Every finding on record at Laurelbrook Nursing Home

Based on interview, record review, and facility document and policy review, the facility failed to report allegations of resident-to-resident abuse and results of the investigations within the required timeframes for 3 allegations that involved 5 residents (Residents #2, #41, #23, #53, and #54) of 5 residents reviewed for abuse. A facility policy titled, Abuse, Neglect and Exploitation, revised 12/29/2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy also indicated, VII. A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Resident #2's admission Record indicated the facility admitted the resident on 08/01/2022 . According to the admission Record, the resident had a medical history that included diagnoses of nontraumatic intracerebral hemorrhage, anxiety disorder, schizoaffective disorder, and bipolar disorder. Resident #41's admission Record indicated the facility admitted the resident on 07/03/2024 . According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction, anxiety disorder, and aphasia following cerebral infarction. A facility initial report to the state agency dated 03/14/2025 revealed that at 12:30 PM on 03/14/2025, Licensed Practical Nurse (LPN) #7 witnessed a physical and verbal altercation between Resident #41 and Resident #2. The report revealed the residents were seated in the facility foyer, separated by a bedside table. Per the report, Resident #2 did not like that Resident #41 was so close, and Resident #2 cursed Resident #41, then both residents stood up. Using the palms of their hands, Resident #41 pushed Resident #2 on their chest, and Resident #2 fell backward onto a bench. Resident #41, who was unsteady on their feet, stumbled and fell on the floor. Per the report, neither resident was injured during the incident, and the residents' responsible parties, the Administrator, Director of Nursing (DON), physician, and ombudsman were notified of the incident. The initial report revealed the facility submitted the physical and verbal abuse allegation to the state agency at 3:46 PM on 03/14/2025, three hours and sixteen minutes after the alleged resident-to-resident abuse. There was no documented evidence that the facility submitted a five-day follow-up report to the state agency. During an interview on 05/06/2026 at 2:32 PM, the DON stated an allegation of abuse should be reported to the state agency within two hours, but he was not always able to report within that timeframe. The DON further stated that a five-day follow-up report was not submitted to the state agency because they were waiting for a response regarding the initial report and never heard back from the state agency. During an interview on 05/05/2026 at 8:01 AM, the Administrator stated a five-day follow-up report was not submitted to the state agency following the resident-to-resident abuse allegation between Resident #2 and Resident #41 on 03/14/2025 because he had trouble uploading the report in the days following their investigation. During a follow-up interview on 05/07/2026 at 8:21 AM, the Administrator stated he expected allegations of abuse to be reported to the state agency within two hours if there was harm but believed if there was no harm, the facility had 24 hours to report an allegation of abuse. The Administrator further stated that the resident-to-resident abuse allegation between Resident #2 and Resident #41 was not reported within two hours because there was no harm to either resident. 2. An admission Record revealed Resident #23 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of degeneration of nervous system due to alcohol, unspecified dementia, alcohol dependence, major depressive disorder, and anxiety disorder. An admission Record revealed Resident #53 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. An initial report dated 11/06/2024 indicated, [Resident #23] was standing in the doorway to [Resident #53's] room when [Resident #53] came across [their] room and hit [Resident #23] in the face. The report revealed the incident occurred on 11/06/2024 at 8:15 AM. The report revealed the facility was aware of the incident on 11/06/2024 at 8:15 AM, but it was not reported to the state until 11/06/2024 at 11:15 PM, approximately 15 hours later. A five-day report dated 11/20/2024 indicated, As Activity staff came down the hall [Resident #23] was noted to be standing in the doorway of [Resident #53's room]. [Resident #53] started yelling at [Resident #23] telling [them] to get out of [their] room. [Resident #53] lunged at [Resident #23] and punched [them] in the face. [Resident #23] lost [their] balance and fell back into the closet door. Activity staff told [Resident #53] that [they] cannot hit other residents. [Resident #23] was removed from the area and Team 2 [the Assistant Director of Nursing] nurse notified of the incident. She requested [Resident #53] be on 1:1 supervision. Further review revealed that the report was submitted on 11/20/2024 at an unspecified time, approximately 14 days after the incident. During an interview on 05/06/2026 at 2:32 PM, the Director of Nursing (DON) stated the facility had a two-hour window to report allegations of abuse to the state agency. He stated that the initial report for the incident between Resident #23 and Resident #53 was delayed because that was the time it took to get everything processed, and the facility had exceeded the two-hour timeframe. During an interview on 05/07/2026 at 8:20 AM, the Administrator stated he and the DON were the Abuse Coordinators at the facility. The Administrator stated the facility reported abuse according to the regulations; if there was harm, they reported immediately or within two hours and if there was no harm, then they reported it within 24 hours. The Administrator stated that regarding the incident between Resident #23 and Resident #53, that initial report was delayed because he believed the facility had 24 hours to make the report. The Administrator stated he was not sure why the five-day report for that incident was not submitted until 11/20/2024. 3. An admission Record revealed Resident #54 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, depression, generalized anxiety disorder, weakness, and bed confinement status. An admission Record revealed Resident #53 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. An initial report dated 11/20/2024 indicated that Resident #54 accused Resident #53 of threatening to choke them. The report revealed the incident occurred on 11/19/2024 at 9:30 PM. The report revealed the facility was made aware of the allegation on 11/20/2024 at 8:45 AM, but it was not reported to the state until 11/20/2024 at 6:16 PM, approximately nine hours later. The facility was unable to provide the five-day Report for the incident between Resident #54 and Resident #53. During an interview on 05/05/2026 at 8:03 AM, the Administrator stated there was no 5-day report for the incident between Resident #54 and Resident #53. During an interview on 05/06/2026 at 2:32 PM, the Director of Nursing (DON) stated the facility had a two-hour window to report allegations of abuse to the state agency. He stated that the initial report for the incident between Resident #53 and Resident #54 was delayed because by the time they completed the report, the facility had exceeded the two-hour timeframe. He stated he did not know why there was no 5-day report for the incident between Resident #53 and Resident #54. During an interview on 05/07/2026 at 8:20 AM, the Administrator stated he and the DON were the abuse coordinators at the facility. The Administrator stated the facility reported abuse according to the regulations; if there was harm, they reported immediately or within two hours and if there was no harm, then they reported it within 24 hours. The Administrator stated that regarding the incident between Resident #53 and Resident #54, the initial report was delayed because he believed the facility had 24 hours to make that report.

