at 8:21 AM, 9:49 AM, and 4:07 PM, and on 6/12/2024 at 3:00 PM, Resident #32 was wandering aimlessly in the facility. During an interview on 6/12/2024 at 8:30 AM, the Director of Nursing (DON) was asked if Resident #32 was a wanderer. The DON stated, Yes . During an interview on 6/12/2024 at 8:40 AM, The MDS Coordinator was asked if Resident #32 was a wanderer. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if Resident #32 should have been coded on the MDS for wandering behavior. The MDS Coordinator stated, Yes .he has wandered since he was admitted here.

Based on review of the facility's staffing documents, review of time detail reports, facility investigation review, medical record review, and interview, the facility failed to provide sufficient staffing to ensure the safety and supervision of wandering residents on 1 of 2 days (10/18/2022) reviewed, which had the potential to affect all 41 residents in the facility. The facility's failure to ensure sufficient staff to maintain the safety and supervision of wandering residents placed Resident #4 in Immediate Jeopardy when she exited the building without staff knowledge or supervision on 10/8/2022, was found 6.5 miles away from the facility approximately 1 hour and 40 minutes later, and then exited the building without staff knowledge or supervision 10 days later, on 10/18/2022 and was located at a tobacco store approximately 0.7 miles from the facility approximately 1 hour later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Director of Clinical Services, and the Regional Director of Operations were notified of the Immediate Jeopardy on 10/20/2022 at 4:00 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-725. The IJ existed 10/8/2022 and is ongoing. The findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Dementia, Left Ulna and Radial Fracture, Hallucinations, Depression, Anxiety, and Cardiac Pacemaker. Review of a care plan dated 5/3/2022 revealed, .I have a hx [history] of wandering and risk for elopement. My paranoia and fearfulness started when I lived at home. This is not a new behavior. I wear a yellow bracelet due to my elopement risk. Review of a Brief Interview for Mental Status Score (BIMS) dated 7/14/2022, revealed Resident #4 had a score of 5, indicating severe cognitive impairment. Review of a Quarterly Evaluation dated 8/20/2022, revealed Resident #4 was cognitively impaired with poor decision-making skills, ambulated independently, had wandered, and was a wander/elopement risk. Review of a Brief Interview for Mental Status Score (BIMS) dated 10/6/2022, revealed Resident #4 had a score of 6, indicating severe cognitive impairment. Review of a care plan with a revision date of 10/10/2022 revealed, .I have a hx [history] of elopement .Interventions .Provide with 30 minute checks to assure my safety . 2. Review of an Incident Report dated 10/8/2022 revealed Resident #4 left the facility without staff knowledge. Resident #4 was last seen by staff at 5:00 PM. Staff realized she was missing approximately 30 to 45 minutes later and began to search for her. The resident was returned to the facility at 6:40 PM, by her Brother-in-Law after she was found standing in a neighbor's driveway, 6.5 miles from the facility. Review of an Incident Report dated 10/18/2022 revealed a police officer from the [NAME] Police Department came to the facility and informed the Administrator that Resident #4 was found at a local tobacco store by the store manager and was sent to the hospital because she was cold and had a pacemaker. 3. Review of the Nursing Home Licensing Checklist revealed the facility had a census of 41 on 10/18/2022. Review of the Nursing Staffing posting dated 10/18/2022 revealed 2 LPNs and 2 CNAs worked the 1st (Day) Shift. Review of the Employee Timecards for 10/18/2022 revealed Licensed Practical Nurse (LPN) #1, LPN #4, and Certified Nursing Assistant (CNA) #4 clocked in to work the day shift that day. 4. During an interview on 10/17/2022 at 2:35 PM, CNA #3 confirmed this was her first day to work in the facility. During an interview on 10/17/2022 at 2:12 PM, CNA #4 confirmed she started working in the facility on 10/13/2022. During an interview on 10/18/2022 at 10:28 AM, LPN #1 stated, I came in about 5:45 AM this morning, and the doors between B hall and C hall were closed and locked, you had to use the keypad. The night nurse, in report, informed me that Resident #4 had been up all night roaming the hall concerned about those doors being closed .Trays hit the floor between 7 and 7:10 [AM]. I saw her through the window of the door, she was right outside her room looking down the hallway. CNA #3 took her breakfast tray and didn't see her in her room. We finished passing trays between 8 and 8:15 [AM]. A [NAME] police department officer alerted us she had gotten out of the building, and they got her and took her to the hospital to be checked out, she was cold. The Cook called me in the room, the pull string to the blinds was hanging out the window, and the window was opened, and it was clear someone had gone out the window . During an interview on 10/18/2022 at 1:42 PM, LPN #4 stated, .I didn't know anything about the elopement until I saw the officer here . During an interview on 10/18/2022 at 2:08 PM, CNA #3 confirmed she was working this morning when Resident #4 eloped. She stated, .I got here about 6 AM . We started passing trays around 7 [7:00 AM], and I actually took her breakfast tray in her room. She wasn't in there, I kept passing trays .the police came in we didn't know why he was here, and that's when we found out she was gone. I feel bad. I should have told the nurse she wasn't in there . She was asked if a code W was called this morning for Resident #4's elopement. She stated, Nope. During an interview on 10/18/2022 at 2:21 PM, the Activities Director confirmed she was a CNA and worked on the floor when the facility was short staffed. She was asked if she worked this morning when Resident #4 eloped. She stated, .when I got here at 8:30, they said they needed help on the floor. I found out after the fact . During an interview on 10/18/2022 at 2:36 PM, CNA #4 confirmed she was working this morning when Resident #4 eloped. She stated, .Trays come out at 7 [7:00 AM]. Before, I would make a round on my section, but today we didn't know where we would be because there were only 2 of us. So, we decided to work together to pass the trays. As we went into each room, we pulled residents up in bed, set the trays up for them. We finished A hall, then went to B hall. There was a resident that had to be fed . By the time I finished feeding her, all the hall trays had been passed. By the time I finished picking up trays on B hall, I saw the police in the building. Before that, we had no idea she was missing . During an interview on 10/20/2022 at 8:55 AM, the Interim Director of Nursing (DON) confirmed CNA #3 and CNA #4 were both new employees, just out of orientation. She stated, I wasn't here that day [10/18/2022] but I thought they had more help . During a telephone interview on 10/20/2022, the Administrator was asked if staff should know where the residents are at all times. She stated, I feel like they should. She was asked if the facility had adequate staff to do that. She stated, .there's a lot of call-ins. We have to work in [different] positions .the DON has to get on the floor constantly .trying to shuffle around until we can make things work . The Administrator was asked if one nurse and one CNA on a hall was adequate to ensure they know where all the residents are. She stated, No, Ma'am. During a telephone interview on 10/21/2022 at 12:14 PM, the Medical Director confirmed she had been notified about Resident #4's elopements. She stated, .leadership, no steady DON .staffing issue causing all this, making it worse . She confirmed she was not aware that there were only 2 CNAs working on 10/18/2022 when Resident #4 eloped, and they were both new employees. She stated, .We have a huge staffing crisis in that facility. I have talked with the owner. We need some help in that facility with regard to staffing, and most of the problem with the elopement was because of that . Refer to F609, F610 and F689.

Based on policy review, facility investigation review, weather website review, surveillance video review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent incidents of elopement for 1 of 3 (Resident #4) sampled residents reviewed for elopement and failed to complete an incident report and implement interventions after falls for 1 of 3 residents (Resident #3) reviewed for falls. The facility's failure to ensure a safe environment to prevent elopements resulted in Immediate Jeopardy (IJ) when Resident #4 eloped from the front exit door which did not have an alarm system in place. On 10/8/2022 Resident #4 was discovered approximately 6.5 miles from the facility in a stranger's driveway. The facility was unaware Resident #4 had exited the building for approximately 1 hour, until a staff member reported to the charge nurse Resident #4 was not in her room. Ten days later on 10/18/2022, Resident #4, at risk for elopement and was wearing a yellow bracelet (a bracelet that indicated she was a wandering resident who was at risk for elopement), eloped from the facility through a window in her room, which did not have a locking system or an alarm system in place. Staff were unaware of Resident #4's location for approximately 1 hour and 15 minutes, when she was found by a store employee at a tobacco store, approximately 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Director of Clinical Services, and the Regional Director of Operations were notified of the Immediate Jeopardy on 10/20/2022 at 4:00 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 10/8/2022 and is ongoing. The findings include: 1. Review of the facility's policy titled, Elopement/Unsafe Wander Plan, dated 2/7/2012, revealed .It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment .Elopement occurs when a resident leaves the premises or a safe area without authorization .an order for discharge or leave of absence .and/or any necessary supervision to do so .Residents at risk will have some type of 'identifier' on their person .colored arm band .All staff are to be educated to the significance of identifiers .Photographs will be taken of at risk residents and dept for identification and maintained in the MAR [Medication Administration Record] location .The photographs will be used to aid in locating the resident should it become necessary .Systems such as alarms, Wander guard systems, and special locks/keypads .will be utilized to the extent possible .Elopement drills are to be done no less than annually .Newly hired staff are to be educated to the Elopement Prevention Plan . Review of the facility's undated policy titled, .ACCIDENTS AND INCIDENTS, revealed, .It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible .This is accomplished through the identification and evaluation of environmental hazards and individual risk factors, implementing interventions to reduce hazards and risks that are identified, and monitoring for the effectiveness of the interventions .Residents are to be routinely evaluated for individual risk factors in areas to include but are not limited to .falls, unsafe wandering or elopement .These evaluations are completed at .admission, quarterly, annually, and with change in condition .Regardless of how minor an accident or incident may seem, it should be reported and an Incident Report form completed . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Dementia, Left Ulna and Radial Fracture, Hallucinations, Depression, Anxiety, and Cardiac Pacemaker. Review of a care plan dated 5/3/2022 revealed, .I have a hx [history] of wandering and risk for elopement. My paranoia and fearfulness started when I lived at home. This is not a new behavior. I wear a yellow bracelet due to my elopement risk . Review of a progress note dated 5/19/2022 revealed, .Continue to have increase in wandering and wanting to go home in afternoon. Will pack her bags and asked to be let out of the door to go home. Wears a yellow brace [bracelet] to identify elopement risk . Review of a Brief Interview for Mental Status Score (BIMS) dated 7/14/2022, revealed Resident #4 had a BIMS score of 5, indicating severely impaired cognition. Review of a Quarterly Evaluation dated 8/20/2022, revealed Resident #4 was cognitively impaired with poor decision-making skills, ambulated independently, had wandered, and was a wander/elopement risk. Review of a Quarterly Evaluation dated 10/6/2022, revealed Resident #4 was at high risk for falls, was cognitively impaired with poor decision-making skills, ambulated independently, wandered, was at significant risk of getting to a potentially dangerous place, and had a yellow elopement bracelet intact. Resident #4 had a BIMS score of 6, indicating severely impaired cognition. Review of a progress note dated 10/7/2022 revealed, .Upon checking, the resident had removed her bracelet. An attempt was made to obtain another bracelet, but they were locked in a secure place . There was no documentation the resident's yellow elopement bracelet was replaced prior to the 10/8/2022 elopement. a. The following is related to the 10/8/2022 elopement of Resident #4: Review of the facility's Elopement incident report for Resident #4 dated 10/8/2022 revealed, .Staff CNAs [certified nursing assistants] on 3-11 [3:00 PM to 11:00 PM] shift were in the process of picking up supper trays. CNAs made this nurse aware that resident did not eat any of her supper tray. This nurse went to resident's room and noticed the resident was not present and tray had not been touched. At this time this nurse alerted all staff to look for the resident. This nurse last physically seen the resident at approximately 5:00pm [5:00 PM] before supper trays came out. She was headed down C hall towards B hall. All areas inside and outside of facility was searched; unable to locate resident. Administrator was notified and arrived at facility at approximately 6:30 PM and we continued to search for the resident. Approximately 6:40 pm, right after arrival of administrator, [named Brother-in-Law of Resident #4], arrived at the facility with resident in his car .stated that his neighbor brought her to his house and he immediately brought her here .family was notified, Dr [physician] was notified .Resident was taken to her room, and a full body audit was completed. No injuries, skin intact, no complaints of pain. 30-minute security checks were care planned for the next 72 hours. After further investigation by the administrator a family member of another resident stated that she exited facility with resident standing at the door and she did not check to make sure the resident did not exit .Resident stated she does not remember going out the door. She stated she was, holding mother's hand and going to her house. Resident stated she, got a ride with a man in a blue car, and then he took her to her mother's home. Resident then stated that she was returned to the facility by .her brother-in-law .Full body audit was done .Resident or someone had removed elopement band, band was replaced .Code on front door was changed . Review of a witness statement dated 10/8/2022, written by Licensed Practical Nurse (LPN) #1, revealed, .CNAs made this nurse aware that the resident did not eat any of her food on her tray. This nurse went to the resident's room and noticed the resident was not present and the food tray had not been touched. At this time, this nurse alerted all staff to look for the resident. This nurse last physically seen the resident at approximately 5:00 PM before supper trays went out, while on med [medication] pass. She was headed down C hall towards B hall. All areas inside and outside of the facility was searched for the resident. Unable to locate resident. Administrator was notified and arrived at the facility at approximately 6:30 PM as we continued to search for the resident. At approximately 6:40 PM, right after the arrival of the administrator, [named Brother-in-Law of Resident #4] arrived at the facility with the resident in his car .and stated that his neighbor brought the resident to his house and he immediately brought her back to the facility .after further investigation by the administrator a family member of another resident stated that she exited the facility with resident [Resident #4] standing at the door after dinner and did not look back to see if the resident exited the building . According to the timeanddate.com website, the high temperature at 6:00 PM on 10/8/2022 was 63 degrees, the low was 43 degrees, and the sunset was at 6:31 PM. During an interview on 10/17/2022 at 1:02 PM, LPN #1 confirmed she was the charge nurse for Resident #4 on 10/8/2022 when she eloped. She stated, .it was about 5 PM [5:00 PM]. She was coming off of C hall onto B hall. I was doing my med pass. She goes onto B hall and visits (Named Resident) .Trays came out after 5 [5:00 PM] and were being passed. I took my cart back up front, between 5:45 and 6:00. The CNAs were now picking up the dinner trays. A CNA came and reported to me [Named Resident #4] had not touched her dinner tray and was not in her room. I went straight to her room and saw she was not in there and the tray was not touched. I came out of the room and told the CNAs to start looking for her, and to let LPN #2 know, she was working A hall. I went to the back of C hall and came up through looking for her because she likes to visit residents on that hall. I didn't see her on that hall. I continued onto B hall checking rooms and bathrooms, making my way up to A hall, and [NAME] had checked A hall, and we met. I told her I can't find her, she said she couldn't find her. I tried to call [Named Interim Director of Nursing [DON]]. We alerted all the staff, and [Name of LPN #2] called the Administrator, but the rest of the staff continued to look for her. I went straight out the doors, and [Named LPN #2] went with me outside. I texted [Named Interim DON] and asked what the policy and procedure for elopement was. At this point I know we got to do something. [Named Interim DON] texted the Administrator was on the way. We were walking around the entire building. [Named LPN #2] went down the hill, the sideline of the woods. The Administrator arrived, we met her at the front door. As we are standing with her [Named Family Member #1] let herself out of the front door with the code in front of all of us. The Administrator said, 'Excuse me, I see you have been here.' [Family Member #1] told her [Named Resident #4] was standing at the door when she left from 5:15 to 5:30 PM, but she didn't check to see if she went out the door, but she was standing near the door .The Administrator told her, 'You can't have the code, and you can't let anybody out.' As she left out, she held the door and said, 'Here's the lady, right here.' And I saw [named Resident #4] in the passenger seat and she was with her brother-in-law [in his car] .He said his neighbor brought [named Resident #4] to him, and he brought her back to the facility. [Named Resident #4] was hugging both of us, I opened her coke for her, we checked her temperature. She had had an accident. I cleaned her up and did a full body audit. She told me she was holding her mother's hand and the blue car gave her a ride to her mother's house, so she went to her sister's house. [Named brother-in-law] lives at Curve, which would take over an hour to walk to .We were in-serviced .on the code to the door not to be given out, the code was changed. And it was changed again 2 days later. They installed the loud door alarms, that were not there before .I do know where the [elopement] book is now and know how to follow the elopement procedure .It was getting dark and cold . During an interview on 10/17/2022 at 2:21 PM, the Social Services Director confirmed she had not done a psychosocial assessment on Resident #4 since the elopement. She confirmed she was able to talk with Family Member #1 who had seen Resident #4 by the exit door that day. She stated, .she said she went to the door, and [Named Resident #4] was beside the door. She wasn't sure if she came out behind her. She couldn't give me a straightforward answer. Once I talked to her, it was later about the blue car, it was solely about the door. I haven't talked to her after that. She is not admitting to anything. I think she stood and watched someone [enter the code]. No one but employees are allowed to have those codes. On her way out the door she watched a staff member put it in, is what I think. She was asked what the facility was doing to protect the codes. She stated, Change it weekly. We have new alarms, any time the door is opened, it goes off. Any time it goes off we are to go check to see who is going out. It won't stop until the door shuts back, even if you push on it, it's going to go off .there never was a problem with the door, they lock good, and you have to put in the code to get out. It was impressed on staff to not give out the code no matter what . During an interview on 10/17/2022 at 6:02 PM, CNA #1 confirmed she was working the evening of 10/8/2022. She stated, .the last time I remember seeing her was when I got here at 2:00 PM, she was standing by the bench up front by herself, near the therapy department. I went to do rounds and answer lights. I noticed about 5:30 to 6 [5:30 PM to 6:00 PM] when we were picking up dinner trays, she didn't eat when I went in her room. I pushed the door back to see if she was in there, called her name, walked around the room. I told my hall partner, [Named CNA #2], let's check rooms and the dining room and shower room. She wasn't in those. Checked all the C hall rooms, went in the main dining room. I told [Named CNA #2] to let [Named LPN #2] and them know we don't see [Named Resident #4]. She did. We all started looking again, we checked this building 3 times, and she wasn't here. Then we went outside and looked around the building. Nothing. I am going to get in my car and ride to [named local grocery store] and rode up town looking for her. I came back to the facility, got back here about 7. By that time the Administrator was here. It was about 7. It was dark, and [Named Resident #4] still wasn't here. I was eating my lunch and they had brought her in .told us the brother-in-law brought her back. We went back to see her. She said she was okay. She told me she didn't remember getting in a car. That's a pretty far walk. After that they gave us in-services .If code W called, start looking for the resident and if not inside, go outside, check the doors, go outside, look, supposed to call the police when you can't find them in the building . During an interview on 10/17/2022 at 6:23 PM, CNA #2 confirmed she had worked the evening of 10/8/2022. She stated, .I remember coming in at 2:00 [PM]. I saw her in the lobby .I started making rounds and answering call lights. Around dinner time, I put her tray in her room, she wasn't in there. I just kept passing trays. [Named CNA #1] went back to pick up her tray, and it hadn't been touched. We told [Named LPN #1] she was missing and let [Named LPN #2] know. We started looking for her, searching the whole facility. When we couldn't find her, they called the Administrator. [Named CNA #1 and Named LPN #2] got in their cars and went looking. I kept looking for her in the building with [Named LPN #1]. The Administrator and [Named Interim DON] came up here, and we searched again. I don't know what happened after that . She confirmed she didn't get the elopement, abuse, or neglect training after the elopement. During an interview on 10/17/2022 at 6:31 PM, LPN #3 confirmed she did not know what code to call for an elopement. She confirmed she had not had abuse or neglect in-services and had not had an elopement drill after Resident #4 eloped on 10/8/2022. During an interview on 10/17/2022 at 6:53 PM, Registered Nurse (RN) #1 confirmed she had not participated in an elopement drill since the 10/8/2022 elopement. During an interview on 10/18/2022 at 10:52 AM, Family Member #1 confirmed she had gone out the front door to smoke on 10/8/2022. She confirmed she went in and out of the facility to smoke whenever she came to visit her family member. She confirmed a staff member had given her the code, but she could not remember which staff member and she stated, they could get in trouble for giving me the code . She confirmed she had not seen Resident #4 go out the door, and she did not see her in the parking lot while she sat in her car smoking. During an interview on 10/18/2022 at 12:15 PM, Resident #4's brother-in-law confirmed he saw a truck pull up to his home sometime after 6:00 PM on Saturday, 10/8/2022. He saw some neighbors from down the road had his sister-in-law in the vehicle. They told him she had walked up to their house and asked if they would give her a ride to her sister's house right up the road. He said he told them to keep her in the truck while he grabbed his keys, so she wouldn't get upset, and he would take her back to the nursing home in his car. He said it was about 6:40 PM, when he arrived at the facility with his sister-in-law. He then confirmed he would show the surveyor where the neighbors lived. The surveyor followed the brother-in-law to the residence approximately 1/4 mile from his house located on Curve Nankapoo Road. According to Google Maps, the location where Resident #4 was found on Curve Nankapoo Road was approximately 6.5 miles from the facility. During an interview on 10/18/2022 at 12:45 PM, the neighbor who found Resident #4 confirmed it happened on Saturday, October 8, 2022, sometime after 6:00 PM, because he had been waiting for his daughter to come and pick up the baby after she got off work. He confirmed it was near sunset. He stated, She just walked up the driveway, there were no vehicles, I had been standing out here so I would have seen a vehicle. She came up from Highway 51 and asked if I could give her a ride to [named Brother-in-Law's] house right up the road. She said she had been walking a long time. She was shivering, and she said she was freezing, her hands were cold. It was cold out .She had on khaki pants, a blouse, and a cardigan. I turned the heat on in the truck and she said that felt good. We took her up to [named Brother-in-Law's] house . During a telephone interview on 10/19/2022 at 9:30 AM, Family Member #2 confirmed she saw Resident #4 walking on Highway 51 toward Curve Nankapoo Road on 10/8/2022. She stated, .I thought it was odd that an older woman was walking on the highway that time of day, it was near sunset, around 6:00 [PM]. We were on our way to a cookout; it was cool that night. I didn't put it together until I talked with [Named Resident in Facility], and she told me [Named Resident #4] had gotten out of the facility and walked to Curve Nankapoo Road .that's when I realized I had seen her .she had pants and a sweater on, and she was walking steadily at a normal pace . During an interview on 10/20/2022 at 8:45 AM, the Interim DON, looked at her phone and confirmed she had received a text message from LPN #1 at 6:21 PM, on 10/8/2022. She confirmed LPN #1 asked her what the protocol for elopement was. She confirmed LPN #1 didn't know where the Elopement book was. b. The following is related to the 10/18/2022 elopement of Resident #4: Review of an Incident Report dated 10/18/2022 at 8:15 AM, revealed, .Resident Elopement .on 10/18/2022 at approximately 8:15am [8:15 AM] [Named Police Officer] from the [NAME] Police Department was brought to my office and stated that one of our residents .was at a local business called [Named Tobacco Store]. At this time I told the nurse to notify the family and a staff member was sent to the business. Dispatch notified [Named Police Officer] that the resident was being transported to the [Named Hospital] due to being cold and having a pacemaker. [Named Medical Director] was notified. The resident has a BIMS score of 6 and was believed to have climbed out of her room window. She crossed over Washington street. The temperature was around 42degrees [42 degrees]. She was wearing pants, a top, and shoes. She is now back at the facility with no injuries, skin intact. Staff was in serviced on elopement, meal deliver, exit seeking . Review of an EMERGENCY DEPARTMENT PHYSICIAN RECORD dated 10/18/2022 at 8:27 AM, revealed, .Patient brought in by EMS [Emergency Medical Service], she had reportedly wandered away form [from] the nursing home during the middle of the night. Patient suffers from significant dementia .Clinical Impression .Dementia .Pt [Patient] reportedly eloped from the nursing home .Discharge .Condition .Stable .Emergency Care Record .Patient does state that she was kidnapped and held hostage at a school this morning . Observation of the video surveillance footage, reviewed by the surveyor at the tobacco store, revealed the following timed events occurred on 10/18/2022: 7:43 AM - Resident #4 was walking from the direction of the facility up Washington Street. Resident #4 did not check traffic and walked across the busy intersection toward the Tobacco Store. 7:45 AM - Resident #4 entered the Tobacco Store and told the clerk she had been kidnapped, and the clerk asked the Manager to come up front. 7:46 AM - The Manager assisted Resident #4 to sit in a chair behind the counter, and the clerk gave her a jacket to put on. The Manager called the police. 7:56 AM - The police arrived and asked her name and where she lived, asked for identification. She had no form of identification. She gave them her old address. She began to pull items out of her bra: 2 pair of socks, couple of dollar bills, a comb, a small pink light with a flower on it, and a necklace. 