Based on interview, record review, facility document and policy review, the facility failed to conduct thorough abuse investigations for three allegations that involved 5 (Residents #2, #41, #23, #53, and #54) of 5 residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, revised 12/29/2025, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy also indicated, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. [exempli gratia, for example], not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and / or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 1. Resident #2's admission Record indicated the facility admitted the resident on 08/01/2022 . According to the admission Record, the resident had a medical history that included diagnoses of nontraumatic intracerebral hemorrhage, anxiety disorder, schizoaffective disorder, and bipolar disorder. Resident #41's admission Record indicated the facility admitted the resident on 07/03/2024 . According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction, anxiety disorder, and aphasia following cerebral infarction. The facility's initial report to the state agency dated 03/14/2025 indicated that at 12:30 PM, Licensed Practical Nurse (LPN) #7 witnessed a physical and verbal altercation between Resident #41 and Resident #2 after being in proximity to each other in the foyer of the nursing home. Per the report, Resident #2 did not like that Resident #41 was in their personal space, so Resident #2 cursed at Resident #41, then both residents stood up in an aggressive stance. The report revealed that using the palm of their hands, Resident #41 pushed Resident #2 on their chest, who then fell backward onto the couch. Pre the report, neither resident was injured during the incident, and the facility notified both residents' responsible parties, the Administrator, Director of Nursing (DON), physician, and ombudsman. The report revealed that nursing staff immediately assessed both residents, with no injuries noted. The report revealed Resident #2 and Resident #41 were immediately separated and placed on 1:1 observation for four hours then every 15-minute checks thereafter for 24 hours. Per the report, both residents had a psychiatric consultation, had medication adjustments, and were found to not present a danger to any other residents. The report revealed both residents de-escalated within a few minutes and apologized to each other. Further review revealed there was no evidence that a threat continued to exist. The facility's investigation did not include interviews or assessments of other cognitive and non-cognitive residents. During an interview on 05/05/2026 at 4:07 PM, LPN #7 stated witness statements from staff in the vicinity were taken, but she was not sure how other residents were assessed for potential abuse following the altercation. During an interview on 05/06/2026 at 2:32 PM, the DON stated a thorough investigation following an allegation of abuse included a resident's comprehensive chart review and staff and resident interviews related to the allegation. The DON further stated there was no indication there was potential abuse with other verbal and non-verbal residents, so they did not assess anyone else other than Resident #2 and Resident #41 for potential signs of abuse. During an interview on 05/07/2026 at 8:21 AM, the Administrator stated a thorough investigation included witness statements and provider follow-up for ongoing clinical concerns. The Administrator stated that for this incident other residents were not interviewed related to potential abuse because it appeared to be an isolated incident. 2. An admission Record revealed Resident #23 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of degeneration of nervous system due to alcohol, unspecified dementia, alcohol dependence, major depressive disorder, and anxiety disorder. An admission Record revealed Resident #53 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. An initial report submitted to the state agency on 11/06/2024 at 11:15 PM, indicated Resident #23 was standing in the doorway to Resident #53's room when Resident #53 came across their room and hit Resident #23 in the face. The report revealed witnesses included the Former Activities Director. A five-day report submitted to the state agency on 11/20/2024, indicated, As Activity staff came down the hall [Resident #23] was noted to be standing in the doorway of [Resident #53's room]. [Resident #53] started yelling at [Resident #23] telling [them] to get out of [their] room. [Resident #53] lunged at [Resident #23] and punched [them] in the face. [Resident #23] lost [their] balance and fell back into the closet door. Activity staff told [Resident #53] that [they] cannot hit other residents. [Resident #23] was removed from the area and Team 2 [the Assistant Director of Nursing] nurse notified of the incident. She requested [Resident #53] be on 1:1 supervision. During an interview on 05/06/2026 at 1:46 PM, the Administrator stated they had provided everything they had on the investigation for the incident between Resident #23 and Resident #53. He stated they completed witness statements and other components of the investigation but were unable to find them. During an interview on 05/06/2026 at 2:32 PM, the Director of Nursing (DON) stated a thorough abuse investigation included interviewing the involved residents, interviewing the involved staff, pulling the medical records for each resident involved, and filling out a concern form. He stated that he did not know where the signed witness statements or body audits were for the incident between Resident #23 and Resident #53. During an interview on 05/07/2026 at 8:20 AM, the Administrator stated a thorough investigation included interviews with witnesses, the perpetrator, and victims. The Administrator stated that to give their statement, they filled out a statement form and if they were unable to write, the interviewer could write it for them. The Administrator stated that regarding the incident between Resident #23 and Resident #53, they talked to people but somehow the statements did not make it into the investigation files. 3. An admission Record revealed Resident #54 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, depression, generalized anxiety disorder, weakness, and bed confinement status. An admission Record revealed Resident #53 was admitted to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. An initial report dated 11/20/2024 indicated Resident #54 accused Resident #53 of threatening to choke them. The report revealed the incident occurred on 11/19/2024 at 9:30 PM. The facility was unable to provide the five-day Report for the incident between Resident #54 and Resident #53. During an interview on 05/06/2026 at 1:46 PM, the Administrator stated they had provided everything they had on the investigation for the incident between Resident #54 and Resident #53. He stated they completed witness statements and other components of the investigation but were unable to find them. During an interview on 05/06/2026 at 2:32 PM, the Director of Nursing (DON) stated a thorough abuse investigation included interviewing the involved residents, interviewing the involved staff, pulling the medical records for each resident involved, and filling out a concern form. He stated that he did not know why they could not find the investigation for the incident between Resident #54 and Resident #53. During an interview on 05/07/2026 at 8:20 AM, the Administrator stated a thorough investigation included interviews with witnesses, the perpetrator, and victims. The Administrator stated that to give their statement, they filled out a statement form and if they were unable to write, the interviewer could write for them. The Administrator stated that regarding the incident between Resident #53 and Resident #54, he stated they talked to people but somehow the statements did not make it into the investigation files

Based on observation, interview, record review, facility policy review, and Centers for Medicare and Medicaid Services (CMS) guidelines, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #29) 2 sampled residents reviewed for infection control. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 10/01/2025, indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy specified in the section Initiation of Enhanced Barrier Precautions that, b. A standing order for enhanced barrier precautions will be used for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling medical devices (e.g., urinary catheters, feeding tubes, tracheostomy, hemodialysis catheters, [sic]) even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism]. The policy specified in the section, Implementation of Enhanced Barrier Precautions that, a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. The policy also indicated, PPE [Proper Protective Equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. The policy also indicated, 4. High-contact resident care activities include, and g. Device care or use: urinary catheters, feeding tubes, tracheostomy, hemodialysis catheter. A Centers for Medicare and Medicaid Services memorandum, QSO-24-08-NH, titled, Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024 and effective 04/01/2024, in the section, Memorandum Summary, revealed, EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Under the section, Guidance, the memorandum revealed, Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. An admission Record revealed the facility admitted Resident #29 on 10/05/2006. According to the admission Record, the resident had a medical history that included diagnoses of gastrostomy status, bed confinement status, and gastro-esophageal reflux disease with esophagitis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #29 had a feeding tube while a resident. Resident #29's Care Plan Report, included a focus area initiated 07/20/2020, that indicated the resident had a PEG (Percutaneous Endoscopic Gastrostomy tube, a tube placed from the abdominal wall into the stomach) tube feeding. Interventions directed staff to provide local care to the tube site as ordered and to monitor the site for signs and symptoms of infection (07/20/2020). Resident #29's Care Plan Report did not include EBP. Resident #29's Order Summary Report, with active orders as of 05/04/2026, revealed, NPO [nil per os, nothing by mouth] diet, NPO texture, NPO consistency, Tube feeding, dated 02/21/2024. The Order Summary Report did not include EBP. Resident #29's Certified Nursing Assistant's (CNA) task list (a list describing essential patient care tasks) did not include EBP. An observation, on 05/04/2026 at 9:49 AM, revealed that Registered Nurse (RN) #3 administered medication to Resident #29 via the PEG tube while wearing gloves, but RN #3 did not wear a gown. RN #3 stated they wore gloves when providing a tube feeding, and RN #3 did not provide an explanation for not wearing a gown. The observation revealed no EBP posting for Resident #29's room. On 05/04/2026 at 10:00 AM, CNA #4 stated she did not wear a gown during incontinence care, dressing, or linen changes for Resident #29. On 05/04/2026 at 3:40 PM, the Director of Nursing (DON) stated RN #3 broke infection control protocol by failing to wear a gown during care provided to Resident #29. On 05/05/2026 at 9:57 AM, the Infection Preventionist (IP) stated she was unaware that Resident #29's room lacked the required signage. The IP confirmed that RN #3 should have worn a gown during medication administration via the PEG tube to prevent the spread of organisms. The IP stated that gowns were required during close-contact care including linen changes, dressing, and incontinence care, and CNA #9 did not follow proper EBP precautions. On 05/05/2026 at 10:12 AM, the Minimum Data Set Coordinator (MDSC) stated that EBP must be documented on the CNA's task list to ensure staff were aware of and followed the required precautions. The MDSC stated Resident #29 did not have an order for EBP. The MDSC stated she had not been adding the EBP to the CNA's task list because she was just made aware of the need the day prior. The MDSC stated she was also responsible to ensure Resident #29 had an order for EBP. On 05/06/2026 at 1:03 PM, the Director of Nursing (DON) stated they expected RN #3 to follow EBP, including wearing gloves and a gown, for Resident #29. The DON stated they expected the same precautions to be followed by CNA #4, including the use of gloves and a gown. On 05/07/2026 at 8:09 AM, the Administrator (ADM) stated the expectation was for facility staff to wear proper PPE during medication administration to Resident #29. The ADM stated CNA #4 was also expected to wear appropriate PPE.

Based on facility policy review, refrigerator temperature logs review, and interview the facility failed to maintain complete refrigerator temperature logs for 3 of 3 refrigerator temperature logs reviewed which had the potential to affect 43 of 43 residents. The findings include: Review of the facility's policy titled, Refrigerators and Freezers, dated 3/11/2019, revealed .The facility will ensure safe refrigerator and freezer .temperatures .Monthly tracking sheets for all refrigerators .will be posted to record temperatures .Monthly tracking sheets will include time, temperatures, initials . Review of refrigerator temperature logs for 8/1/2024-10/22/2024 revealed there was no documentation the refrigerator temperatures had been obtained as follows: Food Black refrigerator #3 8/2024 - 5 of 31 days (8/1/2024, 8/2/2024, 8/3/2024, 8/4/2024, and 8/5/2024) 9/2024 - 2 of 30 days (9/12/2024 and 9/16/2024) 10/2024 - 3 of 22 days (10/3/2024, 10/7/2024, and 10/11/2024) Medication refrigerator labeled Team 1 9/2024 - 2 of 30 days (9/12/2024 and 9/16/2024) 10/2024 - 3 of 22 days (10/3/2024, 10/7/2024, and 10/11/2024) Medication refrigerator labeled Team 2 9/2024 - 2 of 30 days (9/12/2024 and 9/16/2024) 10/2024 - 3 of 22 days (10/3/2024, 10/7/2024, and 10/11/2024) During an interview on 10/23/2024 at 4:45 PM, the Interim Director of Nursing confirmed the refrigerator temperature logs were incomplete and the facility failed to follow the facility's policy maintaining temperature logs.

Based on policy review, medical record review, and interview the facility failed to provide information to the resident or resident responsible party regarding their right to formulate an advance directive for 3 residents (Resident #7, #40, and #94) of 16 residents reviewed for advance directives. The findings include: Review of the facility's policy titled, Advance, Directive, Presence of, revised 11/2013, revealed .Advance Care Plan (Living Will) are written instructions stating how you want your future medical decisions made, in the event that you become unable to make or to communicate such decisions for yourself .A patient/resident may have written directions related to treatment choices .in accordance with state law. An advance directive is a means for the resident to communicate his or her wishes, which may include withdrawing or withholding medications . The .Patient Rights & [and] Responsibilities .statement provided to the resident and/or family member when admitted to the facility includes a statement regarding the honoring of their Advance Directive (Living Will) . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Cardiovascular Disease, Anxiety, Nontraumatic Subdural Hemorrhage, Epilepsy, Dementia with Mood Disturbance, Bipolar Disorder, and Borderline Personality Disorder. Review of the ORDER APPOINTING CONSERVATOR for Resident #7, dated 10/23/2023, revealed no documentation of instructions for advance directives. Review of the LETTERS OF CONSERVATORSHIP for Resident #7 dated 10/26/2023, revealed no documentation of instructions for advance directives. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored 4 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Review of the medical record for Resident #7 revealed there was no documentation the resident had an advance directive or if the resident would like to formulate an advance directive. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Altered Mental Status, Major Depressive Disorder, Encephalopathy, and Bilateral Sudden Vision Loss. Review of an undated APPOINTMENT OF HEALTH CARE AGENT for Resident #40 revealed no documentation of instructions for advance directives. Review of an admission MDS assessment dated [DATE], revealed Resident #40 scored 10 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #40 revealed there was no documentation the resident had an advance directive or if the resident would like to formulate an advance directive. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including Dementia with other Behavioral Disturbance, Pseudobulbar Effect, Anxiety, Depression, and Cerebral Infarction. Review of an admission MDS assessment dated [DATE], revealed Resident #94 had severe cognitive impairment. Review of the medical record for Resident #94 revealed there was no documentation the resident had an advance directive or if the resident would like to formulate an advance directive. During an interview on 10/23/2024 at 4:45 PM, the Interim Director of Nursing confirmed information for developing an advance directive was not provided on admission for Resident #7, #40, and #94 or the resident's representatives.

Based on facility policy review, review of facility documentation and interview, the facility failed to report an allegation of abuse to the State Designated Authority (State Agency) for 1 resident (Resident #321) of 27 residents reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Funds Protocol, undated, revealed .Covered Individual is any owner .employee, manager, agent .of this facility. If a covered individual observes events or becomes aware of information .suspicion of crime has occurred against a resident or individual receiving care from this facility .[the facility] Must notify .The State Survey Agency .Local Law Enforcement .Reports must be within 24 hours (if there is not serious bodily injury) .Within 2 hours (if there is serious bodily injury) .Staff members and persons affiliated with this facility shall not knowingly .Fail to report an incident .withhold information to reporting agencies . Review of the medical record showed Resident #321 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Amnesia, Adjustment Disorder with Anxiety, Psychoactive Substance Abuse-In Remission, Alcohol Abuse Counseling and Surveillance of Alcoholic, Alcohol Abuse, and Homelessness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #321's Brief Interview of Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. The resident required minimal assistance from facility staff with activities of daily living (ADL's). Medical record review of a current care plan for Resident #1 showed Focus .The resident is/has potential to be verbally aggressive . Appropriate interventions were implemented. Review of a facility investigation documentation titled, CONCERN FORM, dated 1/1/2024, revealed the following: 1. Logged as a concern from a Resident. 2. Resident #321 was named on the Concern Form. Continued review showed .[Resident #321's name] complained that CNA .had threatened him and had also hit two other residents .Resident was not able to say who they were .He said I don't know . This document was written and signed by the Director of Nursing Jan. 1, 2024. Review of a facility investigation documentation titled, POC [plan of correction] For Concern, undated, revealed the following persons and dates of notification .Family 1/1/2024 .Doctor 1/2/2024 .Director of Nursing (DON) 1/1/2024 .Administrator 1/2/2024 .Adult Protective Services 1/2/2024 .Crisis 1/2/2024 .Sheriff 1/5/2024 .Ombudsman 1/2/2024 . Continued review revealed no documentation to indicate the State Survey Agency was notified. Review of the Intake Information document generated from the State Agency dated 1/5/2024, 11:49 AM, revealed .[other state agency notification] .is making accusations of physical abuse against the staff member .The administration has reported the accusations to the ombudsmen [ombudsman], and the ombudsmen advised the administration to report it to Adult Protection Services as well . Continued review showed the alleged event was known by key personnel in the facility on 1/1/2024 at 8:45 PM, which included the resident notification because he was his own responsible party. The other state agency notification was another state agency calling in a complaint to the State Survey Agency of physical abuse allegations. The facility failed to submit a timely self-reported Complaint Intake to the State Agency on 1/1/2024 for the allegations of physical abuse made by Resident #321. The facility was greater than 3 days late in reporting. During an interview on 11/23/2024 at 5:33 PM, the Administrator confirmed the facility failed to notify the State Survey Agency timely of the physical abuse allegation made by Resident #321.