7:57 AM - police called for paramedics to come and evaluate her. 8:07 AM - paramedics arrived; they asked if she was hurt. Resident #4 stated, No, they didn't hurt me. The Paramedic asked for her name and birthday, and once he entered it in the computer he confirmed she resided at (Named Long Term Care Facility). 8:09 AM - 2 emergency personnel assisted her to the stretcher and took her out to the ambulance. 8:18 AM - a black [NAME] sedan came from the direction of the nursing home and quickly pulled into the parking lot. The person inside rolled down the window, spoke briefly to the officers, then pulled back out of the parking lot and was seen driving back in the direction of the facility. According to the timeanddate.com website, between 6:00 AM and 12:00 PM on 10/18/2022, the high temperature was 46 degrees and the low temperature was 34 degrees. During an interview on 10/18/2022 at 10:28 AM, LPN #1 stated, I came in about 5:45 AM this morning, and the doors between B hall and C hall were closed and locked, you had to use the keypad. The night nurse, in report, informed me that Resident #4 had been up all night roaming the hall concerned about those doors being closed. I asked if she could go to the front lobby, and she said she did not know otherwise. About 6:05 [AM], she came out of her room to go to the restroom, then she started roaming the hall and went straight to those doors. I asked her what she was doing, and she said she wanted those opened, they were bothering her being closed. I told her that I would talk to the Administrator and asked her to stay with me and wait on breakfast trays trying to deter her from the door. I gave her some pudding. I went on with my med pass. Trays hit the floor between 7 and 7:10 [AM]. I saw her through the window of the door, she was right outside her room looking down the hallway. CNA #3 took her breakfast tray and didn't see her in her room. We finished passing trays between 8 and 8:15 [AM]. A [NAME] police department officer alerted us she had gotten out of the building, and they got her and took her to the hospital to be checked out, she was cold. The Cook called me in the room, the pull string to the blinds was hanging out the window, and the window was opened, and it was clear someone had gone out the window. [Named Maintenance Director] installed an alarm on the window and opened the doors back up that were bothering her. During an interview on 10/18/2022 at 11:30 AM, the Cook confirmed she had gotten to the facility at 4:45 AM this morning and was waiting for someone to let her in. She stated Resident #4 came up to the keypad and was punching numbers randomly, and it was obvious she didn't know how to punch in the key code. The Cook said she told Resident #4 to go get someone to let her (Cook) in, and she did. She said after she went to the kitchen, she came back out and found Resident #4 by the A hall nurse's station sitting in a chair and they talked for a few minutes. She stated, .That's the last time I saw her, and she was still sitting in that chair. When the police said she was missing, I ran to her room and that's when I saw the chair beside the window, I saw the blind pull hanging outside the window, and I went and told the charge nurse. As far as I know, nobody saw her climb out the window. During an interview on 10/18/2022 at 1:42 PM, LPN #4 confirmed she had not had an elopement drill or abuse, neglect, or elopement in-services since she started working in the facility. She had only signed some papers and had nothing in depth. She confirmed she got to the facility this morning around 6:00 AM and started doing her rounds on A Hall. She stated, .I didn't know anything about the elopement until I saw the officer here . During an interview on 10/18/2022 at 2:08 PM, CNA #3 confirmed she was working this morning when Resident #4 eloped. She stated, .I got here about 6 AM, and I saw her sitting up in a chair near the top of the A hall in front of the nurse's station. She was dressed and had shoes on .I don't remember exactly what clothes she had on .We started passing trays around 7 [AM], and I actually took her breakfast tray in her room. She wasn't in there, I kept passing trays .the police came in, we didn't know why he was here, and that's when we found out she was gone. I feel bad. I should have told the nurse she wasn't in there. She walks so much. I'm just glad she was ok . She was asked if a code W was ever called this morning for her elopement. She stated, Nope. During an interview on 10/18/2022 at 2:36 PM, CNA #4 confirmed she was working this morning when Resident #4 eloped. She stated, .I got here at 5:50 AM, and she was standing near the nurse's station at the top of A hall. I spoke to her, she said she was chilly. I guess she went back to her room, and that was the last time I saw her. Trays come out at 7 [AM]. Before, I would make a round on my section, but today we didn't know where we would be because there were only 2 of us. So, we decided to work together to pass the trays. As we went into each room, we pulled residents up in bed, set the trays up for them. We finished A hall, then went to B hall. There was a resident that had to be fed .By the time I finished feeding her, all the hall trays had been passed. By the time I finished picking up trays on B hall, I saw the police in the building. Before that, we had no idea she was missing. Someone said she had gotten out and the department heads were on the floor . She was asked if she received extra training today. She stated, Not today. During an interview on 10/19/2022 at 10:40 AM, the store Manager of a local Tobacco Store confirmed Resident #4 had come into the store on the morning of 10/18/2022, and she agreed to play the video surveillance footage with time stamps. During an interview on 10/19/2022 at 10:50 AM, the store Manager stated, .she was freezing, shivering, we put a jacket on her and got her something to drink. She was scared and kept looking at the door. She had on light pants, slip-on black shoes, a pink shirt, and a dark gray sweater. She said she was held in a basement of a school building, and she escaped, she crawled out a window. She had mud on her pants, on the knees of her pants, like she had fallen. She said her name .she said they didn't hurt her. She said she had not gotten in a car. She said she had a son but didn't know his phone number. She had a few scratches on her hands. She had no form of ID [identification], no bracelet or any type of band . The store Manager was asked if anyone from the facility had come to interview her and get her statement. She stated, No, Ma'am. And no one called me either. I called to check on her and [Named Social Worker] said it wasn't my concern. c. During observation and interview on 10/18/2022 at 2:57 PM, Resident #4 was sitting in the activity room, decorating a small pumpkin. She was very relaxed, pleasant, and conversant. She stated, You know I walked from here all the way to Curve Nankapoo Road on that Saturday night. One car stopped and tried to give me a ride, but I told them just keep going. I didn't stop for nothing, and I kept on moving .I got to the house where the man was, and he gave me a ride to [named her Brother-in-Law]. I miss my sister so much. We were that close [she crossed two fingers in the air] . d. During an interview on 10/18/2022 at 3:45 PM, at the C Hall nurse's station, the ELOPEMENT & BIMS EVALUATIONS book was reviewed with LPN #1. LPN #1 confirmed the book was not up to date, the residents listed in the book were not the current residents, and the resident locations were not accurate. She confirmed the ELOPEMENT & BIMS EVALUATIONS book should be kept up to date so staff would know the residents who are at risk for wandering and elopement. During an interview on 10/18/2022 at 4:15 PM, LPN #2 reviewed the ELOPEMENT & BIMS EVALUATIONS books for A Hall and C Hall. LPN #2 was asked what the purpose of the ELOPEMENT & BIMS EVALUATIONS book was. She stated, .these are to make staff aware of who is at risk for elopement, and the BIMS, what their cognitive state is. She was asked if those were important tools used by the staff. She stated, Yes. She was asked if the books should be kept up to date. She stated, Yes. She confirmed the C hall book was not up to date and stated several residents in the book were no longer in the facility, and some residents with wandering/elopement behaviors were not listed in the book. She confirmed the A hall book was not up to date for the same reasons. During an interview on 10/19/2022 at 1:00 PM, Housekeeper #1 confirmed she had not been in serviced on abuse, neglect or elopement in the last 2 weeks. During an interview on 10/19/2022 at 1:07 PM, LPN #5 was asked what code is called when there is an elopement. LPN #5 stated, L. LPN #5 was asked if training was provided on how to use the Elopement book. LPN #5 stated, No, Ma'am. During a telephone interview on 10/20/2022 at 11:37 AM, the Administrator was asked if the Elopement book should be kept up to date. She stated, Yes, Ma'am. She was asked what percent of staff should be educated about elopement procedures. She stated, .should be all. She confirmed she wasn't aware that all staff didn't know the code called for an elopement is Code W. She confirmed she wasn't aware staff didn't know where the Elopement book was. The Administrator confirmed that when the police officer notified her Resident #4 was at the Tobacco Store, she sent the Business Office Manager to check on her. She confirmed the Business Office Manager drove a black [NAME] sedan. She confirmed the Business Office Manager should [TRUNCATED]

Based on policy review, facility investigation review, weather website review, surveillance video review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement were thoroughly investigated for 1 of 3 sampled residents (Resident #4) reviewed for wandering behaviors and 1 of 1 (Resident #4) residents sampled for elopement. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when on 10/8/2022 Resident #4, a cognitively impaired resident with wandering behaviors and at risk for elopement, exited the facility without staff knowledge, walked approximately 6.5 miles from the facility, was found in a stranger's driveway on a cold October day at sunset, and brought back to the facility after being gone for approximately 1 hour and 40 minutes. Ten (10) days later on October 18, 2022, Resident #4 exited the facility without staff knowledge, through a facility window in her room and was found 0.7 miles from the facility in a local tobacco store, one (1) hour later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Director of Clinical Services, and the Regional Director of Operations were notified of the Immediate Jeopardy on 10/20/2022 at 4:00 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 10/8/2022 and is ongoing. The findings include: 1. Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS, revealed, Residents are to be routinely evaluated for individual risk factors in areas to include but are not limited to .unsafe wandering or elopement .Documentation should include .The date, time, and location of the incident, Circumstances surrounding the incident .Names and accounts of any witnesses including the victim .Date and time physician was notified, time the physician responded, and orders given .Date and time the responsible party was notified .The condition of the person involved .Treatment rendered .Disposition of the victim .corrective action taken to minimize risk of further instances .Investigations .Investigations should begin when the incident is identified. The nurse in charge should identify staff, visitors, or other residents who may have knowledge of the occurrence. These individuals should be interviewed and asked to provide a statement .Some or all the following may be included in the investigation .Medical condition .Diagnoses .Behavior at the time of the incident .Events leading up to the discovery of the incident Interviews of witnesses or caregivers for the past 24 hours .An attempt to determine the root cause of an .incident is made and corrective actions put into place .Staff responsible for the care of the resident is informed of the corrective actions and the care plan is modified to reflect new interventions .forms include .Incident Report .Unusual Incident Report .Investigation Summary .Witness Statement .Witness Interview Statement . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Dementia, Left Ulna and Radial Fracture, Hallucinations, Depression, Anxiety, and Cardiac Pacemaker. Review of a Brief Interview for Mental Status Score (BIMS) dated 7/14/2022, revealed Resident #4 had a score of 5 indicating she was severely impaired cognition. Review of a Quarterly Evaluation dated 10/6/2022, revealed Resident #4 had a BIMS score of 6 indicating she had severe cognitive impairment, was at high risk for falls, had poor decision-making skills, ambulated independently, wandered, was at significant risk of getting to a potentially dangerous place, and required a yellow elopement bracelet intact. Review of a progress note dated 10/7/2022 revealed, .Upon checking, the resident had removed her bracelet. An attempt was made to obtain another bracelet, but they were locked in a secure place . There was no documentation the resident's yellow elopement bracelet was replaced prior to the 10/8/2022 elopement. a. The following is related to the 10/8/2022 elopement of Resident #4: Review of the facility's Elopement incident report for Resident #4 dated 10/8/2022 revealed, .Staff CNAs [certified nursing assistants] on 3-11 [3:00 PM to 11:00 PM] shift were in the process of picking up supper trays. CNAs made this nurse aware that resident did not eat any of her supper tray. This nurse went to resident's room and noticed the resident was not present and tray had not been touched. At this time this nurse alerted all staff to look for the resident. This nurse last physically seen the resident at approximately 5:00pm [5:00 PM] before supper trays came out. She was headed down C hall towards B hall. All areas inside and outside of facility was searched; unable to locate resident. Administrator was notified and arrived at facility at approximately 6:30 PM and we continued to search for the resident. Approximately 6:40 pm, right after arrival of administrator, [named Brother-in-Law of Resident #4], arrived at the facility with resident in his car .stated that his neighbor brought her to his house and he immediately brought her here .family was notified, Dr [physician] was notified .Resident was taken to her room, and a full body audit was completed. No injuries, skin intact, no complaints of pain. 30-minute security checks were care planned for the next 72 hours. After further investigation by the administrator a family member of another resident stated that she exited facility with resident standing at the door and she did not check to make sure the resident did not exit .Resident stated she does not remember going out the door. She stated she was, holding mother's hand and going to her house. Resident stated she, got a ride with a man in a blue car, and then he took her to her mother's home. Resident then stated that she was returned to the facility by .her brother-in-law .Full body audit was done .Resident or someone had removed elopement band, band was replaced .Code on front door was changed . The facility's investigation did not include interviews and statements from the stranger and the brother-in-law, interviews or statements with the CNAs who reported the resident missing, possible routes with mileage the resident could have traveled to get to the stranger's house, what she was wearing, what the weather was like, did not specify, once it was established by staff the resident was missing, police were notified to assist in searching for her, did not explain how the yellow band was missing, and did not contain a root cause analysis. According to the timeanddate.com, the high temperature at 6:00 PM on 10/8/2022 was 63 degrees, the low was 43 degrees, and the sunset was at 6:31 PM. According to Google Maps, the location where Resident #4 was found on Curve Nankapoo Road was approximately 6.5 miles from the facility. During an interview on 10/17/2022 at 6:02 PM, CNA #1 confirmed she was working the evening of 10/8/2022. She stated, .the last time I remember seeing her was when I got here at 2:00 PM, she was standing by the bench up front by herself, near the therapy department. I went to do rounds and answer lights. I noticed about 5:30 to 6 [5:30 PM to 6:00 PM] when we were picking up dinner trays, she didn't eat when I went in her room. I pushed the door back to see if she was in there, called her name, walked around the room. I told my hall partner, CNA #2, let's check rooms and the dining room and shower room. She wasn't in those. Checked all the C hall rooms, went in the main dining room. I told [Named CNA #2] to let [Named LPN #2] and them know we don't see [Named Resident #4]. She did. We all started looking again, we checked this building 3 times, and she wasn't here. Then we went outside and looked around the building. Nothing. I am going to get in my car and ride to [named local grocery store] and rode up town looking for her. I came back to the facility, got back here about 7. By that time the Administrator was here. It was about 7. It was dark, and [Named Resident #4] still wasn't here. I was eating my lunch and they had brought her in .told us the brother-in-law brought her back . She confirmed it was a far walk to Curve Nankapoo Road. During an interview on 10/17/2022 at 6:23 PM, CNA #2 confirmed she had worked the evening of October 8, 2022. She stated, .I remember coming in at 2:00 [PM]. I saw her in the lobby .I started making rounds and answering call lights. Around dinner time, I put her tray in her room, she wasn't in there. I just kept passing trays. [Named CNA #1] went back to pick up her tray, and it hadn't been touched. We told [Named LPN #1] she was missing and let [Named LPN #2] know. We started looking for her, searching the whole facility. When we couldn't find her, they called the Administrator. [Named CNA #1 and Named LPN #2] got in their cars and went looking. I kept looking for her in the building with [Named LPN #1]. The Administrator and [Named Interim DON] came up here, and we searched again. I don't know what happened after that . She confirmed she didn't get the elopement, abuse, or neglect training. During an interview on 10/17/2022 at 6:31 PM, LPN #3 confirmed she did not know what code to call for an elopement. She confirmed she had not had abuse or neglect in-services and had not had an elopement drill after Resident #4 eloped on 10/8/2022. During an interview on 10/17/2022 at 6:53 PM, Registered Nurse (RN) #1 confirmed she had not participated in an elopement drill since the 10/8/2022 elopement. During an interview on 10/18/2022 at 12:15 PM, Resident #4's brother-in-law confirmed he saw a truck pull up to his home sometime after 6:00 PM on Saturday, October 8, 2022. He saw some neighbors from down the road had his sister-in-law in the vehicle. They told him she had walked up to their house and asked if they would give her a ride to her sister's house right up the road. He said he told them to keep her in the truck while he grabbed his keys, so she wouldn't get upset, and he would take her back to the nursing home in his car. He said it was about 6:40 PM, when he arrived at the facility with his sister-in-law. He then confirmed he would show the surveyor where the neighbors lived. The surveyor followed the brother-in-law to the residence approximately 1/4 mile from his house located on Curve Nankapoo Road. During an interview on 10/18/2022 at 12:45 PM, the neighbor who found Resident #4 confirmed it happened on Saturday, October 8, 2022, sometime after 6:00 PM, because he had been waiting for his daughter to come and pick up the baby after she got off work. He confirmed it was near sunset. He stated, She just walked up the driveway, there were no vehicles, I had been standing out here so I would have seen a vehicle. She came up from Highway 51 and asked if I could give her a ride to [named brother-in-law's] house right up the road. She said she had been walking a long time. She was shivering, and she said she was freezing, her hands were cold. It was cold out .She had on khaki pants, a blouse, and a cardigan. I turned the heat on in the truck and she said that felt good. We took her up to [named brother-in-law's] house . During a telephone interview on 10/19/2022 at 9:30 AM, Family Member #2 confirmed she saw Resident #4 walking on Highway 51 toward Curve Nankapoo Road. She stated, .I thought it was odd that an older woman was walking on the highway that time of day, it was near sunset, around 6:00 [PM]. We were on our way to a cookout; it was cool that night. I didn't put it together until I talked with [Named Resident in Facility], and she told me [Named Resident #4] had gotten out of the facility and walked to Curve Nankapoo Road .that's when I realized I had seen her .she had pants and a sweater on, and she was walking steadily at a normal pace . During an interview on 10/20/2022 at 8:45 AM, the Interim DON, looked at her phone and confirmed she had received a text message from LPN #1 at 6:21 PM, on 10/8/2022. She confirmed LPN #1 asked her what the protocol for elopement was. She confirmed LPN #1 didn't know where the Elopement book was. She confirmed she and the Administrator were responsible for the elopement investigations. She was asked if they drove the possible routes to Curve Nankapoo to determine the distance Resident #4 had walked. She stated, .I know she [the Administrator] spoke with the person who brought her back. I've just been hearing bits and pieces . She confirmed anyone who had any knowledge of the circumstances surrounding the elopement should have been interviewed and written a statement. b. The following is related to the 10/18/2022 elopement of Resident #4: Review of an Incident Report dated 10/18/2022 at 8:15 AM, revealed, .Resident Elopement .on 10/18/2022 at approximately 8:15am [8:15 AM] [Named Police Officer] from the [NAME] Police Department was brought to my office and stated that one of our residents .was at a local business called [Named Tobacco Store]. At this time I told the nurse to notify the family and a staff member was sent to the business. Dispatch notified [Named Police Officer] that the resident was being transported to the [Named Hospital] due to being cold and having a pacemaker. [Named Medical Director] was notified. The resident has a BIMS score of 6 and was believed to have climbed out of her room window. She crossed over Washington street. The temperature was around 42degrees [42 degrees]. She was wearing pants, a top, and shoes. She is now back at the facility with no injuries, skin intact. Staff was In serviced on elopement, meal deliver, exit seeking . Observation of the tobacco store video surveillance footage reviewed by the surveyor at the tobacco store revealed the following timed events occurred on 10/18/2022: 7:43 AM - Resident #4 was walking from the direction of the facility up Washington Street. Resident #4 did not check traffic and walked across the busy intersection toward the Tobacco Store. 7:45 AM - Resident #4 entered the Tobacco Store and told the clerk she had been kidnapped. 7:56 AM - The police arrived and asked her name and where she lived, asked for identification. She had no form of identification. 7:57AM - police called for paramedics to come and evaluate her. 8:07 AM - Paramedics arrived. 8:09 AM- 2 emergency personnel assisted her to the stretcher and took her out to the ambulance. Review of an EMERGENCY DEPARTMENT PHYSICIAN RECORD dated 10/18/2022 at 8:27 AM, revealed, .Patient brought in by EMS [Emergency Medical Service], she had reportedly wandered away form [from] the nursing home during the middle of the night. Patient suffers from significant dementia .Clinical Impression .Dementia .Pt [Patient] reportedly eloped from the nursing home .Discharge .Condition .Stable .Emergency Care Record .Patient does state that she was kidnapped and held hostage at a school this morning . During an interview on 10/18/2022 at 1:42 PM, LPN #4 confirmed she had not had an elopement drill or abuse, neglect, or elopement in-services since she started working in the facility. She had only signed some papers and had nothing in depth. She confirmed she got to the facility this morning around 6:00 AM and started doing her rounds on A Hall. She stated, .I didn't know anything about the elopement until I saw the officer [police] here . During an interview on 10/18/2022 at 2:08 PM, CNA #3 confirmed she was working this morning when Resident #4 eloped. She stated, .I got here about 6 AM, and I saw her sitting up in a chair near the top of the A hall in front of the nurse's station. She was dressed and had shoes on .I don't remember exactly what clothes she had on .We started passing trays around 7 [AM], and I actually took her breakfast tray in her room. She wasn't in there, I kept passing trays .the police came in we didn't know why he was here, and that's when we found out she was gone. I feel bad. I should have told the nurse she wasn't in there. She walks so much. I'm just glad she was ok . She was asked if a code W was ever called this morning for her elopement. She stated, Nope. During an interview on 10/18/2022 at 2:36 PM, CNA #4 confirmed she was working this morning when Resident #4 eloped. She stated, .I got here at 5:50 AM, and she was standing near the nurse's station at the top of A hall. I spoke to her, she said she was chilly. I guess she went back to her room, and that was the last time I saw her. Trays come out at 7 [AM]. Before, I would make a round on my section, but today we didn't know where we would be because there were only 2 of us. So, we decided to work together to pass the trays. As we went into each room, we pulled residents up in bed, set the trays up for them. We finished A hall, then went to B hall. There was a resident that had to be fed .By the time I finished feeding her, all the hall trays had been passed. By the time I finished picking up trays on B hall, I saw the police in the building. Before that, we had no idea she was missing . She was asked if she received extra training today. She stated, Not today. During an interview on 10/19/2022 at 10:50 AM, the store manager stated, .she was freezing, shivering, we put a jacket on her and got her something to drink. She was scared and kept looking at the door. She had on light pants, slip-on black shoes, a pink shirt, and a dark gray sweater. She said she was held in a basement of a school building, and she escaped, she crawled out a window. She had mud on her pants, on the knees of her pants, like she had fallen. She said her name .she said they didn't hurt her. She said she had not gotten in a car. She said she had a son but didn't know his phone number. She had a few scratches on her hands. She had no form of ID [identification], no bracelet or any type of band . The store manager was asked if anyone from the facility had come to interview her and get her statement. She stated, No, Ma'am. And no one called me either. I called to check on her and [named social worker] said it wasn't my concern. During an interview on 10/19/2022 at 1:00 PM, Housekeeper #1 confirmed she had not been in serviced on abuse, neglect, or elopement in the last 2 weeks. During an interview on 10/19/2022 at 1:07 PM, LPN #5 was asked what code is called when there is an elopement. LPN #5 stated, L. LPN #5 was asked if training was provided on how to use the Elopement book. LPN #5 stated, No, Ma'am. During an interview on 10/20/2022 at 11:29 AM, the Administrator was asked if she retraced the route Resident #4 had taken to get to Curve Nankapoo Road and measured the distance. She stated, I didn't. She confirmed she did not get the Brother-in-Law to write a statement. She was asked if she interviewed the neighbor who found her and took her to her Brother-in-Law's house. She stated, I didn't know about that, I don't know that story . She was asked if she had identified any problems after the elopement. She stated, I want to say we did. She was asked what percent of staff should be educated about elopement procedures. She stated, .should be all. She confirmed she wasn't aware that all staff didn't know the code called for an elopement is Code W. She confirmed she wasn't aware staff didn't know where the Elopement book was. She was asked if she had gotten statements from CNA #1, CNA #2, CNA #3, and CNA #4. She stated, I'm not sure. She was asked if she should have obtained statements from staff on every shift surrounding the incidents of elopement. She stated, Yes, Ma'am. She was asked when she became aware Resident #4 had eloped on the morning of 10/18/2022. She confirmed she was made aware by the police officer who came to the facility that morning and told her Resident #4 had been found at the tobacco store. The Administrator was asked if her investigation included Resident #4's appearance, and the condition of her clothes. She stated, No, they changed her clothes. She was asked if she interviewed the Manager at the tobacco store or reviewed the video surveillance footage. She stated, No Ma'am. She confirmed she had sent the Business Office Manager to the store to check on Resident #4. She confirmed the Business Office Manager should have parked her car, checked on the resident, and gone into the store to interview the store Manager. She was asked if the facility did thorough investigations of Resident #4's elopements. She stated, No, Ma'am.