Based on medical record review and interview the facility failed to submit a Pre-Admission Screening and Resident Review (PASARR) to the state-designated authority after a new mental health diagnosis was added for 1 resident (Resident #31) of 27 residents reviewed for PASARR. The findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Homelessness, Post Traumatic Stress Disorder, and Major Depressive Disorder. Continued review revealed a diagnosis of Bipolar Disorder was added on 8/27/2024. Review of the PASARR for Resident #31 dated 6/27/2024, revealed the diagnoses of Anxiety Disorder, Depression, and Post-Traumatic Stress Disorder was noted on the PASARR. Continued review revealed no documentation a new PASARR had been submitted after a new mental health diagnosis of Bipolar disorder was added on 8/27/2024. During an interview on 10/23/2024 at 2:32 PM, the Interim Director of Nursing confirmed a submission for a level II PASARR was not submitted to the state designated authority after a new mental health diagnosis was added for Resident #31.

Based on review of a facility policy, medical record review, and interview, the facility failed to obtain a physician's order for a physical restraint for 1 resident (Resident#1) and monitoring of a physical restraint for 14 of 31 days the restraint was utilized of 4 residents reviewed for physical and chemical restraints. The findings included: Review of a facility policy titled, Restraint Policy, not dated, showed .Definition of a Physical Restraint: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the residents' body that the individual can not remove easily, which restricts freedom of movement or normal access to one's body .8 .a doctor's order must be obtained to implement restraints . Resident #1 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Suicidal Ideations, Mood [Affective] Disorder, Adjustment Disorder, Vascular Dementia, Delusional Disorders, Anxiety Disorder, Nonalcoholic Steatohepatitis, Transient Cerebral Ischemic Attack, Non traumatic Intracerebral Hemorrhage, Fatty Liver, Osteoarthritis, and Hepatomegaly. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score assessment of 13 which indicated the resident was cognitively intact. The resident was independent with walking, dressing, personal hygiene, required supervision with no assistance for bed mobility, toilet use, supervision with set up for transfer, walking, required limited assistance of 1-person assist with eating. Review of Resident #1's Physician Order dated 2/26/2023, showed .Pressure alarm while in bed .soft waist restraint while up in a wheelchair as attempts to ambulate and puts self on the floor. Release for 10 minutes every 2 hours while toileting resident .for 14 days [discontinue date of 3/12/2023] .Pressure alarm while in the bed . Review of Resident #1's comprehensive care plan dated 2/26/2023, showed the resident was removing the clip alarm, the soft belt while up in wheelchair was changed to a pelvic posey as the resident was sliding under the soft belt. Review of Resident #1's Medication Administration Record (MAR) for February 2023, showed Pressure alarm while in the bed Started 2/26/2023, a discontinue date of 3/28/2023, and a soft waist restraint while up in a wheelchair as attempts to ambulate and puts self on the floor. Release for 10 minutes every 2 hours while toileting resident. Every shift for 14 days Start date 2/26/2023. Review showed the restraint was monitored every shift (3 shifts/day). Review of Resident #1's Medication Administration Record for March 2023, showed Pressure alarm while in the bed started 2/26/2023, a discontinue date of 3/28/2023, and a soft waist restraint while up in a wheelchair as attempts to ambulate and puts self on the floor. Release for 10 minutes every 2 hours while toileting resident. Every shift for 14 days Start date 2/26/2023. Continued review showed the restraint was monitored every shift (3 shifts/day) through 3/12/2023 (2 shifts). No additional monitoring was documented, and no new order was noted to continue the restraint from 3/12/2023-3/28/2023. During an interview on 12/13/2023 at 12:00 PM, Certified Nursing Assistant (CNA) #2 stated .yes she [Resident #1] did have the restraint when she was in a wheelchair until she discharged .we did give her breaks we toileted her at least every 2 hours, she could still pivot to the commode and take a few steps . During an interview on 12/13/2023 at 1:10 PM, CNA #1 stated .she [Resident #1] was restrained until she discharged [3/28/2023] if she was in a wheelchair .we did release her every two hours and walk her to the toilet . During an interview on 12/13/2023 at 2:50 PM, the Director of Nursing (DON) stated .Resident #1 did have an order for a physical restraint beginning on 2/26/2023 for 14 days, to be released for 10 minutes every 2 hours while toileting, also by placing it on the MAR the nurse was required to physically check the restraint every shift for tightness, red marks, abrasions, proper placement of the restraint .the order discontinued on 3/12/2023, the restraint was continued until discharge on [DATE] [14 days after the discontinue date] . A new physician's order had not been obtained to continue the restraint beyone the 14 days and there was no documentation of the restraint being monitored from 3/12/2023-3/28/2023.

Based on medical record review, facility documentation, and interview, the facility failed to refer 1 resident (Resident #1) of 4 residents reviewed to the state-designated authority for a Level II PASRR (Pre-Admission Screening and Resident Review) after the resident was identified with possible serious mental disorder. The findings include: Review of Resident #1's Pre-Admission Screening and Resident Review (PASRR) Level 1 Screen Outcome dated 11/30/2022, showed .No mental health diagnosis is known or suspected .Mental Health Symptoms .Physical Violence .current or within the past 30 days .Excessive Tearfulness .current or within the past 30 days .Inpatient Psychiatric Hospital .current or within the past 30 days .Psychotropic Medications .Seroquel 25 mg [milligram] daily . The PASRR showed the resident had no diagnosis of Anxiety Disorder or Suicidal Ideations at the time the Level I PASRR was submitted. Therefore, no Level II evaluation was completed due to a negative Level I PASRR. Resident #1 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Suicidal Ideations (added on 3/22/2023), Mood [Affective] Disorder, Adjustment Disorder, Vascular Dementia, Delusional Disorders, Anxiety Disorder (added on 1/25/2023), Nonalcoholic Steatohepatitis, Transient Cerebral Ischemic Attack, Non-traumatic Intracerebral Hemorrhage, Fatty Liver, Osteoarthritis, and Hepatomegaly. Review of facility documentation revealed no documentation a PASRR Level II had been submitted after Resident #1 was admitted to the facility on [DATE] for the diagnoses of Anxiety Disorder or Suicidal Ideations. Review of Resident #1's Admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. During an interview on 12/13/2023 at 3:30 PM, with the Assistant Director of Nursing stated a new PASARR had not been submitted to the state designated authority by the facility for a diagnosis of Suicidal Ideations, or Anxiety.

Based on review of a facility policy, medical record review, and interview, the facility failed to follow a physician's order to apply a back brace daily, for 1 resident (Resident#1) of 4 residents reviewed for physicians' orders. The findings included: Resident #1 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Suicidal Ideations, Mood [Affective] Disorder, Adjustment Disorder, Vascular Dementia, Delusional Disorders, Anxiety Disorder, Nonalcoholic Steatohepatitis, Transient Cerebral Ischemic Attack, Non-traumatic Intracerebral Hemorrhage, Fatty Liver, Osteoarthritis, and Hepatomegaly. Review of Resident #1's Admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The resident was independent with walking, dressing, personal hygiene, required supervision with no assistance for bed mobility, toilet use, supervision with set up for transfer, walking, required limited assistance of 1-person assist with eating. Review of Resident #1's Incident Note dated 1/16/2023 at 1:45 AM, showed .late entry .CNA [Certified Nursing Assistant] notified nurse, resident sitting in the floor leaning against her closet door. No injury noted. I got out of bed, and I was walking over to the light switch to turn off the bedroom light. My slipper came off and I fell landing on my bottom with back against the closet door and hit my head on the closet door. Assessment done and no apparent injury .VS [vital signs] completed. CNA returned resident to her bed . Review of Resident #1's Health Status Note dated 1/16/2023 at 7:00 AM, showed .writer in to assess resident post fall. Resident has increased confusion from baseline, C/O [complained of] head pain, nothing visual. C/o left hip pain, nothing visual. Pain 6 out of 10 after asking many times. MD [Physician] notified and new order to send to ER [emergency room ] for eval. Family notified of transfer .Resident placed on bed rest pending eval. [evaluation] Resident refuses bed pan and walks to bathroom, limping and expressing pain with each step . Review of Resident #1's Health Status Note dated 1/16/2023 at 8:45 AM, showed .out with EMS [Emergency Management Services] at 8:45 AM .report called to .ER . Review of Resident #1's Health Status Note dated 1/16/2023 at 11:51 AM, showed .Report called from .ER .Fracture to L5 [in the lowest lumbar vertebra of the lower back lumbar spine], new order to give Tylenol 325 [milligram] with continued previous Tramadol for pain management .writer asked about results from head injury [ER Staff] responded 'not assessed due to confusion at minimal level .stated resident was being sent back to facility then ended call . Review of Resident #1's Hospital Emergency Department Documentation dated 1/16/2023, showed .hip/thigh problem .CT [computed tomography] .left hip and pelvic pain post fall .here is mild acute compression fracture at L1 [L5] with loss of approximately 15% of the expected high [height] of the vertebral body .bone fragment may be retro pulsed posteriorly 2 to 3 mm .no evidence of involvement of the pedicles or spinous processes .Iliac appear intact. Pubic rami appear intact. Femoral necks are intact. No acute sacral fracture is identified .Marked osteopenia .mild superior endplate compression fracture L5 with minimally retro pulsed bone fragment .no other acute fracture is identified . Review of Resident #1's Incident Note dated 2/12/2020, showed .resident's roommate came out of her room stating resident had fallen. As I approached the room, the resident was yelling for help. Resident was laying on the floor on her side, beside her bed. Resident states she was standing beside her bed without her cane, completing a crossword puzzle and felt dizzy, lost her balance, and fell to the floor. Resident asked her roommate to go get help. Resident was assessed. A&O [alert and oriented] X 3, pain level 5, ROM[range of motion] WNL [within normal limits], Skin assessment completed. No cuts or abrasions noted. Bruising above left eyebrow with swelling. Resident raised to sitting position and assisted to bed. Cold compress applied to swelling. EMT contacted and resident transported to [hospital] .report called to ER. MD, notified, Family notified . Review of Resident #1's ED Notes dated 2/12/2023, showed .Chief complaint Fall .patient is awake and in no distress .patient discharged to [nursing home] .patient condition upon discharge was stable .diagnostic workup in the emergency room was questionable for subacute vs old compression fracture in the L5 roughly about 30% .Patient was discussed with .mid-level working with the orthopedic surgeon .patient is to be prescribed a back brace and follow-up with him in the office .back brace apply 1 once a day . A Physicians Order was included in the resident's ED paperwork showing .Prescription for Back Brace .Dispense amount 1 (one) Frequency Apply 1 once daily (QD) [every day] . No order was present for a follow up with a surgeon. During an interview on 12/13/2023 at 11:30 AM, the Medical Director stated .I do not believe in retrospect any harm came to the resident related to the back brace not being applied .there was not a decline or increase in symptoms or complaints of increased pain .possibly it could have decreased her comfort from not having the brace but her pain was controlled with the medications prescribed .her pain was controlled with Tramadol and Tylenol and there was no indication her pain and comfort from the fracture were not being controlled. The brace would not have prevented progression of the fracture and not having the brace did not change her outcome .she did have osteopenia and due to her dementia, I would not have considered her as a surgical candidate .the fracture could have been spontaneous which led to the fall on 1/16/2023 that would be impossible to determine which occurred first . During an interview on 12/13/2023 at 2:50 PM, the Director of Nursing stated .Resident #1 did go to theER on [DATE] related to a fall, when she returned to the facility, the discharge did include an order for a back brace however, the hospital did not send the order back with her and we were not aware of the order. We did receive the documentation with the order sometime later and we did not follow through with the back brace order.

Based on facility policy review, review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to identify a severe weight loss and decline in 1 or more Activities of Daily Living (ADL) as a significant change in a resident's condition and failed to complete a significant change assessment after a severe weight loss for 1 Resident (#30) of 4 residents reviewed for assessments. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy Care Plans-Comprehensive undated, revealed .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans; When there has been a significant change in the resident's condition; When the desired outcome is not met .At least quarterly . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .MDS [Minimum Data Set] Coordinator will follow RAI guidelines for .a significant change related to weight loss . Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2019 revealed .A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan An SCSA [Significant Change Status Assessment] is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and The resident's condition is not expected to return to baseline within two weeks .Guidelines to Assist in Deciding If a Change Is Significant or Not .An SCSA is appropriate if there are either two or more areas of decline .Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence .since last assessment .Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) . Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The resident's functioning for ADLs included limited assistance for bed mobility; extensive assistance for transfers; activity of walking in room and walking in corridor did not occur; total dependence for locomotion on and off the unit; extensive assistance for dressing; supervision and setup help only for eating and toilet use; and extensive assistance for personal hygiene. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The resident's functioning for ADLs included limited assistance for bed mobility; extensive assistance for transfers, walking in room, and walking in corridor; total dependence for locomotion on and off the unit and dressing; limited assistance for eating; and total dependence for toilet use and personal hygiene. The MDS documented the resident experienced an unplanned weight loss of 5% or more in a month or loss of 10% or more in the last 6 months. Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. weight loss or 12.2% - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days Record review revealed a significant change of status MDS assessment was not completed after Resident #30 had a decline in 1 or more ADL care needs and an unplanned weight loss of 5% in 30 days or 10% or more in 180 days. The failure to complete a significant change assessment prevented a change in the resident's care plan with initiation of interventions to prevent further weight loss per the facility's Weight Management Policy. During a telephone interview on 1/26/2022 at 1:18 PM, the MDS Coordinator confirmed she failed to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced a decline in 2 or more ADL care needs and an unplanned weight loss greater than 10%. Further interview revealed due to the facility's failure to identify the significant change in the resident's condition on 12/21/2021, Resident #30 had further weight loss on 1/26/2022 of 12.5 lbs. (a total of 40.5 lb. weight loss, or 20.2 %, since admission on 9/7/2021). Interview with the Administrator on 2/15/2022 at 6:48 PM, confirmed the facility failed to identify and submit a significant change MDS for Resident #30's severe weight loss. Facility Corrective Actions included: 1. On 2/16/2022 an Interdisciplinary (IDT) team meeting was held to establish the team - Director of Nursing (DON) #1, DON #2, Assistant Director of Nursing (ADON), MDS Coordinator, Registered Dietitian (RD) via telephone or email (in the RD's absence the physician will be notified), Dietary Manager or Designee, and the Activities Director. Discussion included meeting daily, review of Resident #30's weight loss, and review the IDT Meeting agenda. On 2/17/2022 and IDT meeting addressed the RD's recommendations, audited 100% of the charts for the nutritional care plan, and updated with the interventions/recommendations. On 2/18/2022, the Physician will review the RD notes. The Census of 42 residents were evaluated for weight changes. There were 6 residents with weight loss (including Resident #30), 5 residents with weight gain, and 2 significant weight changes (including Resident #30) which were noted. The minutes of the IDT meeting will be taken by one of the IDT members, put into a folder, and maintained in the DON's office. The DON or designee will be responsible for follow-up action taken in the IDT meetings. Concerns will be identified using the 24-hour report, incidents, weight tools, electronic medical record dashboard alerts, and audits. 2. The Medical Director was notified of Resident #30's weight loss on 1/27/2022 and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician ordered to continue weekly weights for 3 weeks or until trend turn around. The Clinical Notes had previously implemented visualized 1 on 1 feeding of Resident #30 on 1/9/2022 and a high protein nutritional supplement beverage on 1/27/2022. 3. The RD completed Comprehensive Nutrition Assessments on 2/16/2022 and 2/17/2022 for 10 residents demonstrating significant weight changes including Resident #30. The RD's recommendations included to continue the current diet and high protein nutritional supplement beverage 3 times daily, continue eating in the dining room, and assist with meals, and to confer with provider to rule out changes in medication that may cause drowsiness. Further review showed the No Added Salt to Resident #30's diet was discontinued. The RD Comprehensive Nutritional Assessment included pertinent resident information, recommendations, and goals. The RD will be involved in the IDT daily meeting via telephone or email (if RD unavailable, the MD will be notified). The administrator or designee will audit the RD's dietary notes utilizing a checklist of documentation requirements of comprehensive nutrition analysis on a weekly basis for 6 weeks and then monthly for 3 months. 4. The MDS Coordinator completed the Significant Change MDS Assessment on 1/26/2022. The MDS Coordinator will be involved in the IDT daily meeting. The DON or designee will audit the nutrition assessments for new admissions, quarterly assessments, significant changes, and annual assessments on a weekly basis for 6 weeks and then monthly for 3 months. 5. The IDT completed a webinar on Significant Change Assessment with a post-test on 2/16/2022. On 2/18/2022, the surveyors validated by review of sign-in sheets, and interview with IDT members, an IDT meeting was conducted on 2/16/2022. Interviewed staff included the Administrator, DON #1, ADON, RD via phone, Activities Director (AD), and MDS Coordinator. The surveyors reviewed the electronic medical records and comprehensive care plans of 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) which were identified with weight changes and validated the facility had revised and updated the care plans, accordingly. The surveyors validated the IDT meeting minutes held on 2/16/2022 was obtained and maintained in the DON's office. Interview with DON #1 validated DON #1 was knowledgeable about the IDT meetings, the agenda, obtaining and maintaining the minutes of the meetings, and the responsibilities of follow up on any issues identified during the meetings. On 2/18/2022, the surveyors reviewed an agenda used for daily meetings held with the DON, ADON, MDS, RD via telephone or email, Physician as needed or in absence of the RD, Dietary Manager or designee, and the Activities Director. The surveyors reviewed the agenda form from a meeting conducted on 2/17/2022. The surveyors validated the agenda information was discussed and included the weight loss of Resident #30, by review of the completed agenda form and interviews with the department head staff including a dietary manager designee, MDS Coordinator, ADON, DON #1, Maintenance Director, the Activities Director, and the Administrator. The agenda and meeting minutes were maintained by the DON. Continued review by the surveyors on 2/18/2022, validated the identified information discussed during the meeting included weight loss, weight gain, and significant weight change of 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91). On 2/18/2022, the surveyors validated the IDT Meeting dated 2/17/2022 had been conducted and included the care plan chart audits. The meeting was held with DON #1, the ADON, and the MDS Coordinator and the findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised. The surveyors validated the 24-hour report form had been completed during the IDT meeting dated 2/17/2022. Interviews with the ADON, the MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN) validated the staff were knowledgeable regarding the 24-hour report and importance of discussing the report during the daily Stand-Up meetings. On 2/18/2022, the surveyors validated Resident #30 had new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors validated Resident #30 had been on weekly weights implemented on 1/27/2022 and continued the weekly weight monitoring form. The surveyors reviewed the Physician's Orders, Comprehensive Care Plan, and Meal Tray Card for Resident #30 and validated the documentation matched for a pureed diet with high protein nutritional supplement beverage 3 times daily. On 2/18/2022, the surveyors observed, and validated Resident #30 received the diet as ordered and consumed 100% of the meals. Continued observation revealed Resident #30 was provided his meals in the dining room with the assistance of staff. On 2/18/2022, the surveyors validated the Comprehensive Nutritional Assessment for Resident #30 had been completed by the RD on 2/16/2022. The Comprehensive Nutritional Assessment included Resident #30's pertinent information and included weight history, laboratory values, recommendations, goals, and metabolic needs. The surveyors reviewed Comprehensive Nutritional Assessments had been completed on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91). During a telephone interview on 2/18/2022, the RD verbalized understanding and was knowledgeable of the new comprehensive nutritional assessment tool and when the assessment was to be completed. The RD verbalized understanding of the new IDT process and her role in those meetings. The surveyors reviewed the Comprehensive Nutritional Assessment and interview with the Administrator on 2/18/2022 validated the Administrator had conducted the audits using the Nutritional Assessment Tool. On 2/18/2022, the surveyors reviewed and validated a teachable moment dated 2/16/2022 had been conducted by the Administrator. Interviews with the Administrator and the MDS Coordinator verified understanding of the teachable moment which consisted of review of the weekly and monthly weights to determine if any significant changes had occurred and if cases were identified, the MDS Coordinator was to bring the information to the IDT meeting. After the IDT determined a significant change existed, the MDS Coordinator was responsible to submit the significant change MDS. Interview with the MDS Coordinator on 2/18/2022 validated she received and understood the education provided. Review of a Significant Change MDS showed the MDS had been submitted on Resident #30. On 2/18/2022, the surveyors validated by review of post-test documentation, sign-in sheets, and interviews with the Administrator, ADON, MDS coordinator, Certified Nursing Assistant (CNA) #4, and CNA #5, the staff had completed an on-line webinar related to Significant Change MDS and completed the posttest documentation. The interviewed staff verbalized understanding of a Significant Change. CNA #4 and CNA #5 verbalized their roles with obtaining weights and notifying DON #1 or DON #2, ADON, and MDS Coordinator of any significant weigh changes. Noncompliance at F-637 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a plan of correction. Refer to F-657 and F-692

Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan for an unplanned weight loss for 1 resident (Resident #30) of 4 residents reviewed. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy Care Plans-Comprehensive undated, revealed .an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans; When there has been a significant change in the resident's condition; When the desired outcome is not met .At least quarterly . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .Care plan updated to reflect interventions . Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's care plan dated 9/7/2021 revealed .NUTRITION: The resident has the potential for nutritional problems, weight changes and dehydration related to teeth and diet restrictions .Goal The resident will maintain adequate nutritional status as evidenced by maintaining weight through review date. Interventions: Monitor intake and record every meal, Provide and serve diet as ordered for all meals and snacks .RD [Registered Dietician] to evaluate on admission, quarterly and as needed to make diet change recommendations . Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required setup help only for eating. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required limited assistance of 1 for eating. The MDS documented an unplanned weight loss of 5% or more in a month or loss of 10% or more in the last 6 months. Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. or 12.2% weight loss - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days - On 2/10/2022 159.0 lbs., a 41.3 lb. weight loss or 20.6% weight loss in 156 days - On 2/15/2022 158.0 lbs., a 42.3 lb. weight loss or 21.2% in 161 days Review of a comprehensive care plan for Resident #30 showed the care plan had not been updated with any nutritional interventions after the resident experienced weight loss on 11/3/2021, 11/29/2021, 12/2/2021, or 1/10/2022. During a telephone interview on 1/26/2022 at 1:18 PM, the MDS Coordinator confirmed she failed to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced an unplanned weight loss greater than 10%. Further interview revealed the facility's failure to identify the significant change in the resident's condition on 12/21/2021 resulted in the facility failing to update the resident's care plan with interventions to prevent further severe weight loss. Further interview revealed the main goal of the facility's weight management meetings was to identify and prevent further weight loss with appropriate interventions. Resident #30 had further weight loss on 1/26/2022 of 12.5 lbs. (A total of 40.5 lb. weight loss, or 20.2% since admission on 9/7/2021). Review of Resident #30's comprehensive care plan revised 1/27/2022, showed interventions of a high protein nutritional supplement beverage 3 times daily and 1 on 1 feeding was added to the care plan. During an interview on 2/14/2022 at 2:20 PM, the Registered Dietitian (RD) stated .the at-risk residents including [Resident #30] should be discussed during the Weekly Weight Management meetings but I don't know if he is or not. I don't participate in that meeting and do not participate in the care planning for the residents . During an interview on 2/15/2022 at 6:48 PM, the Administrator confirmed the facility failed to revise Resident #30's care plan after a severe weight loss. Facility Corrective Actions included: 1. Resident #30's Care plan was revised by the nursing staff on 1/27/2022 to reflect the Resident's change in weight loss, and interventions were implemented as follows: - Alert dietitian if the resident's consumption was poor. - Feed the resident all his meals and snacks. - A copy of the monthly and weekly weight record will be given to the Administrator. - Nutritional Supplement are to be given to the resident as ordered. - If the resident's weight decline persists, the (physician) MD and the Registered Dietitian (RD) are to be contacted. - The resident food intake at each meal to be recorded -Offer substitutes as requested or indicated -Weigh at same time of day and record weekly 2. The Medical Director was notified of Resident #30's weight loss on 1/27/2022. Resident #30 was examined by the Medical Director on 2/10/2022. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director stated to continue weekly weights x (times) 3 (weeks) until trend turned around. The Medical Director had previously implemented 1 on 1 visualized feeding on 1/9/2022 and high protein nutritional supplement on 1/27/2022. 3. On 2/16/2022 the Administrator conducted a teachable moment with the MDS Coordinator concerning reviewing the weight sheets on a weekly and monthly basis to determine if there are any resident cases that qualify for a significant change, taking this information to the Interdisciplinary Team (IDT) meeting, and entering significant change MDS within the allotted 14 days. 4. Monthly weights for 2/2022 were reviewed and compared by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) against the last 6 months to gain percentages. 100% of care plans were audited on 2/17/2022 for weight loss or gain. Census of 42 residents evaluated with 6 weight losses, 5 weight gains, and 2 significant weight changes noted. The Physician reviewed the weights on 2/10/2022 and RD reviewed on 2/16/222 and made recommendations. 5. Care plans will be revised at the same time a significant change is determined by the IDT. 6. On 2/16/2022, the DON, the ADON, and MDS Coordinator evaluated the care planning process used to complete and update the care plans. IDT daily meetings were implemented. The care plan process includes the Certified Nursing Assistants (CNA) obtaining weights weekly and monthly, giving weights to nursing management, and evaluated by the IDT team and Stand-Up meeting members daily. The IDT identifies trends or significant weight changes, and nursing will notify the physician and the care plan will be updated. 7. Beginning 2/16/2022, education on implementation of stand-up meeting with Department Heads Monday thru Friday, establishment of Interdisciplinary Team (IDT) Clinical meetings directed by the DON with Clinical management staff daily, completing timely assessments when resident's condition decline, and review of the policies - Weight Management and Assessment for change in condition. In-services conducted 1 on 1 in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. 8. On 2/15/2022, an agenda was developed to be used for meetings which include monitoring for weight loss. On 2/16/2022, the DON will begin daily IDT Clinical meetings to include DON, ADON, MDS, RD via phone or email and in the RD's absence, the Physician will be notified, Dietary Manager or Designee, and the Activities Director. The meetings will review falls, incidents, weight loss, pressure wounds, and all at risk issues that will aid in communicating issues to revise care plans. Each participant will be assigned a topic to be responsible for reporting at meetings. The minutes of the IDT meeting will be taken by one of the members present and the meeting and the minutes will be kept by the DON. On 2/17/2022, a Comprehensive Nutrition Assessment was added into the electronic medical record to be used upon admission, annually, and for significant change. On 2/18/2022, surveyors validated the comprehensive care plan for Resident #30 had been revised and included the pertinent information related to the resident's nutritional status, weight loss, and interventions. On 2/18/2022, surveyors validated the Medical Director had been notified of Resident #30's weight loss (after the weight loss was identified by the surveyor on 1/26/2022) and Resident #30 had been evaluated on 2/10/2022 with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors verified the nutritional supplement of high protein nutritional supplement beverage was added 1/27/2022, Resident #30 was administered the high protein nutritional supplement beverage by the nursing staff, signed on the Medication Administration Records as being given, and was on the meal tray card. Observations on 2/18/2022 of Resident #30 during meals showed the resident received and consumed 100% of the meals and high protein nutritional supplement beverage. Continued observation showed Resident #30 ate his meals in the dining room and was assisted by the staff. On 2/18/2022, the surveyors reviewed a teachable moment dated 2/16/2022 and interviewed the Administrator and the MDS Coordinator. The teachable moment included the MDS Coordinator who was responsible for reviewing the weekly and monthly weights to determine if any significant changes had occurred. If cases were identified, the MDS Coordinator was to bring the information to the IDT meeting. After the IDT determines a significant change exists, the MDS Coordinator was responsible to submit the significant change MDS. Interview with the MDS Coordinator on 2/18/2022 validated she received and understood the education provided. Review of a Significant Change MDS showed the MDS had been submitted on Resident #30 on 1/26/2022. On 2/18/2022, the surveyors validated the RD had completed the Comprehensive Nutritional Assessment on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) and the comprehensive care plans had been revised. The surveyors verified any recommendations noted on the Comprehensive Nutritional Assessments were updated on the comprehensive care plans. The surveyors validated all residents' weights were obtained (unless order to discontinue) 2/1/2022 - 2/4/2022. The IDT Clinical staff reviewed the weights on 2/10/2022, the IDT meeting minutes dated 2/17/2022, and the results of the weekly/monthly weights. The surveyors validated the documentation and verified the care plans had been revised, as needed on the 11 identified residents of the facility. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN), 10 Certified Nursing Assistants (CNAs), 2 Maintenance staff, and 1 housekeeper and through review of the in-service sign in sheets of remaining staff members. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. Staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The Dietary Manager Designee was able to state her role and responsibilities regarding weight loss and communication and participation during the IDT meetings. On 2/18/2022, the surveyors reviewed an agenda used for daily meetings held with the DON, ADON, MDS, RD via telephone or email, Physician as needed or in absence of the RD, Dietary Manager or designee, and the Activities Director. The surveyors reviewed the agenda form from a meeting conducted on 2/17/2022. The surveyors validated the agenda information discussed, including the weight loss of Resident #30, by review of the completed agenda form and interviews with the department head staff including a dietary manager designee, MDS Coordinator, ADON, DON #1, Maintenance Director, the Activities Director, and the Administrator. The agenda and meeting minutes were maintained by the DON. Continued review by the surveyors on 2/18/2022, validated the identified information discussed during the meeting including weight loss, weight gain, and significant weight changes. On 2/18/2022, surveyors validated IDT Meeting dated 2/17/2022 and included the care plan chart audits. The meeting was held with DON #1, the ADON, and the MDS Coordinator. The findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised accordingly by review of the care plans and interviews with the IDT members. On 2/18/2022, the surveyors validated the Weight Management Policy had been revised on 2/17/2022. Noncompliance at F-657 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-692