Based on facility documents, grievance complaint, Investigation report, policy review, medical record review, observation and interview, the facility failed to ensure residents were free from abuse, neglect and mistreatment by facility staff for 5 of 13 (Residents #16, 45, 55, 57 and 61) residents reviewed in the stage 2 sample review. The failure of the facility to ensure residents were free from mistreatment and neglect resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 57 and 61 and psychological harm to Resident #55 as evidenced by a tearful, emotional response during interview. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F224-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE], and is ongoing The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse-Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Psychosocial harm-Include but not limited to extreme embarrassment, ongoing humiliation, degradation as a human being .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident . 2. Review of the Dignity and Respect policy documented, .It is the policy of this facility to treat each resident with respect . the staff shall display respect for residents when speaking with, caring for, or talking about them . 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's note dated [DATE] at 8:00 PM, was errored out with a line through the documentation indicating it as incorrect. Review of the [DATE] at 8:00 PM, nurse's note written by Licensed Practical Nurse (LPN) #7 revealed, incorrect documentation (error) . Called to resident's room by CNA (Certified Nursing Assistant). Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head. With the assitance (assistance) .of the CNAs, we laid the resident in the floor. This nurse felt for a pulse, listened for breathing and heartbeat. At this time, another nurse called the DON (Director of Nursing) while this nurse and CNAs transferred resident to the bed. DON was called at 8:10 PM. MD (Medical Doctor) notified at 8:28 pm. Resident was bathed and dressed by CNAs. The DON's note dated [DATE] at 8:15 PM, was errored out as incorrect documentation. Review of the [DATE] DON's note for 8:15 PM, revealed incorrect documentation (errored out with a line through the documentation indicating it as incorrect) revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM, spoke to RP (Responsible Party) request that (named funeral home) be called to transport body to funeral home Review of LPN #7's revised documentation revealed [DATE] at 9:00 PM, .Called to resident's room by CNA. Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard. With the assistance of CNAs, we laid the resident in the floor. This nurse assessed for pulse, breathing and heartbeat. None was found. As this time, another nurse called the DON while the resident was transferred to bed. DON called at 8:10 pm. MD notified at 8:28 pm. Resident was bathed and dressed by CNAs. On [DATE] at 1:25 PM, the Administrator was asked for all facility investigations conducted from [DATE] to the present date. The Administrator was unable to provide documentation of any incidents from [DATE] to present. Interview with Confidential Interviewee (CI) #7 on [DATE] at 8:01 AM, by telephone, CI #7 was asked what she knew of Resident #16's death. CI #7 stated, I was not a part of that scenario, I came in to work the following day and I heard about the situation, and when I went to the morning meeting I said to (named DON) State will be in because this is reportable. Is there anything you want me to be checking on, since we have to do a reportable and we're in our window. They will probably come on in. She said 'What do you mean state will be here?' And I said, with that reportable. And she said, 'That's not a reportable. She said after their investigation (she and the Administrator) they determined it was not reportable .Well, they came in that night after the incident happened and started their investigation .I don't know what their investigation involved but I felt like after reading that note that it was a reportable . Interview with CI #8 on [DATE] at 5:32 PM, in the conference room, CI #8 was asked if she knew of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often they check the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the DON came in that night. CI #8 stated, Yes, and the Administrator. CI #8 began to cry. CI #8 was asked if Resident #16 had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked about the maintenance supervisor. CI #8 stated, That was his mom. CI #8 was asked what happened when the resident was found. CI #8 stated, .(Named nurse) was here, and she came around there and checked her. We put her on the bed .I'm trying to think who all was here, we put her on the bed .before the DON arrived. CI #8 was asked if she told the Administrator and DON what happened. CI #8 stated, I told them what had happened. CI #8 was asked if she told them that Resident #16's head was caught in the side rail. CI #8 stated, Yes, and that her legs were on the floor. CI #8 was asked if the resident was in the bed when the DON came. CI #8 stated, Yes. CI #8 was asked if she told both the Administrator and the DON. CI #8 stated, They questioned me. CI #8 was asked if she had been told to not tell anyone. CI #8 stated, I wrote a statement. CI #8 was asked if she wrote what she saw. CI #8 stated, Yes. CI #8 was asked to whom was the statement given. CI #8 stated, (named DON). CI #8 was asked if Resident #16's head was in her normal position (since the resident had kyphosis (rounded upper back)). CI #8 stated, When we got her off the floor it was in normal position. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked how long had it been since staff had seen her last. CI #8 stated, It had been 2 hours .I was going, into her room. CI #8 was asked what time this occurred. CI #8 stated, (she was) put .to bed after supper. It was between 8 and 8:30, I think. CI #8 was asked if the resident was on the bed when the DON got there. CI #8 stated, Um hum (yes). CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair was on the side of the bed that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 was asked who were the other staff there that night but she could only remember CNA #5. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 was asked how Resident #16 was found. CI #12 stated, Whenever I walked in the room the right arm and her head was right there-the side rail things-her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked if she had said her bottom was not touching the floor. CI #12 stated, Right. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up, making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if she had been told not to tell anyone about the incident. CI #12 stated, Um, in all honesty, until we talked to the Administrator and DON we were told not to talk to anyone about this . CI #12 was asked if she had given a written statement. CI #12 stated, Yes. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked what happened next. CI #10 stated, we got her to the floor. CI #10 was asked if there was a pulse. CI #10 stated, No .she was a DNR (do not resuscitate) .I had the nurse check for me. CI #10 was asked if Resident #16 was breathing. CI #10 stated, No. CI #10 was asked what happened then. CI #10 stated, While the nurse was gone I checked for vital signs. Myself and a couple of aides transferred her back to the bed. Then the other nurse called (named DON) because we have to have a RN (registered nurse) to pronounce .(LPN #1) also notified the family .I notified the doctor . CI #10 was asked what she had told the doctor, if she had told him how she was found lying. CI #10 stated, Just that she had passed. CI #10 was asked if anyone called the Administrator. CI #10 stated, I did not but I believe (named DON) did. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if she filled out a written statement. CI #10 stated, Yes ma'am. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked if she knew if the son was aware of the incident. CI #10 stated, No ma'am .I was told (named Administrator) told him. CI #10 was asked if the Administrator and DON came into the facility that night. CI #10 stated, Yes ma'am. CI #10 was asked how Resident #16's face was turned when she was off the bed. CI #10 stated, It was turned to the right toward the headboard. CI #10 was asked if the resident's bottom was touching the floor. CI #10 stated, Yes ma'am. CI #10 was asked to describe how her legs were positioned. CI #10 stated, They were stretched out in front of her .her geri chair was between her chest of drawers and the bed .her legs were under the geri chair .the aides picked up the geri chair .her legs were straight. CI #10 was asked if Resident #16's neck was in a normal position for her. CI #10 stated, It was down and turned . CI #10 was asked if Resident #16 had contractures. CI #10 stated, She did, most of the time she was a wiggle worm. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here, but before. CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. The DON interrupted the interview (by walking into the room) with CI #10 at this point. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was informed that the survey team had asked for all investigations. The facility was unable to provide an investigation of the circumstances of the death of Resident #16. The DON was asked if an unexplained death is to be reported to the State. The DON stated, Yes. The DON was asked if they had any unexplained deaths in the facility. The DON stated, No. The DON was asked if she was present the night of (Resident #16's) death. The DON stated, I was, after she passed away. The nurse called and said (Resident #16) doesn't have any respirations and I can't find a pulse. I said is she a DNR. She said yes and I told her I was on my way. The DON was asked if she always comes in if a resident expires. The DON stated, Since my other RN resigned, I have to come in. The DON was asked what happened after she arrived. The DON stated, I checked her. She had expired. I didn't call the doctor or the family. I don't remember if I called or if other staff called. I asked what happened. Course it was her birthday. It looked like she had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if Resident #16 had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left. The DON was asked if there was an investigation. The DON stated, No, I just asked them what was going on and what happened. The DON was asked if she had any witnesses write a statement. The DON stated, (named assigned nurse) put her statement in .the computer. Two other ladies made statements. The DON was asked if there were just 2 statements made. The DON stated, Yes, (named assigned nurse) put hers in the computer. The DON was asked if there was any further investigation. The DON stated, No. The DON was asked if the Administrator came to the facility that night. The DON stated, Yes, he came to talk to (named Resident's son). The DON was asked if it was normal for the Administrator (that lives 70 miles away) to come to the facility when there is a death. The DON stated, No, but him and (named son) are pretty close so he wanted to make sure (named son) was ok. The DON was asked if Resident's son was aware that she was found on the floor. The DON stated, Yes. The DON was asked what time she arrived. The DON stated, I have no idea. I'm sorry. The DON was asked what time the Administrator arrived. The DON stated, It wasn't too long after I did. The DON was asked who called the Administrator. The DON stated, I did. The DON was asked what she told the Administrator. The DON stated, That (named son's) mom had passed away. The DON was asked why she thought the nurse's note that was marked out was incorrect documentation. The DON stated, Because the way she had explained .was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. The DON stated, There is only this much space between (holding fingers up to show the amount of space) . To clarify what the DON had said, the surveyor asked, do you mean LPN #7 could not demonstrate the position Resident #16 was found without placing her head between the side rails. The DON shook her head and stated, Exactly, because it was impossible .I looked at the mattress and the rail. Nothing could fit between the mattress and the rail. You can't squeeze it .They would have to forcefully remove her and that is not what the nurse said. It was impossible. The facility's failure to identify and investigate the circumstances of Resident #16's unexpected death resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents in the facility. 4. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Anxiety Disorder, Kyphosis (outward curvature of the spine), Major [MEDICAL CONDITION], Contracture of the Knee and Hip, and Dementia with Behavioral Disturbances. Record review revealed the resident had a fall from the bed on [DATE]. The resident scooted too close to edge of bed and rolled off. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, was asked about problems with Resident #45's care. CI #4 stated, .I told them (staff) you can't jerk (her clothes off) cause you will break her legs .she is so little. CI #4 was asked who she had said this to. CI #4 stated, (Named CNA #1) .the DON said 'she (Named CNA #1) hires and she fires them.' .She (Named CNA #1) came in there and got ready to lay her down. She didn't lay her down, she throwed her down. She (Named CNA #1) was mad cause she (Resident #45) had .her clothes on. They didn't want her to have clothes on .They (staff) stand right outside the room pointing to the door and listen .(Named nurse) told her that she ( Resident #45) was not supposed to have clothes on. She (Named CNA #1) got so mad and threw the chair around so fast. (Named CNA #1 said) 'There is no problem with that woman anyway' .She took her (Resident #45) out of the chair and threw her in the bed .There are about 3 of them that don't care about these people .If they were a little more caring they might be alright but right now, no ma'am .I don't want her (Named CNA #1) in there . Interview with CI #1 on [DATE] at 1:45 PM, in the conference room, CI #1 stated, The DON and Social Worker (SW) are very close and they cover for each other .(CNA #1) jerked (the resident's) chair .was rough. CI #1 was asked if she was rough handling or talking to Resident #45. CI #1 stated, Both .this is about the 4th incident that I have had with her .on [DATE] (resident) had a scratch on her leg. (Named family member) talked to the DON about it .CNA #1 was the CNA (assigned to her at the time of the scratch). CI #1 stated, .was told (the resident) fell out of the bed during the night. (Resident #45) is immobile .hasn't walked for a year and a half .my fear is that they know I am in here talking to yall (survey team). I have found CNA #1 openly hostile .CNA #1 carries a lot of power and she can be vindictive . Interview with CI #3 on [DATE] at 5:55 PM, in the conference room, CI #3 was asked about the care for Resident #45. CI #3 was asked if she had seen anyone be rough with the residents. CI #3 stated, Oh yes, turning them and pulling their clothes off .I know (CNA #2), I have seen her .(Resident #45) had a big scratch on her leg and we asked how she got the scratch on her leg. (CNA #1) had the 2 of them (Resident #45 and Resident #61- roommates) that day . CI #3 was asked what she has seen that she considers rough. CI #3 stated, They just take her back and push her over and she hollers, 'Oh! Oh!' They be trying to turn her and clean her. You can hear the bed go boom, boom (bed hitting against the wall) . Interview with CNA #1 on [DATE] at 1:04 PM, in the conference room, CNA #1 was asked regarding complaints against her care of Resident #45. CNA #1 stated, She said we didn't take care of her. And I said 'Yes we do.' The DON told me not to take care of Resident #45 anymore, to keep the chaos down . CNA #1 was asked how many people it takes to put (Resident #45) in the bed. CNA #1 stated, One .I set her chair up and grab her under the arms and transfer her over to the bed. CNA #1 was asked if Resident #45's feet touch the floor. CNA #1 stated, No ma'am . CNA #1 was asked if Resident #45 moans when she puts her in the bed. CNA #1 stated, Sometimes. Interview with CI #1 on [DATE] at 3:42 PM, by telephone, CI #1 was asked to whom she reported her concerns. CI #1 stated, Which time .I talked to the SW. CI #1 was asked if she ever reported that some one was rough with Resident #45. CI #1 stated, Yes. (CNA #1) was rough . CI #1 was asked who she reported the rough treatment to. CI #1 stated, (Named DON) because that is why I did not want (CNA #1) back in the room. CI #1 was asked exactly what the rough treatment was. CI #1 stated, Jerking on her clothes . CI #1 stated, I told her CNA #1 was very rough .Her attitude was very short with her and this was not the first time she was uncooperative . CI #1 was asked if she had ever witnessed them in the room, talk over the residents. CI #1 stated, I have heard her say, 'I don't have time for that.' 'That's not my job' .She is very short with people . CI #1 was asked if they had a concern, did she feel like it would be addressed. CI #1 stated, .DON or Administrator- No I do not. I believe they will tell me that it has been. CI #1 stated, .There have been 3 occasions since Christmas. (The resident) had a large scratch on .face, and then .fell out of the bed, and then there was (the skin tear on her leg) .But no one knows how they happened. I don't know nothing has been done. No one has gotten back to me. They didn't say, oh, (the resident) must have slipped .It is very frustrating that (the resident) keeps having accidents and no one knows anything about it . Review of the nurses notes for [DATE], [DATE], February 2017, [DATE], and [DATE] revealed there was no documentation of these injuries. Interview with the DON on [DATE] at 10:12 AM, in the conference room, the DON was asked for the investigations for the 3 incidents related to #45's related to the fall, the skin tear and the scratch the resident sustained [REDACTED].There was no investigation or documentation of a scratch . Interview with the Administrator on [DATE] at 7:30 PM, in the conference room, the Administrator had been asked for an incident report and investigation for a scratch to Resident #45's face some time after Christmas. The Administrator stated, There were no incidents on a scratch on Resident #45's face since Christmas. Interview with CI #16 on [DATE] at 10:54 AM, in the DON office, CI #16 was asked if Resident #45 had more incidents since the surveyors were in the facility. CI #16 stated, .She has had on ,[DATE] a bruise on her left forearm and an abrasion on left shin. An abrasion on right forearm on ,[DATE] from the body audit we did that day. CI #16 was asked about something on her thigh. CI #16 stated, Skin tear to the left thigh on ,[DATE] .her frail skin it would be torn easily. The facility failed to ensure Resident #45 was free from mistreatment when staff were allowed to handle her roughly and not meet her needs. 5. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] and quarterly MDS dated [DATE] revealed Resident #55 was cognitively intact. Observations in Resident #55's room on [DATE] at 4:42 PM, revealed Resident #55 lying in bed. Resident #55 stated, I stay in bed, I can't walk . Interview with Resident #55 on [DATE] at 4:42 PM, in the resident's room, the resident was asked if she could tell the surveyor about a time when she was mistreated or someone spoke harshly to her while in the facility. The resident stated, .I've been treated okay since y'all came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . The resident was asked who said those things to her. The resident stated, DON. The resident was asked what the DON said. The resident stated, One time .She said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, Mr. (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident) she's getting too big and you need to stop bringing her pizza .I don't hate this place just the people that were here . The resident was asked if anyone here now mistreats you. The resident stated, No ma'am, I've not seen those people since y'all been here so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful and agitated during the interview and apologized for becoming so upset. Interview with CI #5 on [DATE] at 9:04 AM, CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry. CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me (Named Resident 55) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on [DATE] at 2:59 PM, in the DON office, CI #16 was asked what were her expectations when a resident is tearful. CI #16 stated, I would expect that they would address and identify what was causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility provided appropriate care and services to prevent verbal abuse of Resident #55. The failure to provide an environment free from retaliation and mistreatment resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON. 6. Medical record review revealed Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] and the annual MDS dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident had severe cognitive impairment. The care plan revised on [DATE] documented, Focus .COMMUNICATION problem r/t (related to) [MEDICAL CONDITIONS]([MEDICAL CONDITION]) .Intervention .Allow adequate time to respond .Do not rush .Resident is able to answer simple yes and no questions. Does well when given word/answer options . Interview with CNA #2 on [DATE] at 7:32 AM, in the Conference Room, CNA #2 was asked if there are residents that certain CNAs are not to assist with. CNA #2 stated, Named (Resident #57) I was told to not go back into that room . left her wet . A phone interview with CI #15 on [DATE] at 2:11 PM, was asked if they were having problems with the staff. CI #15 stated, (Resident #57) doesn't want her (CNA #2) in the room, she will say no, no, no she's mean .I was the one to go ask for her (referring to CNA #2) not to go in her (Resident #57) room . CI #15 when you asked for CNA #2 not to go back into her room did they do anything. CI #15 stated, Not to my knowledge . CI#15 stated, I know something happened . A phone interview with CI #17 on [DATE] at 2:45 PM, CI #17 was asked have you voiced your concerns about staff to anybody. CI #17 stated, Nurses .got no reaction .right after Memorial Day 2016 I called Corporate office .the lady on the phone asked why I didn't take the complaint to the nurse and I said the complaint is about the nurse and she said oh . CI #17 was asked do you feel like anybody here in management address or listens to your concerns. CI #17 stated, (management) just rolls their eyes . Interview with the Administrator on [DATE] at 10:00 AM, in the Administrator's office, the Administrator was asked have there been any complaints about handling residents' rough. The Administrator stated, Not directly to me . Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of [DATE], [DATE] and [DATE] regarding Resident #57. Interview with the Social Worker (SW) on [DATE] at 10:33 AM, in the conference room, the SW was asked if there were any complaints or grievances for the month of November and December. The SW stated, No. The SW was asked if there were only five complaints and grievances for the month of January, only one complaint and grievances for the month of February, only one complaint and grievance for the month of March and only four complaints and grievances for the month of April. The SW stated, Yes. The SW was asked what type of complaint would be put on the complaint log. The SW stated, .call lights, food issues, staff members . The SW was asked would any complaint big or little go on the complaint log. The SW stated, Yes, if I know about it . The facility failed to ensure Resident #57 was free from mistreatment when the staff were allowed to handle her roughly and not meet her needs. 7. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #61 was severely impaired cognitively and required extensive assistance for all ADLs. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 was asked about Resident #61. CI #4 stated, .There are

Based on review of the Administrator's job description, review of the Director of Nursing's job description, review of the Medical Director's Contract, employee personnel files, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized residents were free from verbal, physical, and mental abuse, psychosocial harm, neglect and mistreatment and failed to complete and thoroughly investigate and report allegations of abuse, neglect, mistreatment, injuries of unknown origin and unexpected death to the state agency. Failure of the facility to ensure residents were free from verbal, physical, and mental abuse, psychosocial harm, neglect and injuries of unknown origin and an unexpected death resulted in Immediate Jeopardy (IJ) for Resident #16, 45, 57. and 61 The QA committee failed to ensure the Residents were free from mistreatment and neglect by staff when the facility failed to implement their abuse prevention policy and procedure to perform an Abuse Registry check on 2 of 2 (family paid sitters) sitter files reviewed and a reference check on 1 of 11 (Certified Nursing Assistant (CNA) #1) employee files reviewed. Failure of QA to implement the abuse policy resulted in IJ for Resident #16, 45, 57, and 61 and psychological harm to Resident #55. The facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented and monitored appropriate plans of action to correct issues. The failure of the facility to prevent abuse, investigate allegations of abuse, mistreatment, injuries of unknown origin, and report the investigations to the state agency resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 57, and 61 and psychological harm to Resident #55. Immediate Jeopardy is a situation is which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Regional One Nurse Consultant were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F221-J, F224-K, F225-K,F226-K, and F323-J which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The Administrator's Job Description & (and) Orientation Checklist documented, .Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain excellent care for the residents while achieving the facility's business objectives .Ability to promote positive relationships with residents, visitors and government regulators .Directs and coordinates medical, nursing and administrative staffs and services .Conducts regular rounds to monitor resident needs are being addressed .Understands, complies with and promotes all rules regarding Residents' Rights . 2. The Director of Nursing Job Description & Orientation Checklist documented, .To manage overall operation of the Nursing Services department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all the Residents' needs .Ability to promote positive relationships with residents, visitors and government regulators .Monitor department activities, communicate policies .Assess resident's physical and psychosocial status .Monitor .established standards and facility policies .Monitor associate relations practices to ensure practices that maintain high morale and staff retention .Understands, complies with and promotes all rules regarding Residents' Rights .Report all accidents and incidents . 3. The AGREEMENT FOR MEDICAL DIRECTOR documented, .As Medical Director, Physician shall be responsible for the overall coordination of the medical care delivered to the residents of the Facility .Participate in appropriate meetings including but not limited to .Quality Assurance Committee meetings . 4. Interview with the Administrator on [DATE] at 6:58 PM, in the Administrator's office, the Administrator was asked what were his expectations of staff related to abuse. The Administrator stated, To provide and facilitate an abuse free environment and to report on allegations of abuse, neglect and mistreatment . The Administrator was asked what his responsibilities were as Administrator. The Administrator stated, .to oversee the day to day operations of the facility and act as the managing director of this facility and provide oversight to administrative operations departments as well as other department. The Administrator was asked if Resident #61's death should have been reported to the Department of Health. The Administrator stated, Based on the information that I received and after contacting my, uh, superior, in that situation it was not deemed to be reportable. The Administrator was asked when the last time the Medical Director attended a QA meeting. The Administrator stated, .January, I think was the last one he was at, yeah it was January. The Administrator was asked if he could provide the sign in sheet. The Administrator stated, Yeah that's what I'm looking for, I don't see it .I can't provide anything that he has signed. The Administrator looked back through his notes to June of 2016 and there was no documentation the Medical Director attended a QA meeting back to [DATE]. The Administrator was asked if he thought he had an effective QA program. The Administrator stated, Yes. The Administrator was asked if the facility should implement their policies on screening, training, prevention, identification, investigation, protection and reporting abuse. The Administrator stated, Yes. The Administrator was asked if it was acceptable to not follow their policy. The Administrator stated, No. The Administrator was asked should a Kiosk be left unattended with Residents information within view. The Administrator stated, No. The Administrator was asked if that would be a HIPAA violation. The Administrator stated, Yes. The Administrator was asked if that was acceptable. The Administrator stated, No. The Administrator was asked if there should be expired foods in the resident's refrigerator. The Administrator stated, No. The Administrator was asked if the resident's care plan should be followed. The Administrator stated, Yes . 5. The QAA failed to provide the appropriate liability and appeal notice. Refer to F156 6. The QAA Committee failed to ensure resident's were free from any physical restraints. Refer to F221 7. The QAA Committee failed to protect residents from psychological harm. Refer to F223. 8. The QAA Committee failed to protect residents from mistreatment, neglect and/or misappropriation. Refer to F224. 9. The QAA Committee failed to ensure a complete, thorough, and timely investigation was conducted for all allegations of abuse, neglect, mistreatment and injuries of unknown origin, failed to ensure the allegations were reported to the appropriate state officials and failed to ensure reference checks were performed on all staff. Refer to F225. 10. The QAA Committee failed to implement written policies and procedures that protected the residents from abuse/further abuse, neglect, mistreatment and injuries of unknown origin. Refer to F226. 11. The QAA Committee failed to ensure residents were treated with dignity and respect Refer to F 241 12. The QAA Committee failed to accommodate individual needs by providing daily care consistent with the resident's desire for not being awakened early in the morning. Refer to F246 13. The QAA Committee failed to ensure a resident's care plan was followed. Refer to F 282 14. The QAA Committee failed to ensure Activities of Daily Living (ADL) related to baths/showers were performed. Refer to F 312 15. The QAA Committee failed to ensure residents that were fed by enteral means received the appropriate treatment and services to prevent complications of the enteral feeding. Refer to F 322 16. The QAA Committee failed to ensure residents were free from accident hazards. Refer to F 323 17. The QAA Committee failed to provide treatment for [REDACTED]. Refer to F 328 18. The QAA Committee failed to ensure medications were properly stored during medication administration as medications were unattended and out of sight. The deficient practice for F431 is a repeat deficient and was cited on the recertification survey on [DATE]. Refer to F 431 19. The QAA Committee failed to ensure practices to prevent the potential spread of infection were maintained. The deficient practice for F441 is a repeat deficient practice and was cited on the recertification survey on [DATE]. Refer to F 441 20. The QAA Committee failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, by failing to ensure all residents were safe and protected from abuse. The Administration failed to ensure complete and thorough investigations. The Administration failed to implement their written policies and procedures. The Administration failed to ensure staff members were knowledgeable on abuse procedures. The Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections. The Administration failed to recognize an ongoing concern with allegations of abuse, neglect and mistreatment, injuries of unknown origin and accidental death, which resulted in IMMEDIATE JEOPARDY (IJ) for Resident #16, 45, 57 and 61. Refer to F490 21. The QAA Committee failed to ensure the Medical Director implemented resident care policies related to allegations of abuse, neglect, mistreatment and injuries of unknown origin. Refer to F501. 22. The QAA Committee failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of correction which placed residents in Immediate Jeopardy.

Based on the Medical Director Agreement, facility policy review, medical record review, observation and interview, the Medical Director failed to ensure the implementation of resident care policies, ensure residents received appropriative care in a safe environment, ensure all allegations of abuse, injuries of unknown origins and accidental/unusual deaths were thoroughly investigated and reported to the proper authorities resulted in a SERIOUS and IMMEDIATE THREAT to the health, safety and well-being of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, #45, #61, and #57 and psychological harm to Resident #55. Immediate Jeopardy is a situation is which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F221-J, F224-K, F225-K, F226-K, and F323-J which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's AGREEMENT FOR MEDICAL DIRECTOR documented, As Medical Director. Physician shall be responsible for the overall coordination of the medical care delivered to the residents of the Facility .Assist in the development of policies and procedures to govern nursing, medical and other health related services provided .Review accident and/or incident reports to identify potential hazards to health and safety at the facility and recommend and/or consult with Administrator regarding elimination of the same .participate in appropriate meetings .Quality Assurance Committee meetings .review and take appropriate action on reports from the Director of Nursing regarding significant clinical issues. 2. Interview with the Medical Director (Med.Dir.) on [DATE] at 3:33 PM, by telephone, the Med.Dir. was asked how often he visited Lauderdale Community Living Center. The Med.Dir. stated, At least twice a month . The Med.Dir. was asked what his responsibilities were for the facility. The Med.Dir. stated, I'm the Medical Director. I talk to the Director of Nursing (DON) and their Director (Administrator) for any problem that happens. If there is a problem they let me know. I have patients there also. The Med.Dir. was asked who he reported to. The Med.Dir. stated, .mostly the Director (Administrator) or CO (Chief Officer) .I have been their director for some time XXX,[DATE] years, maybe more. The Med.Dir. was asked if he was informed of events, incidents, and accidents in the facility. The Med.Dir. stated, Yes, I am, on my patients, I am. The Med.Dir. was asked if he was informed about any other residents. The Med.Dir. stated, I don't think so. They have their own doctors. If they (the other doctors) can not be reached then the staff, they are supposed to call me. The Med.Dir. was asked if he attended the Quality Assurance (QA) meetings. The Med.Dir. stated, .I haven't attended any the last several months. I used to . The Med.Dir. was asked what input does he have into the QA meetings. The Med.Dir. stated, If they have issues, they tell me about that, but it has been some time now since I have been to one. The Med.Dir. was asked if he ever met with the Governing Body. The Med.Dir. stated, No ma'am . The Med.Dir. was asked what he knew about the death of Resident #16. The Med.Dir. stated, .You have discovered something wrong with that .I might have to go to my office and talk to my nurse practitioner to answer your questions. The Med.Dir. was asked if he was aware there were allegations that the resident's head was caught between the side rail and the mattress. The Med.Dir. stated, To the best of my knowledge I was not .Was this when she died or before that .so she was found like that? The Med.Dir. stated, I don't recall that. I do not recall at this point in time, but I would have to look at my records. Interview with the Med.Dir. on [DATE] at 3:19 PM, by telephone, the Med.Dir. was asked if it was necessary to have an order to use side rails. The Med.Dir. stated, I don't know. The Med.Dir. was asked if it was common for Registered Nurses to pronounce residents expired. The Med.Dir. stated, They can. The Med.Dir. was asked if there was a sudden unexpected death in a nursing home should he be notified. The Med.Dir. stated, If the physician (patient) is mine they notify me but if it is another's (another physician), I'm notified anyway because I'm the Medical Examiner of (named County). I hear about it any way. It is brought to my attention. Usually, if there is a primary care doctor then they inform them. I expect them to call me. The Med.Dir. was asked who should call him. The Med.Dir. stated, The nurse. The Med.Dir. was asked if that was because he was the Medical Examiner. The Med.Dir. stated, No, because I am the Medical Director there . The Med.Dir. was asked if he had been notified when Resident #16 had died . The Med.Dir. stated, I do not remember that. No ma'am. The Med.Dir. was asked if he should have been notified. The Med.Dir. stated, If something was unusual about it, they should call me .I just heard the story since you guys were here. I did not hear of it before that. 3. The Medical Director failed to ensure resident's were free from any physical restraints. Refer to F221 4. The Medical Director failed to ensure that the facility appropriate care and services necessary to avoid physical neglect, physical abuse, emotional harm, or death. Refer to F223 and 224. 5. The Medical Director failed to ensure that the facility followed policies to keep residents free from abuse, neglect, or mistreatment. The Medical Director failed to ensure allegations of abuse/mistreatment and injuries of unknown origins were investigated. The Medical Director failed to ensure staff thoroughly investigated accidental/unusual resident deaths. Refer to F225 6. The Medical Director failed to ensure that the facility implemented policies and procedures that protected residents from abuse, mistreatment and injuries of unknown origin. Refer to F226. 7. The Medical Director failed to ensure that the facility followed their policies and procedures regarding the proper administration of enteral tube feeding. Refer to F322. 8. The Medical Director failed to ensure the facility followed their policies and procedures regarding an effective Administration. Refer to F490. 9. The Medical Director failed to participate in Quality Assurance (QA) Committee meetings and ensure the facility followed their policies and procedures for an effective QA committee. Refer to 520.

Based on policy review, medical record review, observation, and interview, the Governing Body (GB) failed to provide oversight of the facility's operations and ensure residents received care in a safe environment. The GB failed to ensure policies were implemented to ensure residents were free from abuse, and mistreatment, and staff followed established policies in a manner that enabled the use of its resources effectively and efficiently to prevent abuse, neglect and mistreatment of [REDACTED]. The failure of the GB to provide oversight of the facility's operations resulted in a SERIOUS and IMMEDIATE THREAT to the health, safety and well-being of all residents and resulted in IMMEDIATE JEOPARDY to Residents #16, #45, #61 and #57, and psychological harm to Resident #55. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, DON, and Regional Nurse Consultant (RC #1) were notified of the IMMEDIATE JEOPARDY ON [DATE] AT 1:07 PM in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F221-J, F224-K, F225-K, F226-K, and F323-J which is Substandard Quality of Care. An extended survey was conducted on [DATE]. The IMMEDIATE JEOPARDY was effective [DATE], and is ongoing. The findings included: 1. Interview, by telephone, with the Vice President of Operations (VPO) on [DATE] at 5:17 PM, in the Conference Room, the VPO was asked what were the responsibilities of the Governing Body (GB). The VPO stated, We assist with developing policies and procedures, we hire the Administrators in the building, we provide oversight to the Administrator and provide resources. The VPO was asked how policies and procedures are distributed to the facility. The VPO stated, They are located on the computer system, it is a shared drive, an iDrive, as well as any time there is a new update we send it out by email, letting them know it has been added and attach the policy to the email. The VPO was asked to whom the Medical Director answered. The VPO stated, .the Administrator and the GB to a certain degree, but his contract is with the Managing Company. The VPO was asked if the GB was made aware of allegations of abuse, neglect and mistreatment in the facility. The VPO stated, No. The VPO was asked when she was made aware of these issues regarding abuse, neglect and mistreatment. The VPO stated, When the RNC #1 notified me .this week (week State Survey Agency was in the facility). The VPO was asked if the GB was aware of complaints that residents were being handled roughly or that staff was complaining of care provided to residents or degrading the resident in the residents' presence. The VPO stated, No. The VPO was asked if she should have been made aware of these issues. The VPO stated, If the residents felt that they were being degraded or mishandled, yes. The VPO was asked what incidents should be reported to the State. The VPO stated, .injuries of unknown origin, if there is no witness or if the resident's BIMS (Brief Interview of Mental Status) is 9 or below. The VPO was asked what were the expectations of the GB when an allegation of abuse, neglect, or mistreatment is made. The VPO stated, Once the allegation is made they're supposed to interview the resident, any witnesses, etc, notify me and the nurse consultant, so that we can go over it with them and make a determination on the injury of unknown origin, but all allegations of abuse have to be reported. The VPO was asked if she expected an investigation to be performed when they had an allegation of abuse. The VPO stated, Yes but the facility is supposed to continue the investigation and call us to decide if its exactly an allegation .if a resident made an allegation that someone hit me, that is an immediate. The VPO was asked if it is acceptable to not report an accidental death to the State. The VPO stated, If its an accidental death and not a natural causes death. The VPO was asked if she was a nurse. The VPO stated, I am a RN (Registered Nurse). The VPO was asked if it was acceptable to not report allegations of abuse, neglect, or mistreatment to the state. The VPO stated, No, allegations of abuse need to be reported. The VPO asked this surveyor, Do you need to ask me anything about the resident? The surveyor asked what resident she was referring to, The VPO stated, the accidental death .No, the natural causes death. They called me about it .(Named Administrator) .That night. The VPO was asked to tell this surveyor what she knew. The VPO stated, .they called me and basically one of the nurses had made a remark about the siderails, the DON was either at the building or on her way .I instructed the Administrator to go to the building .my questions were, had the siderail been assessed prior and he told me yes, the maintenance man has assessed all siderails prior to this event .it was his (the maintenance man) mother .He was there too that night and they explained to him how she was found and he did not feel that the siderail or any of that was a concern . The VPO informed this surveyor that they followed up with the coroner report and the cause of death was cardiac failure and based on assessments and the interviews they had at the time it was felt that she was getting up, had a [MEDICAL CONDITION], and fell landing, hitting the side rail. So based on the investigation it was felt like the siderail was not part of the death, but that she died and fell into that position. The VPO was asked why was there ever a question that she got caught in the siderail. The VPO stated, Because a nurse made a statement about the siderail then struck it out, she assumed before she investigated. The VPO was asked why the facility called her if they felt that Resident #16 died of natural causes. The VPO stated, One, because it was the maintenance man's mother and because the nurse made the statement about the siderail. My question to him was the nurses need to give an assessment, facts of what they seen but they don't need to make an assumption that it (her death) was caused by this, that or the other, because we don't know until we do an investigation. The VPO was asked if she told her (LPN # 7) to rewrite her statement since she felt it wasn't factual. The VPO stated, I just told them if it wasn't based on the facts, it just needs to be a factual note. Interview with the Administrator on [DATE] at 6:58 PM, the Administrator was asked what was the role of the Governing Body. The Administrator stated, They provide the oversight in management over the entity (facility) itself. The Administrator was asked how he kept them informed. The Administrator stated, As in, just day to day, that's a good question. In the past we have had conference calls and onsite visits. 2. The Governing Body failed to provide oversight and ensure resident's were free from physical restraints. Refer to F221 3. The Governing Body failed to provide oversight and ensure residents were protected from psychological harm. Refer to F223. 4. The Governing Body failed to provide oversight and ensure residents were protected from mistreatment and neglect. Refer to F224. 5. The Governing Body failed to provide oversight and ensure a complete, thorough, and timely investigation was conducted for all allegations of abuse, neglect, mistreatment and injuries of unknown origin, failed to ensure these allegations were reported to the appropriate State officials, failed to ensure the abuse registry and reference checks were performed on all staff prior to employment and failed to ensure the accidental/unusual death of a resident was thoroughly investigated and reported to proper authorities. Refer to F225. 6. The Governing Body failed to provide oversight and ensure written policies and procedures were implemented in order to protect the residents from abuse, neglect, mistreatment and injuries of unknown origin. Refer to F226. 7. The Governing Body failed to provide oversight of the facility's Administration to ensure the Administration followed written policies related to allegations of abuse, neglect, mistreatment and injuries of unknown origin, and protected residents from psychological harm. The Governing Body failed to ensure Administration conducted timely and thorough investigations related to abuse and accidents of unknown origin. Refer to F490. 8. The Governing Body failed to ensure the Medical Director implemented written resident care policies related to allegations of abuse, neglect, mistreatment and injuries of unknown origin. Refer to F501. 9. The Governing Body failed to ensure the QA program was effective in identifying issues and concerns related to abuse, neglect, mistreatment and injuries of unknown origin within the facility and maintaining plans of correction. Refer to F520.

Based on review of the Administrator's and Director of Nursing's job descriptions, policy review, medical record review, observation, and interview, the facility failed to be administered in a manner that enabled its use of resources effectively and efficiently to attain and maintain the highest practicable, physical, mental and psychosocial well being of each resident. Administration failed to ensure thorough and timely investigations of allegations of abuse, mistreatment, injuries of unknown origins, and of accidental and unusual deaths. The Administration failed to ensure all staff were trained and competent on the use of equipment per manufacturer's guidelines, and were knowledgeable of and implemented facility policies and procedures for the provision of resident care. The failure of Administration to assume responsibility for the care delivered by the staff to the residents, and ensure all residents received care in a safe environment resulted in a SERIOUS and IMMEDIATE THREAT to the health, safety and well-being of all residents and resulted in an IMMEDIATE JEOPARDY (IJ) to Residents #16, #45, #57, and #61 and psychological harm to Resident #55. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC #1) were informed of the IMMEDIATE JEOPARDY on [DATE] at 1:07 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F221-J, F224-K, F225-K, F226-K, and F323-J which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. Review of the Administrator's Job Description & (and) Orientation Checklist documented, .Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain excellent care for the residents while achieving the facility's business objectives .Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws .Ability to promote positive relationships with residents, visitors and government regulators .Directs and coordinates medical, nursing and administrative staffs and services .Conducts regular rounds to monitor resident needs are being addressed .Understands, complies with and promotes all rules regarding Residents' Rights . 2. Review of the DON Job Description & Orientation Checklist documented, .To manage overall operation of the Nursing Services department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all the Residents' needs .The DON will report directly to the administrator. The administrator delegates the administrative authority, responsibility and accountability necessary for carrying out the assigned duties .Is responsible for every aspect of the Nursing Department .Ability to promote positive relationships with residents, visitors and government regulators .Monitor department activities, communicate policies .Assess resident's physical and psychosocial status .Monitor care activities and documentation to ensure the delivery of nursing care according to the physician's orders [REDACTED].Communicate with residents, family members and management regarding resident status .Ensure compliance with State, Federal, and company QA (Quality Assurance) standards .Monitor associate relations practices to ensure practices that maintain high morale and staff retention .Carries out, coordinates, or manages assigned administrative functions .Understands, complies with and promotes all rules regarding Residents' Rights .Report all accidents and incidents . 3. Interview with the Administrator on [DATE] at 10:59 AM, in the Conference Room, the Administrator was informed that the State Survey Agency was looking into complaints of staff handling residents roughly, verbal abuse, and staff who were not allowed to go into certain resident's rooms. The Administrator was asked if these complaints should be on the facility's Grievance Log. The Administrator stated, If they make a formal grievance, yes, should be investigated. The Administrator was asked if he would suspend staff in this instance. The Administrator stated, After I talked to the family and determined .then I would suspend. The Administrator was asked if he expected injuries of unknown origin to be investigated. The Administrator stated, Yes, definitely, and that should come about with an I an A (Incident/Accident Report) .should go in the investigation . Interview with the Administrator on [DATE] at 10:00 AM, in the Administrator's office the Administrator was asked if an accidental death was a reportable event. The Administrator stated, Yes. The Administrator was asked if they had had any reportable events. The Administrator stated, Not to my knowledge. The Administrator was asked about Resident #16's death. The Administrator stated, She had passed when I came to see (named Resident #16's son.) The Administrator was asked what he knew of the death. The Administrator stated, When I got here she was back in the bed. Staff said she had passed. Staff said they had got her up out of the floor. The Administrator was asked if he took witness statements that night. The Administrator stated, I did talk to the staff. On [DATE] at 10:01 AM the DON was informed the survey team had asked for all facility investigations of any incident. The DON was asked if an accidental or unusual death had occurred in the facility, the DON stated, No. The DON stated she was in the facility the night of Resident #16's death. The DON stated it looked like Resident #16 had slid out of the bed after she expired, That's what we assumed . The DON stated this incident was not reported to the State. When the DON was asked if an investigation was done, she stated, There was nothing formal. I just asked them what happened . The DON stated she wrote the witnesses statements and the witnesses signed the statements. The DON was asked if there should have been an investigation. The DON stated, By investigation, do you mean getting the data, analyzing and doing to a conclusion? . I made the wrong decision . Interview with the Administrator on [DATE] at 6:58 PM, in the Administrator's office, the Administrator was asked what were his expectations of staff related to abuse. The Administrator stated, To provide and facilitate an abuse free environment and to report on allegations of abuse, neglect and mistreatment . The Administrator was asked what were his responsibilities as Administrator. The Administrator stated, .to oversee the day to day operations of the facility and act as the managing director of this facility and provide oversight to administrative operations department as well as other departments. The Administrator was asked to whom he reported. The Administrator stated, We haven't had a Director of Operations in a while but in times past I have reported to the Regional Director of Operations and also to the VP (Vice President) of Operations of our managing company. The Administrator was asked if Resident #16's death should have been reported to the State Department of Health. The Administrator stated, Based on the information that I received and after contacting my, uh, superior, in that situation it was not deemed to be reportable. The Administrator was asked when was the last time the Medical Director attended a QA meeting. The Administrator stated, .January, I think was the last one he was at, yeah it was January. The Administrator was asked if he could provide the sign in sheet. The Administrator stated, Yeah that's what I'm looking for, I don't see it .I can't provide anything that he has signed. The Administrator looked back through his notes to June of 2016 and there was no documentation the Medical Director attended a Quality Assurance (QA) meeting back to [DATE]. 4. Administration failed to ensure resident's were free from any physical restraints. Refer to F221 5. Administration failed to protect residents from psychological harm. Refer to F223. 6. Administration failed to protect residents from mistreatment and neglect. Refer to F224. 7. Administration failed to ensure a complete, thorough, and timely investigation was conducted for all allegations of abuse, neglect, mistreatment and injuries of unknown origin, failed to ensure the allegations were reported to the appropriate state officials and failed to ensure reference checks were performed on all staff. Refer to F225. 8. Administration failed to implement written policies and procedures that protected the residents from abuse/further abuse, neglect, mistreatment and injuries of unknown origin. Refer to F226. 9. Administration failed to ensure the Governing Body provided management and oversight of the facility. Refer to F493. 10. Administration failed to ensure the Medical Director implemented resident care policies related to allegations of abuse, neglect, mistreatment and injuries of unknown origin. Refer to F501. 11. Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of correction placed residents in Immediate Jeopardy. Refer to F520.

Based on policy review, employee file review, medical record review, and interview, the facility failed to identify abuse, investigate all allegations of abuse and mistreatment, report allegations of abuse, investigate injuries of unknown origin, investigate a resident death for possible entrapment, and provide a safe environment free of retaliation for 5 of 13 (Resident #s 16, 45, 55 and 57 and 61) sampled residents in the stage 2 review. The facility failed to ensure all residents were free of abuse, neglect and mistreatment by the failure to implement policies and procedures placed all residents in a SERIOUS and IMMEDIATE THREAT to their health and safety resulting in IMMEDIATE JEOPARDY (IJ) to Resident #s 16, 45, 57 and 61 and psychological harm to Resident #55, as evidenced by the tearful, emotional responses during an interview. Immediate Jeopardy is a situation is which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F226-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE]. The findings included: 1. Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy documented, .The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment, neglect, exploitation, and abuse of residents .The prohibition plan includes the following components .5. Investigation of allegations .6. Protection of the resident during investigations .7. Reporting and responding .The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Staff training policy documented, .how and when to report allegations without fear of reprisal .The facility management staff will receive training needed to provide good leadership, encourage teamwork, and promote a pleasant, safe environment . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, .Staff supervision for inappropriate behaviors during interaction with or care of residents .The facility will continue to make the work environment a pleasant and safe one for all employees so they may provide a pleasant and safe environment for the residents. Staff will be supervised to identify behaviors such as derogatory language: rough handling; ignoring residents while giving care .The facility administrator and or the Director of Nursing should review risk management reports at each administrative meeting to identify possible situations of abuse. This may include but is not limited to incident reports, including injuries of unknown origin and grievance reports . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan INVESTIGATION policy documented, .All injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated .The administrator and/or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of result to the proper authorities. Review of the Dignity and Respect Policy documented, .It is the policy of this facility to treat each resident with respect .the staff shall display respect for residents when speaking with, caring for, or talking about them . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's note dated [DATE] at 9:00 PM revealed LPN #7 was called to the resident's room. The LPN documented, .entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard The LPN documented the resident was without vital signs and expired. The following interviews were conducted via telephone and in the facility concerning the resident being found lifeless with her head between the side rail and mattress: On [DATE] at 8:01 AM Confidential Interviewee (CI) #7 stated they heard about the incident on [DATE]. CI #7 stated she told the DON this is a reportable incident. CI #7 stated the DON replied it was not a State reportable incident. CI #7 stated after reading the nurse's note, they felt like it was a reportable. On [DATE] at 5:32 PM CI #8 stated Resident #16 fell out of the bed and got hung in the side rails, with her legs on the floor and her neck caught between the side rails. Resident #16 had a pressure alarm on the bed that did not alarm. CI #8 began to cry and said she had never seen Resident #16 attempt to get out of the bed. CI #8 stated she told the Administrator and DON the resident's head was caught in the side rails. CI #8 stated she wrote a statement of what she had observed and gave it to the DON. The resident was not breathing or moving. CI #8 stated .her head was facing the wall, her face was to the railing and was caught up . CI #8 stated Resident #16 had an air overlay on the mattress. On [DATE] at 8:55 PM CI #12 stated the resident 's right arm and head were pinned in the side rail, and her feet were almost at the wall. Her bottom was not touching the ground. CI #12 stated the resident's jaw seemed to be in the rail and was turned looked unusual. On [DATE] at 8:00 AM CI #10 stated when she walked in the room Resident #16 was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. The resident did not have a pulse and was not breathing. CI #10 stated she notified the doctor that the resident was found on the floor and had passed. Resident #16's face was turned to the right toward the headboard, her legs were stretched out in front of her and were under the geri chair. The resident had a discolored area on her jaw. On [DATE] at 10:01 AM the DON was informed the survey team had asked for all facility investigations of any incident. The DON was asked if an accidental or unusual death had occurred in the facility, the DON stated, No. The DON stated she was in the facility the night of Resident #16's death. The DON stated it looked like Resident #16 had slid out of the bed after she expired, That's what we assumed . The DON stated this incident was not reported to the State. When the DON was asked if an investigation was done, she stated, There was nothing formal. I just asked them what happened . The DON stated she wrote the witnesses statements and the witnesses signed the statements. The DON was asked if there should have been an investigation. The DON stated, By investigation, do you mean getting the data, analyzing and doing to a conclusion? . I made the wrong decision . The facility failed to thoroughly investigate the resident's death. The circumstances of the resident's death was not reported to the Medical Director, the police, Adult Protective Services, the Medical Examiner, or the State Survey Agency. The witness statements were discarded and were re-written by the DON. The facility's failure to investigate and report all incidents of accidental deaths placed all residents in a SERIOUS and IMMEDIATE threat to their health, safety and well-being, resulting in IMMEDIATE JEOPARDY. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Anxiety Disorder, Kyphosis (outward curvature of the spine), Major [MEDICAL CONDITION], Contracture of the Knee and Hip, Dementia with Behavioral Disturbances. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 stated, .I told the staff you can't jerk her legs because they will break her legs with her being so little . CI #4 stated that CNA #1 came into the room and got ready to lay the resident down and just threw her down. CI #4 stated .She (CNA #1) got so mad and threw the chair around so fast . CI #4 stated the Social Worker wanted to split up the resident and her roommate, to move the resident to another room to separate the group. Interview with CI #1 on [DATE] at 1:45 PM, in the Conference Room, CI #1 requested that CNA #1 not provide further care for Resident #45. CI #1 was asked if CNA #1 was rough handling her or talking to her. CI #1 stated, Both .this is about the 4th incident that I have had with her (CNA #1) .on [DATE] (the resident) had a scratch on her leg . CI #1 was asked if CNA #1 provided care for the resident after the request to not provide care. CI #1 stated, Yes .She said she didn't have time to tell CNA #1 yet that day .my fear is that they know I am in here talking to y'all. I have found (CNA #1) openly hostile for a while. (CNA #1) carries a lot of power and she can be vindictive . Interview with CI #3 on [DATE] at 5:55 PM, in the Conference Room, CI #3 was asked about concerns she had with Resident #45's care. CI #3 stated, the names of CNA #5 and CNA #9 do a good job. CI #3 stated, .The other ones (CNAs) don't do good at all . and are rough with the resident when providing care such as turning, dressing and undressing the resident. CI #3 stated Resident #45 sustained .a big scratch on her leg . while being cared for by CNA #1. CI #3 stated Resident #45 hollers Oh! Oh! when the staff come in rough and pushing her over. .You can hear the bed go boom, boom .(loud noise). Interview with CNA #2 on [DATE] at 7:32 AM, in the conference room, when CNA #2 was asked how many people are necessary to get Resident #45 out of the bed, CNA #2 stated, Sometimes . 2. CNA #2 stated she did not use a lift to assist in getting Resident #45 out of the bed. CNA #2 stated it didn't seem to hurt Resident #45 when she is gotten up, CNA #2 stated, . she doesn't complain. CNA #2 stated Resident #45 was not really able to talk, she just . she says a few words. She says something sometimes. I don't know if she understands what I am saying. CNA #2 was unaware of any staff who was not to provide care to Resident #45. CNA #2 stated she was told not to go into Resident #57's room for some reason, but didn't know why she was unable to go into the room. Interview with CNA #1 on [DATE] at 1:04 PM, in the Conference Room, CNA #1 stated the DON told me not to take care of Resident #45 anymore to keep the chaos down. When CNA #1 was asked how she moved Resident #45 to the bed, CNA #1 stated, if you set her up in the chair, put your arms under her arms and bring her around to the bed, she will be sitting down on the bed. CNA #1 stated the geri chair has a arm rail on it, but it is not in the way. CNA #1 stated, . If you sit her up, you just turn her and put her on the bed. She is not heavy . She weighs maybe 96 (pounds) . When CNA #1 was asked if she had made changes to the CNA assignments during the past month, she stated changes were made because 2 families complained about CNA #7 being slow. She stated Resident #57's son would turn the call light on, and CNA #7 would go and turn it off and say she was in the middle of something and she would be back, but didn't return. CNA #1 stated this happened 3 times. She stated there was no formal complaint. CNA #1 was asked if this complaint was documented on the grievance log, and CNA #1 stated, .I don't know where it goes from there. Interview with CI #5 on [DATE] at 2:05 PM, in the Conference Room, when CI #5 was asked about the care in the facility, CI #5 stated, . Some of my little residents .can look at you and tell something is going on . they moved me off B hall, I cried .It seems like I am the only one they move .If they (DON, Social Worker and CNA #1) are in that circle, they (DON, Social Worker and CNA #1) will pick on you .If I say something, they will make my job more hard. I can deal with the residents, but you are dealing with the nurse or that nurse it is hard .You can't win. Like talking to y'all, I may get in trouble. When CI #5 was asked if she had heard anyone talking harshly to the residents, CI #5 stated, I'll get in trouble . When CI #5 was asked about Resident #45's scratch on her leg, CNA #2 stated, .CNA #1 does it (transfers Resident #45) by herself, but I always need somebody with me . Interview with CI #5 on [DATE] at 2:08 PM, in the Conference Room, when CI #5 was asked if she had worries about repercussions for talking to the surveyors the previous day, CI #5 stated, .Still worried . (about) Getting fired. CI #5 further stated a lot of other staff want to talk but they are scared. CI #5 stated she had talked with a State lady from APS with the SW present in the room, and the SW told CI #5 .answer the questions and don't tell her any more . Telephone interview with CI #1 on [DATE] at 3:42 PM, when CI #1 was asked who she talked to about her concerns regarding Resident #45, CI #1 stated she had talked to the SW. CI #1 said she reported CNA #1 was rough with Resident #45. CI #1 stated she reported the rough treatment to the DON. CI #1 stated this is why she did not want CNA #1 back in the room. When CI #1 was asked exactly what the rough treatment was, CI #1 stated jerking the resident's clothes to get them off, jerking the resident's head and moving her body parts (rough) and jerking the resident around to undress her. After CI #1 complained and told the DON she did not want CNA #1 in Resident #45's room, CNA #1 was assigned to Resident #45. CI #1 stated CNA #1 came in the room yesterday and looked at Resident #61, turned around and walked out. CI #1 stated CNA #1 just proved she could walk into the room if she wanted to. When CI #1 was asked to clarify exactly what she told the DON, CI #1 stated, I told her (CNA #1) was very rough with (Resident #45). Her attitude was very short with her (Resident #45) and this was not the first time she was uncooperative (with Resident #45) . CI #1 stated she had heard CNA #1 saying, I don't have time for that. or That's not my job. CI #1 stated if she had a concern and complained to the DON or Administrator, she did not feel the concern would be addressed. CI #1 stated she felt like there would be repercussions for talking with the survey team. CI #1 stated, .They (DON, Social Worker and CNA #1) play mind games .all the time . CI #1 stated there has been three occasions since Christmas. Resident #45 had a large scratch on her face, she fell out of the bed, and then a skin tear on her leg, but no one knows how these happened. CI #1 stated, .It is very frustrating that she keeps having accidents and no one knows anything about it . Interview with CI #2 on [DATE] at 4:35 PM, in the Conference Room, when CI #2 was asked if he worried about repercussions from CNA #1, CI #4 stated, Yes she is very bold. (Named SW) is another . She is bold . Interview with CNA #1 on [DATE] at 5:40 PM, in the Conference Room, CNA #1 was asked if the Administrator talked to her about any allegations. CNA #1 stated he talked to her about not going back into 2 other residents' rooms. CNA #1 stated that was because the family didn't want her back in there. Interview with the Administrator on [DATE] at 7:30 PM, in the Conference Room, the Administrator was asked for an incident report and investigation for a scratch to Resident #45's face that occurred some time after Christmas. The Administrator stated, There were no incidents on a scratch on Resident #45's face since Christmas. The facility failed to provide documentation of an investigation of an injury of unknown origin. Telephone interview with Medical Doctor (MD) #1 on [DATE] at 5:20 PM, MD #1 stated he comes to (named facility) every 2 months. When MD #1 was asked if he expected skin tears to be investigated to determine why they occurred, MD #1 stated, Yes and no . He stated it should be figured out why the skin tear happened. He stated, Their skin is frail. I think the nursing staff should watch how they move them .If it is frequent the nursing staff should be looked at about how they are handling the patient. MD #1 stated he thought the nursing staff investigated why a Resident has a skin tear, especially if there was a recurrent trend. He stated, .They should think why is this happening .I think they should look into it if there is a trend. MD #1 stated, Falls are the same way. Falls can happen from time to time but if they are happening often .every time a fall happens they should see how the fall happened. Did it happen about a staff management issue or did the fall (just) happen . MD #1 stated Resident #45 couldn't fall out of the bed because she doesn't move. MD #1 was informed that Resident #45 did actually have a fall recently. MD #1 was asked if he had been made aware of that. MD #1 stated, I don't remember being called about a fall on (name of Resident #45). Interview with CI #16 on [DATE] at 10:54 AM in the DON office, CI #16 was asked if Resident #45 had more incidents since the surveyors were in the facility, and CI #16 stated on [DATE] a bruise was discovered on her left forearm and an abrasion on left shin, as well as an abrasion on right forearm, and a skin tear to the left thigh on [DATE]. The facility's failure to investigate all allegations of abuse neglect, neglect, mistreatment and incidents of unknown origin and protect the residents during the investigation placed the Resident in a SERIOUS and IMMEDIATE threat to their health and safety, resulting in IMMEDIATE JEOPARDY. 4. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was cognitively intact, experienced feelings of depression and hopelessness and had no behaviors coded. Interview with Resident #55 on [DATE] at 4:42 PM, in the resident's room, when the resident was asked if she could tell the surveyor about a time when she was mistreated or someone spoke harshly to her while in the facility, Resident #55 stated, .I've been treated okay since y'all came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . (the) DON (Director of Nursing) .said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident 55) she's getting too big and you need to stop bringing her pizza . Resident #55 stated since the survey team arrived, she has not seen the people here, so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful, and agitated during the interview and apologized for becoming so upset. Interview with CI #5 on [DATE] at 9:04 AM, when CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry, CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me (Named Resident 55) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on [DATE] at 2:59 PM, in the DON office, CI #16 was asked what her expectations were when a resident is frequently tearful. CI #16 stated, I would expect that they would address and identify what is causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility assessed Resident #55 for reasons that caused her to cry and be tearful. There were no interventions to assist the resident with coping skills for verbal abuse. The failure to prevent verbal abuse and provide timely interventions resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON. 5. Medical record review revealed Resident #57 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident had severe cognitive impairment. The annual MDS dated [DATE] revealed Resident #57 resident had severe cognitive impairment. The care plan revised on [DATE] documented, Focus .COMMUNICATION problem r/t (related to) [MEDICAL CONDITIONS].Invention Allow adequate time to respond .Do not rush .Resident is able to answer simple yes and no questions. Does well when given word/answer options . Interview with Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, the SW stated any complaint she knew about would be added to the complaint/grievance log. Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of [DATE]. Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of [DATE] regarding Resident #57. A telephone interview with CI #15 on [DATE] at 2:11 PM, CI #15 stated there had been a problem with staff back in January or December. Cl #15 stated, She (CNA #2) talks ugly to the residents. CI #15 has heard Resident #57 say no, no, no she's mean (CNA #2) . CI #15 stated when she asked the DON not to have CNA #2 to go in Resident #57's room nothing was changed. A telephone interview with CI #17 on [DATE] at 2:45 PM, CI #17 was asked have you had concerns with the staff being rough with Resident #57. CI #17 stated [DATE]th or 15th 2017 was the last time she heard CNA #2 handling Resident #57 roughly . CI #17 stated right after Memorial Day 2016 she called Corporate office, the lady on the phone asked why didn't I take the complaint to the nurse and I said the care is about the nurse and she said oh . Interview with the Administrator on [DATE] at 10:00 AM, in the Administrator's office, the Administrator stated stated he talked to CNA #2 the other day about someone she couldn't take care of in November or October. The Administrator stated, I believe . (it was Resident #57) . The Administrator verified there should there have been an investigation of why CNA #2 can't take care of Resident #57. When the Administrator was asked if there are allegations staff are handling resident's rough, should that have been investigated. The Administrator stated, Yes, because the term rough needs to be identified what they mean by rough . The facility's failure to protect residents and investigate all allegations of mistreatment placed all residents in a SERIOUS and IMMEDIATE threat to their health and safety, resulting in IMMEDIATE JEOPARDY. 6. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 was asked about the care Resident #61 received. CI #4 stated there are 3 CNA's (CNA #1, #2 and #7) that don't care about the residents. CI #4 stated CNA #1 moved Resident #61 and tore her arm. She stated CNA #1 couldn't help but tear the skin, the way she was turning her. CI #4 stated CNA #1 gets mad to have to turn Resident #61. CI #4 states CNA #1 says 'I get so sick of turning this woman' CI #4 states CNA #1, #2 and #7 come in mad and they go out mad. CI #4 states she has seen Resident #61 so many times when her head hit the rails, she would have to put a pillow between the rails and her head. CI #4 stated Resident #61's head has to be high and it slides off of the pillow, it is going to the rail if you don't have a pillow there to stop it, because she slumps over. CI #4 stated, I called Adult Protection Services. Interview with CNA #1 on [DATE] at 1:00 PM, in the conference room, when CNA #1 was asked about the skin tear on Resident #61's arm while in her care, CNA #1 stated, I noticed blood on right arm. It was dried blood, so it was old. I told the nurse, I may have bumped it. I didn't know I did . Interview with the Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, when the SW brought in the grievance and complaint log, the SW stated there was no grievances for the month of October, November or December. The SW stated there was 5 complaint/grievances for January, 1 for February, 1 for March, and 4 for April. The SW stated all complaint/grievances were placed on the complaint log if she is aware of them. The facility failed to provide documentation of facility investigations for the complaint/grievances in the log for January, February, March, and [DATE]. Interview with the DON on [DATE] at 4:43 PM, in the DON's office, the DON stated the facility investigated each complaint/grievance on the log. Interview with CI #2 on [DATE] at 4:35 PM, in the conference room, when CI #2 was asked if she had filed complaints/grievances with the DON, CI #2 stated she had been to her ,[DATE] times and showed her things, like the feeding pump not plugged up and off. When they get her up they hang it on the pole. CI #2 stated the thing that scares me the most is that it is not 1 or 2 (staff) it is the majority of them. She stated, It is a no win situation. CI #2 stated she was fearful of repercussions against Resident #61 for any complaint/grievance reported. CI #2 stated she has found Resident #61's head in the rail, the bed flat, not tilted at all (Resident #61 is a tube feeder), the mucus in her throat. CI #2 stated she is afraid she is going to choke to death. CI #2 stated the nurses don't suction her unless she goes to get them. She states she gets tired of fighting them (staff). CI #2 stated, I have found (named Resident #61) flat down so many times .[DATE] resident lying flat .CNA #7 had her left arm so far behind her it looked like she didn't have one. I knew she was in pain her face was red . CI #2 stated she worried about repercussions from CNA #1. She stated CNA #1 is . bold, (as in intimidating) . CI #2 stated she also worried about repercussions from the Social Worker because, .she is bold . Review of complaint/grievance logs for January, February, March and [DATE] revealed 3 grievances filed for poor care to Resident #61 which included lying flat in bed while tube feeding infusing and oxygen tubing on the floor. The facility failed to provide documentation the complaint/grievances were investigated. The facility failed to protect the residents from staff that were accused of alleged abuse by the failure to suspend the staff during an investigation of the allegation. The facility failed to perform reference checks on staff before they were hired. The facility failed to do thorough investigations of injuries of unknown origin. 7. Interview with the Administrator on [DATE] at 11:00 AM, in the conference room, the Administrator was asked how he ensured there were no repercussions to residents or families when grievances were made, he stated, The staff is in-serviced on our grievance policy and they are informed there should be no direct or indirect (complaints) against them . The Administrator was informed the survey team was informed 3 employees had been named in allegations of handling residents rough, being verbally abusive and they were not allowed to go into certain resident's rooms. The Administrator stated if a family requests a particular staff not be allowed in a certain room, then .We try to honor the request. The Administrator stated if a family had an issue with a staff member being unprofessional, he would talk with the family and record it on the log. The Administrator stated an injury of unknown origin should be investigated. He stated an Incident-Accident report should be completed and include where the injury is and what caused it. The Administrator stated he was not aware of any staff the facility has mandated not to go into a particular resident's room. The Administrator was informed that CNA #1, CNA #2, and CNA #7 were the staff that were alleged to be handling some residents roughly, being verbally abusive, and they were not allowed to go into certain resident rooms because of those allegations. When the Administrator was asked if he had any complaints against CNA #1, the Administrator stated, Last week the only thing I heard of her, there was a sitter that was with Resident #45 and there was a discussion back and forth with the sitter .The family will walk up to me in passing. Mom's sitter and CNA #1 had a discussion. The Administrator did not know how it was resolved. He stated, She just let me know there was a discussion . The Administrator was informed the majority of interviewees told the survey team they feared repercussions for talking to us. The Administrator was informed, the interviewees were saying there were already being repercussions. The person doing the staffing, CNA #1 is the one who is being accused of repercussions. Observations in the facility on [DATE] and [DATE], during the 6:00 AM-2:00 PM shift, revealed CNA #1 and CNA #2 were caring for residents, and on [DATE] CNA #1 was caring for residents, after the Administrator was informed by the State Surveyors of alleged abuse and/or neglect by these staff. Review of the CNA assignment sheets for [DATE] revealed CNA #1 and CNA #2 had resident assignments that day. 8. Interview with Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, the SW brought in the Grievance and Complaint log. The SW confirmed five complaints/grievances for the month of January, one complaint/grievances for the month of February, one complaint/grievances for the month of March and four complaint/grievances for the month of April. The SW was asked what type of complaint you would put on the complaint log. The SW stated the complaints/grievances were concerns with call lights, food issues and staff members. The SW stated any complaint she knew about would be added to the complaint/grievance log. Refer to F225

Based on facility documents, policy review, medical record review, observation, and interview, the facility failed to ensure all allegations involving death, abuse, neglect, mistreatment and injuries of unknown origin were thoroughly investigated; and the facility failed to prevent further potential abuse, neglect and mistreatment for 5 (Resident #s 16, 45, 55, 57, and 61) residents of the 13 residents reviewed for abuse or neglect. The facility failed to thoroughly investigate the incident of a resident found dead between the bed side rail and the mattress; and take immediate actions that would prevent potential entrapment deaths of other residents; and report the death to the State Survey Agency. The failure of the facility to investigate a death, prevent abuse and mistreatment, investigate all allegations of abuse and mistreatment, investigate injuries of unknown origin, and report appropriate investigations to the State Agency resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 61, and 57 and psychological harm to Resident #55. Immediate Jeopardy is a situation is which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F 225-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse-Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Psychosocial harm-Include but not limited to extreme embarrassment, ongoing humiliation, degradation as a human being .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident .All injuries or bruises that are suspicious in any way or injuries of an unknown origin must be investigated. An injury is classified as an injury of unknown origin when both of the following conditions are met. 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The Administrator and / or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of results to the proper authorities .An interview with and statement from staff members (on all shifts) having contact with the resident during the period of the alleged incident .Interviews with and statement from the resident's roommate, family members, and visitors as needed. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan .REPORTING/RESPONSE policy documented, .It is the policy of this facility that persons employed by this facility with knowledge or reasonable cause to believe that any resident has been the victim of abuse, exploitation, neglect, or mistreatment must report or cause a report to be made to the appropriate state agencies as prescribed by the laws of that state. Failure by staff (including management and supervisory staff) to report possible/alleged incidents of abuse/neglect to Administration per policy, will result in disciplinary action up to and including immediate termination. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan policy documented, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress .The prohibition plan includes the following components: 5. Investigation of allegations .7. Reporting and responding .The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Staff training policy documented, .how and when to report allegations without fear of reprisal .Training will also include accession resources that are available to staff and family members who may benefit from counseling through chaplain services and social services .The facility management staff will receive training needed to provide good leadership, encourage teamwork, and promote a pleasant, safe environment . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, .Staff supervision for inappropriate behaviors during interaction with or care of residents .The facility will continue to make efforts to decrease staff turnover and provide training and assistance to staff to ensure that the best care possible will be provided in a caring manner .The facility will listen to staff and continue to make improvements .The facility will continue to make the work environment a pleasant and safe one for all employees so they may provide a pleasant and safe environment for the residents. Staff will be supervised to identify behaviors such as derogatory language: rough handling; ignoring residents while giving care .The facility administrator and or the Director of Nursing should review risk management reports at each administrative meeting to identify possible situations of abuse. This may include but is not limited to incident reports, including injuries of unknown origin and grievance reports. Ongoing efforts to minimize abuse, neglect, misappropriation of property, and exploitation will be accomplished through the facility's QAPI (Quality Assurance Performance Improvement) program . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan INVESTIGATION policy documented, .All injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated .The administrator and/or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of result to the proper authorities. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan PROTECTION policy documented, .Residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment . The facility's Investigating Grievances and Concerns policy documented, It is the policy of this facility and its facilities to investigate all grievance and complaints filed with this facility .The investigation and report will include, as each may apply .a. The date and time the incident took place; b. The circumstances surrounding the incident; c. Where the incident took place; d, The names of any witnesses and their account of the incident; e. The resident's account of the incident; f. The employee's account of the incident; g. Accounts of any other individuals involved .'h. Recommendations of the corrective action. Upon receipt of a grievance and/or concern, the Grievance Official will coordinate the investigation of the allegation and file a written report with Facility Administrator of such findings with five (5) working days of receiving the grievance and /or complaint .The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be to correct any identified problems. Such report will be made by the Administrator or Grievance Official within ten (10) working days of the filing on the grievance or complaint with this facility .All reports of abuse, neglect, mistreatment, or misappropriation of property must be reported to the administrator within twenty-four (24) hours of their occurrence. An immediate investigation must be made, and the findings of such investigation must be made, and findings of such reported to the administrator within three (3) working days of the occurrence of such incidents. 2. Review of the manufacturer's recommendations for the Panacea Bed Manual, used by the facility, revealed, .An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be .related to the use of restraints and bed system entrapment guidance .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefit outweigh the risk of entrapment . Review of the manufacturer's guidelines for the Panacea Air Overlay, used by the facility, revealed, .Failure to comply with all directions and warnings may result in injury or death .Due to the alternating pressure feature .some devices and products may not be appropriate for the use with this device. Do not use pressure pad alarm or alert systems in conjunction with the overlay .This device is not designed to replace good care giving practices, including, but not limited to .Adequate care plans and training for staff personnel for entrapment and fall prevent . The facility's Bed Rail Guideline policy documented, .It is the policy of this center to limit the use of bed rails and similar devices unless the benefit outweighs the risks .A physician order [REDACTED]. The facility's Mechanical Lift Evaluation policy documented, .In order to facilitate a safe lifting environment for staff and resident. Mechanical lifts are to be utilized for lifting and transferring residents whenever possible . 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, had moderately impaired cognitive skills, required extensive assist of two (2) plus persons for bed mobility and transfers between surfaces such as from bed to chair. The MDS revealed the resident had bilateral range of motion impairments of upper and lower extremities. Review of the annual MDS dated [DATE] revealed the resident was unable to participate in the BIMS assessment and had severely impaired cognitive skills and required extensive assist of two (2) plus persons for bed mobility and transfers between surfaces such as from bed to chair. Review of the undated care plan documented, .Resident is dependent of staff for .Physical mobility issue which caused pain r/t (related to) weakness and contractures, and dx (diagnosis) of kyphosis/Scoliosis .pain is aggravated by movement .has LIMITED PHYSICAL MOBILITY .contracture(s) (of the) extremities . On [DATE] at 1:25 PM, the Administrator was asked for all investigations conducted since [DATE]. The Administrator was unable to provide evidence the incidents involving Resident #16 were thoroughly investigated. a. Review of the care plan revealed Resident #16 had a skin tear to the left elbow that was resolved on [DATE]. There was no incident report or investigation provided by the facility regarding this skin tear. b. Record review revealed the resident had a fall from the bed on [DATE]. There was no incident report or investigation provided by the facility regarding this fall on [DATE]. Neuro checks were not completed per facility policy. Neuro checks (vital signs, pupils for reactions equal and reactive to light) were not done for [DATE] at 9:30 AM or 5:30 PM. The undated care plan revealed the resident fell from the bed [DATE] and sustained a scratch injury to the cheek. The facility intervention was to remove the air mattress and replaced the mattress with an air overlay. Interview with the Region Nurse Consultant (RNC) #1 on [DATE] at 3:25 PM, in the conference room, the RNC #1 confirmed all neuro checks were not completed in accordance with the facility policy. c. Review of the nurse's note dated [DATE] at 8:00 PM (20:00) was errored out as incorrect documentation. Review of the [DATE] nurse's note by LPN #7 for 8:00 PM, revealed, incorrect documentation (error). The documentation error revealed, .Called to resident's room by CNA. Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head. With the assistance .of the CNAs, we laid the resident in the floor. This nurse felt for a pulse, listened for breathing and heartbeat. At this time, another nurse called the DON (Director of Nursing) while this nurse and CNAs transferred resident to the bed. DON was called at 8:10 pm. MD (Medical Doctor) notified at 8:28 pm. Resident was bathed and dressed by CNAs. Review of the [DATE] DON's note for 8:15 PM, documented incorrect documentation errored out with a line through the documentation indicating it as incorrect revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM, spoke to RP (Responsible Party) request that (named funeral home) be called to transport body to funeral home Review of LPN #7's additional documentation after the incorrect documentation for [DATE] at 9:00 PM, revealed, .Called to resident's room by CNA. Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard. With the assistance of CNAs, we laid the resident in the floor. This nurse assessed for pulse, breathing and heartbeat. None was found. As this time, Another nurse called the DON while the resident was transferred to bed. DON called at 8:10 pm. MD notified at 8:28 pm. Resident was bathed and dressed by CNAs. Review of the [DATE] physician orders [REDACTED]. There was no documentation for the justification of the facility's use of side rails for Resident #16. Review of the facility's Record of Death dated [DATE] documented, .resident noted with (signed for no) pulse, (sign for no) respirations . There was no other documentation on the form related to the resident's death. Review of the death certificate revealed Resident #16's death occurred on [DATE] at 8:00 PM, the cause was cardiac failure and was signed by the resident's physician. Interview with Confidential Interview (CI) #1 on [DATE] at 1:45 PM, in the conference room, CI #1 was asked about concerns. CI #1 stated, .(named Resident #16) was in the floor when the CNA (Certified Nursing Assistant) (did not give the name) found her the night of .([DATE]). (Named DON) called all the CNAs into this room (Conference Room) and told them that they could not discuss this with any one at any time .thought her neck was broken. They were told to straighten up the body before medical personnel were called in . Interview with Confidential Interviewee (CI) #7 on [DATE] at 8:01 AM, by telephone, CI #7 was asked what she knew of Resident #16's death. CI #7 stated, I was not a part of that scenario, I came in to work the following day and I heard about the situation, and when I went to the morning meeting I said to (named DON) State will be in because this is reportable. Is there anything you want me to be checking on, since we have to do a reportable and we're in our window. They will probably come on in. She said 'What do you mean state will be here?' And I said, with that reportable. And she said, 'That's not a reportable. She said after their investigation (she and the Administrator) they determined it was not reportable .Well, they came in that night after the incident happened and started their investigation .I don't know what their investigation involved but I felt like after reading that note that it was a reportable . Interview with the Corporate Vice President (VP) of Legal on [DATE] at 4:50 PM, per telephone, the VP of Legal was asked if the DON and Administrator were educated on what incidents are reportable to the State. The VP of Legal stated, Oh yeah, and there are policies they have access to ,[DATE] .kiosks in the hallways to access those policies. Interview with CI #8 on [DATE] at 5:32 PM, in the Conference Room, CI #8 was asked if they were aware of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often they check the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the DON came in that night. CI #8 stated, Yes, and the Administrator. CI #8 began to cry. CI #8 was asked if she had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked about the maintenance supervisor. CI #8 stated, That was his mom. CI #8 was asked what happened when the resident was found. CI #8 stated, .(Named nurse) was here, and she came around there and checked her. CI #8 was asked if the nurse found a pulse. CI #8 stated, She said it was very, very light. We put her on the bed .I'm trying to think who all was here, we put her on the bed .before the DON arrived. CI #8 was asked if she told the Administrator and DON what happened. CI #8 stated, I told them what had happened. CI #8 was asked if she told them that Resident #16's head was caught in the side rail. CI #8 stated, Yes, and that her legs were on the floor. CI #8 was asked if the resident was in the bed when the DON came. CI #8 stated, Yes. CI #8 was asked if she told both the Administrator and the DON. CI #8 stated, They questioned me. CI #8 stated, I wrote a statement. CI #8 was asked if she wrote what she saw. CI #8 stated, Yes. CI #8 was asked to whom was the statement given. CI #8 stated, (named DON). CI #8 was asked if Resident #16's head was in her normal position (since the resident had kyphosis.) CI #8 stated, When we got her off the floor it was in normal position. CI #8 was asked if there was a pulse. CI #8 stated, One said she had a light pulse, it was real faint and the other said she didn't hear anything. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked if the resident was a Do Not Resuscitate (DNR.) CI #8 stated, I don't know. CI #8 was asked how long had it been since staff had seen her last. CI #8 stated, It had been 2 hours .I was going, into her room. CI #8 was asked what time this occurred. CI #8 stated, (she was) put .to bed after supper. It was between 8 and 8:30, I think. CI #8 was asked if the resident was on the bed when the DON got there. CI #8 stated, Um hum. (yes) CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair was on the side that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 explained that the resident was between the bed and the geri chair. CI #8 was asked who the other staff there that night but she could only remember CNA #5. CI #8 was asked if the same bed was in the room. CI #8 stated, I think it is. CI #8 was asked if the resident had a special mattress. CI #8 stated, She had the bubbles, the thing on the foot of the bed. CI #8 was asked if it was an air overlay. CI #8 stated, Yes. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 stated, .The CNA yelled .We ran to the room. I didn't know if I should go in .She was trying to figure out if she had a pulse but the girl there didn't know .No one knew if she was a CPR (cardio-pulmonary resuscitation) so I ran to see if she was a CPR. CI #12 was asked if she was a CPR. CI #12 stated, No ma'am, she was a DNR (Do Not Resuscitate). CI #12 was asked how was Resident #16 was found. CI #12 stated, Whenever I walked in the room the right arm and her head was right there. The side rail things-her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked if she had said her bottom was not touching the ground. CI #12 stated, Right. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up. The jaw line under the mandible was up making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if she had been told not to tell anyone about the incident. CI #12 stated, Um, in all honesty, until we talked to the Administrator and DON we were told not to talk to anyone about this, but nothing was said afterwards. No one said anything after that. I don't know if it was accidental or some other medical reason, I am not sure. They had told me not to say anything until it had been investigated more. CI #12 was asked if she had given a written statement. CI #12 stated, Yes. CI #12 was asked if Resident #16 was on the bed when the DON there. CI #12 stated, Yes. CI #12 was asked if there were any marks on Resident #16. CI #12 stated, If I remember correctly, there was one on the jaw line. I'm not 100% (percent) but I think there was. CI #12 was asked on which side. CI #12 stated, On the left side of her face. CI #12 stated, .I would like to know more about it. Was an autopsy done? I don't know. No one ever said anything else about it. I don't know. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked what happened next. CI #10 stated, we got her to the floor. CI #10 was asked if there was a pulse. CI #10 stated, No .she was a DNR .I had the nurse check for me. CI #10 was asked if Resident #16 was breathing. CI #10 stated, No. CI #10 was asked if there was a pulse. No. CI #10 was asked what happened then. CI #10 stated, While the nurse was gone I checked for vital signs. Myself and a couple of aides transferred her back to the bed. Then the other nurse called (named DON) because we have to have a RN (registered nurse) to pronounce .(LPN #1) also notified the family .I notified the doctor .we cleaned her up. CI #10 was asked what she had told the doctor, if she had told him how the resident was found. CI #10 stated, Just that she had passed. CI #10 was asked if anyone called the Administrator. CI #10 stated, I did not but I believe (named DON) did. CI #10 was asked if Resident #16 had fallen. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked if she told the son that she fell out of the bed. CI #10 stated, I was in another room when the son arrived .I did go in the room with him and his wife and told him I was sorry. That was all I said. CI #10 was asked if she knew if the son was aware of the incident. CI #10 stated, No ma'am .I was told (named Administrator) told him. CI #10 was asked if the Administrator and DON came into the facility that night. CI #10 stated, Yes ma'am. CI #10 was asked if the resident's bottom was touching the floor. CI #10 stated, Yes ma'am. CI #10 was asked to describe how her legs were positioned. CI #10 stated, They were stretched out in front of her .her geri chair was between her chest of drawers and the bed .her legs were under the geri chair .the aides picked up the geri chair .her legs were straight. CI #10 was asked if her neck was in a normal position for her. CI #10 stated, It was down and turned . CI #10 was asked if Resident #16 had contractures. CI #10 stated, She did, most of the time she was a wiggle worm. CI #10 was asked what type of mattress Resident #16 had. CI #10 stated, an air mattress. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here, but before. CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. The DON interrupted the surveyor's interview with CI #10 at this point. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was informed that we have asked for all investigations. An investigation of this incident was not provided by the facility. The DON was asked if an accidental death is to be reported to the State (Tennessee Department of Health). The DON stated, Yes. The DON was asked if they had any accidental deaths in the facility. The DON stated, No. The DON was asked if she was present the night of Resident #16's death. The DON stated, I was, after she passed away. The nurse called and said (Resident #16) doesn't have any respirations and I can't find a pulse. I said is she a DNR. She said yes and I told her I was on my way. The DON was asked if she always comes in if a resident expires. The DON stated, Since my other RN resigned, I have to come in. The DON was asked what happened after she arrived. The DON stated, I checked her. She had expired. I didn't call the doctor or the family. I don't remember if I called or if other staff called .it was her birthday. It looked like she had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if she had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left. The DON was asked if there was an investigation. The DON stated, No, I just asked them what was going on and what happened. The DON was asked if she had any witnesses write a statement. The DON stated, (named assigned nurse) put her statement in .the computer. Two other ladies made statements. The DON was asked if there were just 2 statements made. The DON stated, Yes, (named assigned nurse put hers in the computer. The DON was asked if there was any further investigation. The DON stated, No. The DON was asked if the Administrator came to the facility that night. The DON stated, Yes, he came to talk to (named Resident's son.) The DON was asked if it was normal for the Administrator (that lives 70 miles away) to come to the facility when there is a death. The DON stated, No, but him and (named son, who is the facility's maintenance supervisor) are pretty close so he wanted to make sure (named son) was ok. The DON was asked if Resident's son was aware that she was found on the floor. The DON stated, Yes. The DON was asked what time she arrived. The DON stated, I have no idea. I'm sorry. The DON was asked what time the Administrator arrived. The DON stated, It wasn't too long after I did. The DON was asked who called the Administrator. The DON stated, I did. The DON was asked what she told the Administrator. The DON stated, That (named son's) mom had passed away. The DON was asked about the nurse's progress note that was marked out. The DON stated, I told her to show me how (Resident #16) was in the bed. That is not what is in your note. The DON was asked how she knew the note was incorrect. The DON demonstrated how the resident was found. Then I read her note I had her show me exactly. What she had on her note was not what she demonstrated to me. The DON was asked what was incorrect. The DON stated, I think she said something about being strangled or choked, I am not sure now. The DON was asked why she thought that was incorrect. The DON stated, Because the way she had explained her earlier that was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. The DON was asked if the resident was sent for an autopsy. The DON stated, No, I don't know. The DON was asked who picked her up. The DON stated, The funeral home. The family wanted to wait awhile before calling the funeral home. The DON was asked if she would have had to do something if there was an autopsy. The DON stated, I'm not sure. The DON was asked if this was reported to the State (Tennessee Department of Health). The DON stated, No. The DON was asked if there was an investigation done. The DON stated, There was nothing formal. I just asked them what happened .before I left I told them to write when the body was transported . The DON was asked what the doctor was told. The DON stated, That she had expired, that she has passed away. I'm not sure if they told him she was on the floo

Based on policy review, manufacturer's guidelines review, medical record review, observations and interview the facility failed to follow facility policies, manufacturer's guidelines and resident care plans for fall interventions, side rail use, and mechanical lift use for 2 of 5 (Residents #16, and 45) sampled residents reviewed for accidents of the 34 included in the stage 2 review. The failure of the facility to ensure Resident #16, a vulnerable resident, was assessed, care planned, and had a physician order for [REDACTED].#16 was found between the siderail and the mattress without a pulse or respirations. Immediate Jeopardy is a situation is which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM in the Conference Room. The facility was cited Immediate Jeopardy at F323-J, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE] and is ongoing The findings included: 1. The facility's Bed Rail Guideline Policy documented, .It is the policy of this center to limit the use of bed rails and similar device unless the benefit outweighs the risk. No rails of any type will be applied to a bed without prior assessment as to the appropriateness of the use and the device selected. This policy applies to the use of any type of rail attached to the bed .Maintain the placement of specialized support surfaces (low air loss or alternating pressure mattresses) within the bed frame .A physician order will be obtained, a care plan implemented, and side rails will be checked for functionality and placement .Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly and prn . The manufacturers guidelines for the Panacea Air Overlay, used by the facility, revealed, .Failure to comply with all directions and warnings may result in injury or death .Due to the alternating pressure feature .some devices and products may not be appropriate for the use with this device. Do not use pressure pad alarm or alert systems in conjunction with the overlay .This device is not designed to replace good care giving practices, including, but not limited to .Adequate care plans and training for staff personnel for entrapment and fall prevent . The facility's Fall Risk Management policy documented. .Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness .Potential risk factors should be identified, evaluated and addressed as needed. The facility's Mechanical Lift Evaluation policy documented, In order to facilitate a safe lifting environment for staff and resident. Mechanical lifts are to be utilized for lifting and transferring residents whenever possible. 2. Medical record review revealed Resident #16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired for daily decision making, and had no falls since admission. a. The Progress Notes dated [DATE] documented, .Called to resident's room .resident in floor beside bed .scratch to left side of face .No other apparent injuries noted .Neuro checks involved . The care plan initiated [DATE] documented, Focus .resident has had an ACTUAL FALL [DATE] - fall from bed - scratch to cheek .Intervention .Neuro-checks as per policy upon hospital return .Date Initiated [DATE] . After the fall on [DATE] at 2:45 AM, neuro checks were not done at the following times: [DATE] at 9:30 PM [DATE] at 1:30 AM [DATE] at 9:30 AM [DATE] at 5:30 PM Interview with Regional Nurse Consultant (RNC) #1 on [DATE], in the Conference Room, RNC #1 was asked were you able to find the neuro checks for the every 8 hours checks on Resident #16. RNC #1 stated, We did not have the last 2 . The RNC #1 was asked should it have been done. The RNC #1 stated, Yes. b. Review of the medical record for Resident #16 revealed there was no physician order for [REDACTED]. The [DATE] 8:00 PM nurse's note by Licensed Practical Nurse (LPN) #7 was errored out with with a line through the documentation indicating it as incorrect. The documentation error referenced as incorrect documentation revealed, .Called to resident's room by CNA (certified nursing assistant) . When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head .This nurse felt for a pulse, listened for breathing and heartbeat. Another nurse's note by LPN #7 for [DATE] at 9:00 PM documented, .Called to resident's room by CNA . When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard . This nurse assessed for pulse, breathing and heartbeat. None was found. Review of the [DATE] Director of Nursing (DON) note for 8:15 PM revealed, incorrect documentation errored out with a line through the documentation indicating it as incorrect revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM . Interview with Confidential Interviewee (CI) #8 on [DATE] at 5:32 PM, in the Conference Room, CI #8 was asked if she knew of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She (Resident #16) was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often the facility checks the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the resident had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair (reclining geriatric chair) was on the side that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 was asked if the resident had a special mattress. CI #8 stated, She had the bubbles, the thing on the foot of the bed. CI #8 was asked if it was an air overlay. CI #8 stated, Yes. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 stated, .Whenever I walked in the room .her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up. The jaw line under the mandible was up making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if there were any marks on Resident #16. CI #12 stated, If I remember correctly, there was one on the jaw line. I'm not 100 per cent but I think there was. CI #12 was asked on which side of her face was the mark. CI #12 stated, On the left side of her face. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked if Resident #16 had fallen. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked what type of mattress Resident #16 had. CI #10 stated, an air mattress. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here . CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was asked if they had any accidental deaths in the facility. The DON stated, No .It looked like she (Resident #16) had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if the resident had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left . Because the way she had explained her earlier that was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. Interview with Resident #16's Medical Doctor (MD) #1 on [DATE] at 5:20 PM, by telephone, MD #1 was asked if he was notified when there were events, incidents, or accidents of his residents in the facility. MD #1 stated, Yes. They said they just found her (Resident #16) dead. MD #1 was asked if he was aware of allegations that her head was caught between the side rails and mattress. MD #1 stated, Not that I know of. I was told she was found dead. If she had a heart attack, she may have struggled or that may have caused her death. MD #1 was asked if he would expect that if she was found with her head between the mattress and side rail and her bottom on the floor, that they would tell him. MD #1 stated, Oh, yeah, that kinda sounds like a choking incident or a neck injury. MD #1 was asked if the resident had a problem with her neck. MD #1 stated, She had arthritis and osteoporosis. She was thin and frail. MD #1 was asked if the kyphosis could exacerbate the possibility of severe injury to the neck. MD #1 stated, It depends on how it was caught .She was thin. She could not have pulled herself out of that position. Interview with RNC #1 on [DATE] at 10:42 AM in the conference room, RNC #1 was asked what is the difference between an air mattress and an overlay. RNC #1 stated, .The overlay goes over the current mattress. So there is a standard mattress and the overlay is zipped or secured around our mattress. Interview with the Maintenance Supervisor (MS), son of deceased Resident #16, on [DATE] at 10:42 AM in Room 118, the MS was asked if he or the nurses apply the overlays. The MS stated, I do not install them . The MS was asked if his mother ever tried to get up. The MS stated, She has in the past. She was a fall risk, but I mean not so much toward the end (recently) . The MS was asked if Resident #16 was mobile. The MS stated, Not very mobile, she had dementia and since the stroke. The MS was asked to describe her mobility. The MS stated, She had jerk motions. She had to be fed .I wouldn't have wanted to see her on the floor. Interview with CI #10 on [DATE] at 1:36 PM in Room 118, CI #10 was asked if she had been in-serviced about side rails or air overlays. CI #10 stated, No. CI #10 was asked how resident #16's head was positioned when CI #10 came into the room. CI #10 stated, It was turned up against the side rail. CI #10 was asked what was on the other side. CI #10 stated, the bed .the mattress. Her arm was up on the mattress, I am not sure if it was straight or bent, the left side of the lower jaw was on the side rail. Interview with CI #12 on [DATE] at 5:19 PM in Room 118 CI #12 was asked if she had been in-serviced about side rails in the last year. CI #12 stated, No. CI #12 was asked if she had been in-serviced about bed overlays. CI #12 stated, No, honestly I didn't even know what a bed overlay was until I came to work here . CI #12 was asked if she was present the night of Resident #16's death. CI #12 stated, Yes. CI #12 was asked what was the position of Resident #16's head. CI #12 stated, The side rail is hitting right here (pointing to lower chin) head is turned to right and up. The rail was at her jawline, if I'm not mistaken she actually had a bruise right there where the rail was touching. CI #12 was asked what had to be done to get the resident to the floor. CI #12 stated, .I guess we had to pull her a little bit to get her from the rail, had to pull her to the side and once that happened, they just eased her to the floor . Second interview with CI #8 on [DATE] at 9:28 PM in Room 118 CI #8 was asked if she had an in-service on side rails. CI #8 stated, Not that I know of. CI #8 was asked if she had an in-service on air mattresses. CI #8 stated, .I don't think so . CI #8 was asked if she had an in-service on overlays. CI #8 stated, I don't even know what that is. CI #8 was asked to describe to the best of their ability the position of Resident #16's head the night of her death. CI #8 stated, I know her head was caught in the railing. She was facing the wall . CI #8 was asked to describe moving the resident to the floor. CI #8 stated, We had to get her neck from the railing. Her neck was caught in the railing. We had to scoot the mattress back away from her neck. It was close to the railing. CI #8 was asked if her right neck was touching the mattress. CI #8 stated, I'm trying to think. One part of the mattress, but she had the bubble thing on top. Interview with CI #18 on [DATE] at 5:25 PM, by telephone, CI #18 was asked if she had been in-serviced about side rails. CI #18 stated, No ma'am. CI #18 was asked if she had been in-serviced on air mattresses. CI #18 stated, No ma'am .not at (named facility). Interview with CI #16 on [DATE] at 10:54 AM in the DON office, CI #16 was asked if Resident #16 had an order for [REDACTED].#16 stated, No, but .it is a nursing intervention. CI #16 was asked if it was necessary to have an order for [REDACTED].#16 stated, No. CI #16 was asked if side rails were on the current care plan when she died . CI #16 stated, It was not on the most up to date care plan. CI #16 was asked if there was an order for [REDACTED].#16 stated, No order for the overlay. CI #16 was asked if Resident #16 had an order for [REDACTED].#16 stated, No there is no order for the pressure alarm .or the overlay. CI #16 was asked if there were any concerns using a pressure alarm with the overlay. CI #16 stated, I guess that would depend if the pressure alarm was on the top or under the overlay .I would put it under the overlay. That is the only way I know how to answer that question. CI #16 was asked if the pressure alarm would be effective under the overlay. CI #16 stated, Yes. CI #16 was asked if there were any concerns if the pressure alarm is on top of the overlay. CI #16 stated, I would prefer for it to be under it for stability. CI #16 was asked if the pressure alarm would be effective on the top of the overlay. CI #16 stated, Yeah. Interview with CI #16 on [DATE] at 12:15 PM in Room 118, CI #16 was asked if Resident #16 was care planned for the pressure alarm. CI #16 stated, Yes ma'am .and we should have an order for [REDACTED].#16 was asked if Resident #16 should have had an order for [REDACTED].#16 stated, Yes. Interview with the Interim Administrator (RNC #1) on [DATE] at 9:50 AM, in Room 118, the Interim Administrator was asked where the policies for the facility's beds and the overlays were located. The Interim Administrator stated, We always refer to manufacturer's recommendations for policy for overlays. Interview with the Interim Administrator on [DATE] at 11:12 AM, in Room 118, the Interim Administrator was shown the manufacturer's guidelines that the MS had given the survey team for the Panacea Air Overlay and the Panacea Bed Manuals. The Interim Administrator was asked to read what the Panacea Bed Manual said on page 4, regarding air mattresses. The Interim Administrator read from the manual, .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefit outweigh the risk of entrapment. The Interim Administrator was asked if those were the guidelines the facility was working under. The Interim Administrator stated, for the beds? Correct, I guess. I can't say 100%. He (MS) gave it to you, so he should know. It is not my area of expertise. The Interim Administrator was asked to read the manufacturers guidelines of the air overlay on page 6, number 3 about the use of pressure alarms with overlays. The Interim Administrator read from the manual, Do not use pressure pad alarm or alert systems in conjunction with the overlay. The Interim Administrator was asked according to the Panacea overlay manual and according to the guidelines, should a pressure pad be used with an overlay. The Interim Administrator stated, No. The failure of the facility to ensure policies and manufacturers guidelines were followed and that Resident #16 was assessed, care planned, and had a physician's order for siderails, resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and placed them in IMMEDIATE JEOPARDY when Resident #16 was found between the siderail and the mattress without a pulse or respirations. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There were no physician orders in April or [DATE], for use of side rails. The care plan updated [DATE] documented, .Kyphosis The resident has an ADL SELF PERFORMANCE DEFICIT r/t (related to) Alzheimer's disease, Kyphosis, Bilateral lower extremity contractures .TRANSFER: The resident uses .lift with transfers. Provide with up to extensive staff assistance with this task .The resident has had an ACTUAL FALL XXX[DATE]-No injury .Fall mat to side of bed .Pressure alarm to bed .Resident moved and scooted too close to edge of bed and rolled off . a. Observations in Resident #45's room on [DATE] at 4:00 AM, revealed Resident #45 lying in the bed on her right side with eyes closed. Resident #45's head was bent forward. The upper quarter side rails were up. There was no fall mat on the floor. There was no sitter present in the room. Observations in Resident #45's room on [DATE] at 4:48 PM, revealed Resident #45 was lying in the bed with the pressure pad alarm on the side rail. The pressure pad alarm was not on. The upper quarter side rails were up. Observations in Resident #45's room on [DATE] at 6:58 PM, [DATE] at 4:13 PM and [DATE] at 9:18 revealed Resident #45 was lying in bed with the upper quarter rails up. Interview with LPN #3 on [DATE] at 4:51 PM, in Resident #45's room, LPN #3 was asked if Resident #45 had a bed alarm. LPN #3 stated, Yes ma'am. LPN #3 was asked when the alarm should be turned on. LPN #3 stated, When she is in bed. LPN #3 was asked if the light should blink green. LPN #3 stated, I'm not sure. I believe it blinks green. It is not on. LPN #3 was asked if it should have been on. LPN #3 stated, Yes ma'am and turned it on. b. Interview with CNA #1 on [DATE] at 1:04 PM in the Conference Room, CNA #1 was asked how many people it takes to put Resident #45 in the bed. CNA #1 stated, One .I set her chair up and grab her under the arms and transfer her over to the bed. CNA #1 was asked if Resident #45 stands up. CNA #1 stated, No ma'am. CNA #1 was asked how she picks her up and moves her to the bed. CNA #1 stated, She is not heavy. If you set her up in the chair and then you put your arms under her arms and bring her around to the bed and she will be sitting down on the bed. CNA #1 was asked if there is an arm rail on the chair. CNA #1 stated, It is a geri chair, so yes it does. CNA #1 was asked how she gets Resident #45 over the arm rail. CNA #1 stated, The arm rest is not in the way. If you sit her up, you just turn her and put her on the bed. She is not heavy. CNA #1 was asked if Resident #45's feet touch the floor. CNA #1 stated, No ma'am. She is not heavy. CNA #1 was asked how much Resident #45 weighs. CNA #1 stated, In her 90s, maybe 96 now. CNA #1 was asked if Resident #45 moans when she puts her in the bed. CNA #1 stated, Sometimes. CNA #1 was asked if the sitters are in the room when she puts her in the bed. CNA #1 stated, They are always in there. Interview with CNA #5 on [DATE] at 2:05 PM, in the Conference Room, CNA #5 stated, When I transfer (Resident #45), CNA #1 does it by herself, but I always need somebody with me. The sitter will help me transfer her. CI #5 was asked if she had seen CNA #1 transfer Resident #45 by herself. CI #5 stated, Naw, but I ask her and she says, 'No, I got her.' I don't ever transfer her by myself. CI #5 was asked how she knew who to use the lift to transfer. CNA #5 stated, They let us know. Resident #45 can't transfer with a lift. Sometimes the family doesn't like that. If she is in the bed, we use the draw sheet. Interview with Family Member (FM) #1 on [DATE] at 3:42 PM by telephone, FM #1 was asked if there were concerns with them using the lift to get her up. FM #1 stated, They don't use a lift getting her up. I'm not aware of it. They just pick her up and put her in the chair .1 person or 2 . Interview with the DON on [DATE] at 7:53 AM, the DON was asked how Resident #45 should be gotten up. The DON stated, She can be transferred by the staff or a mechanical lift. The DON was asked if the care plan said to use a lift, would she expect a lift to be used. The DON stated, If it is in her care plan then yes. The DON was asked if the CNAs use a lift to get her up. The DON stated, I'm not sure. Interview with MD #1 on [DATE] at 5:20 PM, by telephone, MD #1 stated, Falls can happen from time to time but if they are happening often .every time a fall happens they should see how the fall happened .Resident #45 couldn't fall out of the bed because she doesn't move. MD #1 was informed that Resident #45 did actually have a fall recently. MD #1 was asked if he had been made aware of that. MD #1 stated, I don't remember that. She didn't have any major injuries from it. I don't remember being called about a fall on (Resident #45). Interview with CI #16 on [DATE] at 12:15 PM, in Room 118, CI #16 stated, .We should have an order for [REDACTED].#16 was asked if Resident #45 should have an order for [REDACTED].#16 stated, Yes . Interview with CI #16 on [DATE] at 8:45 AM, in Resident #45's room, CI #16 was asked if Resident #45 had a fall mat in her room. CI #16 stated, No ma'am. Upon returning to the DON office, CI #16 was asked if Resident #45 was care planned for a fall mat. CI #16 stated, Yes. CI #16 was asked if there should be a fall mat in Resident #45's room. CI #16 stated, Yes.

Based on policy review, medical record review, observation, and interview the facility failed to ensure residents were free from physical restraints for 2 of 34 (Residents #16 and #45) residents reviewed for side rails in the stage 2 review. The failure of the facility to ensure Resident #16, a vulnerable resident was assessed, care planned, and had a physician order [REDACTED]. Immediate Jeopardy is a situation is which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM in the Conference Room. The facility was cited Immediate Jeopardy at F221-J, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE] and is ongoing The findings included: 1. The facility's Bed Rail Guideline policy documented, .It is the policy of this center to limit the use of bed rails and similar device unless the benefit outweighs the risk. No rails of any type will be applied to a bed without prior assessment as to the appropriateness of the use and the device selected. This policy applies to the use of any type of rail attached to the bed .Maintain the placement of specialized support surfaces (low air loss or alternating pressure mattresses) within the bed frame .A physician order [REDACTED].Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly and prn . The manufacturer's guidelines for the Panacea Air Overlay (a flotation device), used by the facility, revealed, .Failure to comply with all directions and warnings may result in injury or death .Due to the alternating pressure feature .some devices and products may not be appropriate for the use with this device. Do not use pressure pad alarm or alert systems in conjunction with the overlay .This device is not designed to replace good care giving practices, including, but not limited to .Adequate care plans and training for staff personnel for entrapment and fall prevent . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] physician orders [REDACTED]. The current undated care plan for Resident #16 did not have documentation to use side rails. The facility's .Quarterly Evaluation Bundle (assessment tool) dated [DATE], documented that the resident had not expressed a desire to have side rails raised while in bed. The resident did have fluctuations in levels of consciousness or a cognitive deficit. The resident did have visual deficits. The resident was not able to get in and out of bed safely. The resident did not have a history of falls (at that date). The resident did have problems with balance or poor trunk control. The resident did not use ,[DATE] side rails for positioning or support. The side rail did not help the resident rise from a supine position to a sitting/standing position. The resident did not have postural [MEDICAL CONDITION]. There was no evidence the resident had (or may have had) a desire to get out of bed. The resident did receive medications that required safety precautions. On the form entitled quarterly evaluation bundle summary and findings documented half rails left and right were marked. The resident did not request to have side rails while in bed. The section that documented side rails are indicated and served as an enabler to promote independence was marked No. Side rails were not indicated at that time. Review of the [DATE] nurse's note for Resident #16 by Licensed Practical Nurse (LPN) #7 at 8:00 PM, reflected, incorrect documentation errored out with a line through the documentation indicating it as incorrect. The documentation error referenced revealed, .Called to resident's room by CNA (certified nursing assistant). Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head. With the (assistance) of the CNAs, we laid the resident in the floor. This nurse felt for a pulse, listened for breathing and heartbeat. At this time, another nurse called the DON (Director of Nursing) while this nurse and CNAs transferred resident to the bed. DON was called at 8:10 pm. MD (Medical Doctor) notified at 8:28 pm. Resident was bathed and dressed by CNAs. Review of the [DATE] DON's note for 8:15 PM, documented incorrect documentation errored out with a line through the documentation indicating it as incorrect revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM, spoke to RP (Responsible Party) request that (named funeral home) be called to transport body to funeral home Review of LPN #7's documentation after the incorrect documentation revealed LPN #7 documented on [DATE] at 9:00 PM, .Called to resident's room by CNA. Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard. With the assistance of CNAs, we laid the resident in the floor. This nurse assessed for pulse, breathing and heartbeat. None was found. As this time, Another nurse called the DON while the resident was transferred to bed. DON called at 8:10 pm. MD notified at 8:28 pm. Resident was bathed and dressed by CNAs. On [DATE] at 1:25 PM, The Administrator was asked for all investigations conducted since [DATE]. The Administrator was unable to provide evidence the incident involving Resident #16 was thoroughly investigated. Interview with Confidential Interviewee (CI) #8 on [DATE] at 5:32 PM, in the Conference Room, CI #8 was asked if she knew of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often they check the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the DON came in that night. CI #8 stated, Yes, and the Administrator. CI #8 began to cry. CI #8 was asked if she (referring to Resident #16) had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked if she told the Administrator and DON what happened. CI #8 stated, I told them what had happened. CI #8 was asked if she told them that Resident #16's head was caught in the side rail. CI #8 stated, Yes, and that her legs were on the floor. CI #8 was asked if the resident was in the bed when the DON came. CI #8 stated, Yes. CI #8 was asked if she told both the Administrator and the DON. CI #8 stated, They questioned me. CI #8 was asked if she had been told to not tell anyone. CI #8 stated, I wrote a statement. CI #8 was asked if she wrote what she saw. CI #8 stated, Yes. CI #8 was asked to whom was the statement given. CI #8 stated, (named DON). CI #8 was asked if Resident #16's head was in her normal position since the resident had an outward curvature of the spine. CI #8 stated, When we got her off the floor it was in normal position. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair (reclining geriatric chair) was on the side that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 was asked what other staff were there that night but she could only remember CNA #5. CI #8 was asked if the same bed was in the room. CI #8 stated, I think it is. CI #8 was asked if the resident had a special mattress. CI #8 stated, She had the bubbles, the thing on the foot of the bed. CI #8 was asked if it was an air overlay. CI #8 stated, Yes. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 stated, .Whenever I walked in the room .her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked if she had said her bottom was not touching the ground. CI #12 stated, Right. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up. The jaw line under the mandible was up making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if there were any marks on Resident #16. CI #12 stated, If I remember correctly, there was one on the jaw line. I'm not 100% (percent) but I think there was. CI #12 was asked on which side of her face was the mark. CI #12 stated, On the left side of her face. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked if Resident #16 had fallen. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked what type of mattress Resident #16 had. CI #10 stated, an air mattress. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here . CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was informed that the surveyors had asked for all investigations. An investigation of this incident was not provided by the facility. The DON was asked if an accidental death should be reported to the State Tennessee Department of Health. The DON stated, Yes. The DON was asked if they had any accidental deaths in the facility. The DON stated, No .It looked like she (Resident #16) had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if she had any marks on her (Resident #16). The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left . Because the way she (CNA) had explained to her earlier that was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. Interview with Resident #16's Medical Doctor (MD) #1 on [DATE] at 5:20 PM, by telephone, MD #1 was asked if he was notified when there were events, incidents, or accidents of his residents in the facility. MD #1 stated, Yes they said they just found her dead. MD #1 was asked if he was aware of allegations that her head was caught between the side rails and mattress. MD #1 stated, Not that I know of. I was told she was found dead. If she had a [MEDICAL CONDITION], she may have struggled or that may have caused her death. MD #1 was asked if he would expect that if she was found with her head between the mattress and side rail and her bottom on the floor, that they would tell him. MD #1 stated, Oh, yeah, that kinda sounds like a choking incident or a neck injury. MD #1 was asked if the resident had a problem with her neck. MD #1 stated, She had arthritis and [MEDICAL CONDITION]. She was thin (small) and frail. MD #1 was asked if the kyphosis could exacerbate the possibility of severe injury to the neck. MD #1 stated, It depends on how it was caught .She was thin. She could not have pulled herself out of that position. Interview with Region Nurse Consultant (RNC) #1 on [DATE] at 10:42 AM, in the conference room, RNC #1 was asked what the difference is between an air mattress and an overlay. RNC #1 stated, .The overlay goes over the current mattress. So there is a standard mattress and the overlay is zipped or secured around our mattress. Interview with the Maintenance Supervisor (MS), son of the deceased Resident #16, on [DATE] at 10:42 AM, in room [ROOM NUMBER], the MS was asked if he or the nurses install the overlays. The MS stated, I do not installed them . The MS was asked if Resident #16 ever tried to get up. The MS stated, She has in the past. She was a fall risk, but I mean not so much toward the end (recently) .I don't think the administration handled it well .It is serious business . The MS was asked if it was the same bed in Resident #16's room. The MS stated, Yes. The MS was asked if he had done any repairs on the bed since her death. The MS stated, No. The MS was asked if Resident #16 was mobile. The MS stated, Not very mobile, she had dementia and since the stroke. The MS was asked to describe her mobility. The MS stated, She had jerk motions. She had to be fed .I wouldn't have wanted to see her on the floor. Interview with CI #10 on [DATE] at 1:36 PM, in room [ROOM NUMBER], CI #10 was asked if she had been in-serviced about side rails. CI #10 stated, .No. CI #10 was asked if she had been in-serviced on air overlays. CI #10 stated, No. CI #10 was asked how her head was positioned when she went into the room. CI #10 stated, It was turned up against the side rail. CI #10 was asked what was on the other side. CI #10 stated, The bed .the mattress. Her arm was up on the mattress, I am not sure if it was straight or bent, the left side of the lower jaw was on the side rail. Interview with MS on [DATE] at 3:16 PM in room [ROOM NUMBER], the MS was asked what he had been doing today. The MS stated, looking at some beds making corrective actions .I started ever since there was an issue since yall left (on [DATE]) .I don't know why. I didn't ask. I was in there when you were exiting, the bed entrapment-I don't know. The MS stated, I'm getting educated. The MS was asked if he found any problems with any of the beds. The MS stated, I really didn't come across many, it might have been one .I put in a few wedges, by compliance they might not need it, but to be safe. The MS was asked who had said anything about entrapment. The MS stated, No one, I read it on a piece of paper and as far as the gap in the side rails we didn't have any gaps too big. The MS was asked what he knew about entrapment. The MS stated, I am learning more. If the mattress is too small and if the rails aren't right. If there are gaps too big they can get their arms or legs or heads caught, if they are too big. The MS was asked if he had done anything to Resident #16's bed. The MS stated, No, I haven't done anything to that bed. It is in spec. (specifications) (meets requirements). Interview with CI #12 on [DATE] at 5:19 PM, in room [ROOM NUMBER], CI #12 was asked if she had been in-serviced about side rails in the last year. CI #12 stated, No. CI #12 was asked if she had been in-serviced about bed overlays. CI #12 stated, No, honestly I didn't even know what a bed overlay was until I came to work here . CI #12 was asked if she was present the night of Resident #16's death. CI #12 stated, Yes. CI #12 was asked what was the position of Resident #16's head. CI #12 stated, The side rail is hitting right here (pointing to lower chin) head is turned to right and up. The rail was at her jawline, if I'm not mistaken she actually had a bruise right there where the rail was touching. CI #12 was asked to describe the bruise. CI #12 stated, I'd give it probably 2 or 2 ½ (inches) length. There wasn't much of a width to it (held thumb and forefinger approximately 1 inch apart). CI #12 was asked where the rail was. CI #12 stated, Right there below the ear (pointing to her own ear) and then she rubbed her left lower jawline. CI #12 was asked what had to be done to get her to the floor. CI #12 stated, .I guess we had to pull her a little bit to get her from the rail, had to pull her to the side and once that happened, they just eased her to the floor .so when we pulled her to the side like I said, then gently put her on the floor, so when we pulled her to the side we had to angle her to the side to get her flat. CI #12 was asked if she had given a written statement. CI #12 stated, I personally did not. (Named DON) wrote it . CI #12 was presented with the statement that she had signed, and was asked to re-read it and check it for accuracy. CI #12 re-read the statement and stated, When they say her bottom was close to the floor, her bottom was not touching the floor. Close to the floor but it was not touching the floor. It said her arm and shoulder were lying on the mattress, I would say more pushed against the mattress. They were not lying on the mattress .Maybe I should have sat down and reread this (the DON pre-prepared statement) before I signed it. That's weird how can it be two things. I don't remember her elbow being bent. It was like this. It was straight out. It was the left side of the face, I would say more of the jaw part than the chin area. More right up under that mandible, that bone right there. CI #12 was asked if there were some discrepancies to the statement. CI #12 stated, Yes. CI #12 stated, I would say that's not right. CI #12 was asked if she read that statement before it was signed. CI #12 stated, I did but .she (DON) brought it to me and said read this and sign. Second interview with CI #8 on [DATE] at 9:28 PM, in room [ROOM NUMBER], CI #8 was asked if she had an in-service on side rails. CI #8 stated, Not that I know of. CI #8 was asked if she had an in-service on air mattresses. CI #8 stated, .I don't think so . CI #8 was asked if she had an in-service on overlays. CI #8 stated, I don't even know what that is. CI #8 was asked to describe to the best of their ability the position of Resident #16's head the night of her death. CI #8 stated, I know her head was caught in the railing. She was facing the wall . CI #8 was asked who assisted getting her to the floor. CI #8 stated, Me, (named CI #10, CI #12, CI #11), and another CNA and I can't remember who it was . CI #8 was asked to describe moving the resident to the floor. CI #8 stated, We had to get her neck from the railing. Her neck was caught in the railing. We had to scoot the mattress back away from her neck. It was close to the railing. CI #8 was asked if her right neck was touching the mattress. CI #8 stated, I'm trying to think. One part of the mattress, but she had the bubble thing on top. Interview with CI #18 on [DATE] at 5:25 PM, by telephone, CI #18 was asked if she had been in-serviced about side rails. CI #18 stated, No ma'am. CI #18 was asked if she had been in-serviced on air mattresses. CI #18 stated, No ma'am .not at (named facility). Interview with CI #16 on [DATE] at 10:54 AM, in the DON office, CI #16 was asked if Resident #16 had an order for [REDACTED]. CI #16 was asked if it was necessary to have an order for [REDACTED].#16 was asked if side rails were on Resident #16's current care plan when she died . CI #16 stated, It was not on the most up to date care plan. CI #16 was asked if there was an order for [REDACTED].#16 was asked if Resident #16 had an order for [REDACTED]. CI #16 was asked if there were any concerns using a pressure alarm with the overlay. CI #16 stated, I guess that would depend if the pressure alarm was on the top or under the overlay .I would put it under the overlay. That is the only way I know how to answer that question. CI #16 was asked if the pressure alarm would be effective under the overlay. CI #16 stated, Yes. CI #16 was asked if there were any concerns if the pressure alarm is on top of the overlay. CI #16 stated, I would prefer for it to be under it for stability. CI #16 was asked if the pressure alarm would be effective on the top of the overlay. CI #16 stated, Yeah. Interview with CI #16 on [DATE] at 12:15 PM, in room [ROOM NUMBER], CI #16 was asked if Resident #16 was care planned for the pressure alarm. CI #16 stated, Yes ma'am .and we should have an order for [REDACTED]. Interview with the Interim Administrator (RNC #1) on [DATE] at 9:50 AM, in room [ROOM NUMBER], the Interim Administrator was asked where the policies for the facility's beds and the overlays were. The Interim Administrator stated, We always refer to manufacturer's recommendations for policy for overlays. Interview with the Interim Administrator on [DATE] at 11:12 AM, in room [ROOM NUMBER], the Interim Administrator was shown the manufacturer's guidelines that the MS had given the survey team for the Panacea Air Overlay and the Panacea Bed Manuals. The Interim Administrator was asked to read what the Panacea Bed Manual said on page 4, regarding air mattresses. The Interim Administrator read from the manual, .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefit outweigh the risk of entrapment. The Interim Administrator was asked if those were the guidelines the facility was working under. The Interim Administrator stated, for the beds? Correct, I guess. I can't say 100%. He (MS) gave it to you, so he should know. It is not my area of expertise. The Interim Administrator was asked to read the manufacturer's guidelines of the air overlay on page 6, number 3 about the use of pressure alarms with overlays. The Interim Administrator read from the manual, Do not use pressure pad alarm or alert systems in conjunction with the overlay. The Interim Administrator was asked according to the Panacea overlay manual and according to the guidelines, should a pressure pad be used with an overlay. The Interim Administrator stated, No. The failure of the facility to ensure Resident #16, a vulnerable resident, was assessed, care planned, and had a physician order [REDACTED]. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #45's April and [DATE] physician orders [REDACTED].>Observations in Resident #45's room on [DATE] at 4:00 AM, [DATE] at 4:48 PM, and [DATE] at 6:58 PM revealed Resident #45 lying in bed with quarter rails at the top of the bed in the raised position. Interview with the Interim DON on [DATE] at 10:54 AM in the DON office, the Interim DON was asked if Resident #45 had an order for [REDACTED].

Based on policy review, medical record review, and interview, the facility failed to protect 1 of 13 (Resident #55) residents of the 34 residents included in the stage 2 review for abuse from verbal abuse and fear of retaliation. Resident #55 suffered verbal abuse resulting in psychological harm as evidenced by her tearful, emotional response during interview. The findings included: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy documented, .The resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone .facility staff .Psychosocial harm- Include but are not limited to extreme embarrassment, ongoing humiliation . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] and a Quarterly Review assessment dated [DATE] revealed Resident #55 had a Brief Interview of Mental Status (BIMS) of 15 indicating she was cognitively stable for daily decision making and was not on a physician prescribed weight loss regimen. A PSYCHIATRIC PROGRESS NOTE dated 9/12/16 revealed Resident #55 had a depressed and flat mood/affect and indicated no change in response to treatment. [MEDICATION NAME] (anti-depressant) was increased to 20 milligram (mg) every (q) day. A PSYCHIATRIC PROGRESS NOTE dated 10/26/16 revealed Resident #55's mood/affect was within normal limits (WNL) and was improving in response to treatment. [MEDICATION NAME] was continued. A PSYCHIATRIC PROGRESS NOTE dated 4/3/17 revealed mood/affect WNL, stable response to treatment, and no change in medications. A Social Services note dated 11/3/16 documented, .Resident refuses to get up some days and states she just doesn't feel like it . A physician's progress note dated 1/18/17 documented, Psychiatric: Insight: good judgement .Memory: recent memory normal and remote memory normal . A physician's progress note dated 3/1/17 documented, .PSYCH (psychology) sleep disturb (disturbance) . Review of the monthly Medication Administration Records (MARS) from admission date of [DATE] through 5/4/17 revealed Resident #55 received [MEDICATION NAME] as ordered. Interview with Resident #55 on 4/24/17 at 3:41 PM during Stage 1 resident interviews, Resident #55 was asked if she was treated with respect and dignity. Resident #55 started to say something, hesitated and stated, It would make things worse, if I made them mad. During this interview Resident #55 would not answer the questions related to staff treatment or tell the surveyor any specific concerns she had related to being intimidated, mentally or verbally mistreated. The survey team re-entered the facility on 5/3/17 to continue the investigation and it was discovered the Director of Nursing, the Social Worker, Certified Nursing Assistant #1, #2 and #7 were suspended pending allegations of abuse and intimidation. The Administrator had also resigned. Interview with Resident #55 on 5/3/17 at 4:42 PM in the resident's room, the resident was asked if she was ever mistreated or had someone speak harshly to her while she was in the facility. The resident stated, .I've been treated okay since y'all (you all) came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . The resident was asked who said those things to her. The resident stated, DON (Director of Nursing). The resident was asked what the DON said. The resident stated, One time .She said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, Mr. (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident) she's getting too big and you need to stop bringing her pizza .I don't hate this place just the people that were here. The resident was asked if anyone else had talked to her like that. The resident stated, Uh-uh (No) .she was the only one, ma'am. The resident was asked if there is anyone who is still here that is mistreating her. The resident stated, No ma'am, I've not seen those people since y'all been here so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful, and agitated during the interview when she was relating the telephone conversation the DON had with her boyfriend and apologized for becoming so upset. Interview with Confidential Interviewee (CI) #5 on 5/4/17 at 9:04 AM, in the hallway outside Resident #55's room, CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry. CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me Ms. (Named Resident) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on 5/4/17 at 2:59 PM, in the DON office, CI #16 was asked what were her expectations when a resident is frequently tearful. CI #16 stated, I would expect that they would address and identify what is causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility provided appropriate care and services to prevent verbal abuse and derogatory remarks made to Resident #55. The failure to prevent verbal abuse and fear of retaliation, resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that a resident at risk for falls had interventions implemented after each fall to prevent further falls for 1 of 8 (Resident #1) sampled residents identified with falls. Resident #1 sustained falls on 1/21/11 and 2/9/11. The facility failed to develop interventions after the falls, which resulted in a subsequent fall on 3/4/11, that resulted in actual harm when Resident #1 required medical intervention and sutures from that fall. The findings included: Review of the facility's "Falls Potential and Prevention Protocol" policy documented, "...All falls will be communicated on the 24 Hour Report for review at stand up morning meeting. The care plan will be updated..." Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the fall investigation dated 1/21/11 (11:15 AM) documented, "Resident in (on) floor..." Review of the nurses notes dated 2/9/11 documented, "Resident sitting in (on) floor..." There was no documentation of modification of the interventions to prevent further falls in the medical record. Review of the nurses note dated 3/4/11 at 7:10 AM documented, "...Resident fell on to the floor face down. Laceration over R (right) eye, R arm/wrist appears to be injured. Skin tear to L (left) arm..." Nurses notes dated 3/4/11 at 2:05 PM documented, "...Resident has a laceration with stitches to R eye lid... R wrist... swollen and bruised..." Observations in room 125 on 3/7/11 at 8:55 AM, revealed Resident #1 with bruising around the right eye with sutures above the eyelid. During an interview in room 101 on 3/7/11 at 2:15 PM, the Assistant Director of Nursing (ADON) was asked if any of the falls between 1/8/11 and 3/4/11 had new interventions on the care plan. The ADON stated, "No." Resident #1 sustained falls on 1/21/11 and 2/9/11. The facility failed to develop interventions after the falls, which resulted in a subsequent fall on 3/4/11, that resulted in actual harm when Resident #1 required medical intervention and sutures from that fall.