Based on facility policy review, medical record review, review of physician logs, interviews, and observations, the facility failed to identify a significant weight loss and implement interventions to prevent further weight loss for 1 resident (Resident #30) of 4 residents reviewed for nutrition and hydration status. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited F-692 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .It is the policy to promptly .identify and track all weights and to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .Weights will be immediately reviewed and the Dietary Manager or their designee will calculate the actual weight loss/gain .Weights will be obtained on all admission (admits and readmits) weekly for four weeks .A resident that has experienced a significant weight loss will be placed on the Review Program .The physician .will be notified of the significant weight loss .Weight loss will be documented on the Weight Loss Notification Form .Each resident will be discussed weekly in the Weight Management Meeting .Documentation shall include, but not limited to: What is being done to promote weight gain .The resident's response to the intervention .If a resident requires weekly weights for the sole purpose of weight monitoring, the resident will be placed [on the] Review Program, and it shall be understood that the following will automatically occur .The resident will be placed on weekly weights until the resident's weight is stable for four consecutive weeks .Completion of a weight loss notification form .Discuss in the weekly Weight Management meeting .Care plan updated to reflect interventions .Address any unavoidable weight change . Review of the facility policy titled, HEIGHT AND WEIGHT MONITORING undated, showed .The purposes of the procedure are to determine the resident's weight .to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem .It is the facility's standards of practice to weigh the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly . Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's care plan dated 9/7/2021 revealed .NUTRITION: The resident has the potential for nutritional problems, weight changes and dehydration related to teeth and diet restrictions .Goal The resident will maintain adequate nutritional status as evidenced by maintaining weight through review date. Interventions: Monitor intake and record every meal, Provide and serve diet as ordered for all meals and snacks .RD [Registered Dietician] to evaluate on admission, quarterly and as needed to make diet change recommendations . Review of the Weight Summary Report for Resident #30 showed the following 3 Admission weights were obtained upon admission to the facility. - Admission weight on 9/7/2021 was 200.5 pounds (lbs.) - Admission weight on 9/8/2021 was 199.5 lbs. - Admission weight on 9/9/021 was 199.0 lbs. Review of Resident #30's Nutritional assessment dated [DATE] showed .preferred beverages milk, juice, water .Diet order NAS [No Added Salt] puree .no decrease in food intake .no weight loss .His weight is 201 lbs. and age of 80. He eats 89.2% Breakfast, 85.7% of lunch 87.5% of supper for a total of 87.4% of his meals . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Review of the Weekly Weight form dated 9/13/2021 for Resident #30 showed a weight of 193.5 lbs. Review of a Medical Doctor/Nurse Practitioner (MD/NP) Log dated 9/16/2021 showed .Chief Complaint .New admit 9/7 [9/7/2021] BLE [bilateral lower extremity] [CONDITION(S)] .Weight .200.5 . Further review showed the weight noted on the MD/NP log was the initial admission weight of 200.5 lbs. and did not reflect the 193.5 lbs. obtained on 9/13/2021, which showed a 7 lb. weight loss. Review of the Weekly Weight form for Resident #30 showed the following weights were obtained. - Weekly Weight on 9/20/2021 was 194.5 lbs. - Weekly Weight on 9/27/2021 was 196 lbs. - Weekly Weight on 10/4/2021 was 194.5 lbs. Review of the Monthly Weight form dated 10/7/2021 for Resident #30 showed a weight of 194.5 lbs. Review of a MD/NP Visit Log dated 10/21/2021 showed .recommendation .Basic Metabolic Panel [BMP] [a laboratory blood test for kidney function, glucose (sugar) levels, and electrolytes in your blood] .Weight .194.5 . Review of a Monthly Weight form dated 11/3/2021 for Resident #30 showed a weight of 186.5 lbs. Continued review showed Resident #30 had a weight loss of 14 lbs. or 6.98% in 60 days. Further review showed weekly weights were not implemented after the resident's weight loss on 11/3/2021. Review of the Weight Summary report showed .Warnings . for a significant weight loss on 11/3/2021. Medical record review showed a comprehensive nutritional assessment had not been completed by the RD on Resident #30 after a weight loss of 14 lbs. (6.98%) on 11/3/2021. Review of a MD/NP Visit Log dated 11/11/2021 showed .Weight .186.5 . Continued review revealed no new orders were noted. Review of Resident #30's Emergency Department to Hospital Admission/discharge date d 11/23/2021 [resident hospitalized [DATE]-[DATE]] showed .Persistent significant fecal retention .the entirety of the colon, from the right colon through the rectum, is moderately distended with stool. Findings most consistent with ileus/constipation .Assessment and Plan .will be hospitalized .He is not ill-appearing .[Resident #30] had epistaxis [nosebleed] which prompted medical attention leading to the finding of distention and dilated loops of bowel . Review of the weight record dated 11/29/2021, on re-admittance from the hospital to the facility, showed Resident #30 weighed 176.0 lbs. (a loss of 10.5 lbs. from 11/3/2021 - 11/29/2021 and a loss of 24.5 lbs. since facility admission). Continued review showed the facility did not obtain weekly weights for Resident #30 upon re-admission to the facility per the facility's policy. Review of the Monthly Weight form dated 12/2/2021 for Resident #30 showed a weight of 177.5 lbs. (a loss of 24 lbs. or 11.4% in 90 days). Review of a MD/NP Visit Log dated 12/9/2021 showed .Chief Complaint .re-admit [to the long-term care facility] 11/29/21 [11/29/2021] .Weight 177.5 .Orders .No [no new orders] . Review of a Physicians progress note dated 12/9/2021 showed .Well-developed, well-nourished .Epistaxis .had polyp .Healing well .cont [continued] weight loss. Will direct visualized feeding assistance . Continued review showed no additional nutritional interventions were ordered. Review of Resident #30's RD nutritional assessment dated [DATE] showed .resident is on .pureed diet with thin liquids, no decrease in po [by mouth] intake, weight loss greater than 6 pounds, preferred drinks milk, juice, and water. Body Mass Index (BMI) 22 [normal body weight BMI range 18.5-24.9] . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Continued review showed no nutritional interventions were recommended or ordered by the RD. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment and required limited assist of 1 for eating. The MDS documented an unplanned weight loss of 5% or more in a month or loss of 10% or more in last 6 months. Review of an Order Summary Report dated 12/21/2021 showed No Added Salt Pureed Texture diet, [MEDICATION(S)] (diuretic) 40 milligram (mg) every morning, Multivitamin 1 daily, [MEDICATION(S)] (antipsychotic) 200 mg in the evening and at bedtime, and [MEDICATION(S)] (diuretic) 50 mg 3 times daily. Review of a Physician's Order dated 1/9/2022 showed .Feed Resident [Resident #30] . Continued review showed no other nutritional interventions were ordered. Review of a Monthly Weight form dated 1/10/2022 for Resident #30 showed a weight of 172.5 lbs. (a loss of 28 lbs. or 13.9% in 4 months). Review of the Weight Summary report showed .Warnings . for a significant weight loss on 1/10/2022 (28 lbs. or 13.9% in 4 months). Continued review showed the Monthly Weight form dated 9/2021 - 2/2022 showed Resident #30 had a Body Mass Index (BMI) of 24.1 and an Ideal Body Weight (IBW) of 165.9. The Monthly Weight form did not provide a date the BMI had been calculated and was unclear if the BMI was calculated upon admission or after the severe weight loss. Review of Resident #30's RD assessment dated [DATE] showed the resident was eating 25-75% of meals and drinking 1000 milliliters (ml)-1500 ml daily. There was no further documentation related to the weight loss or nutritional interventions. The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Review of a Nutrition/Dietary Note dated 1/25/2022 showed .[Resident #30] needs cueing more at meals .given opportunity to eat independently at meals, initially, but recent staff is needed to assist him .Diet NAS puree .Will be assisted with meals .11.5% wt [weight] loss in 3 months, 3% wt loss in one month, 13.9% wt loss since admission .Currently at healthy BMI range 22. Prevent further wt loss .Continue current interventions [1 on 1 feeding] . The assessment did not indicate the resident's caloric, fluid, carbohydrate, fat, or protein needs. Continued review showed no additional nutritional interventions were implemented. During a telephone interview on 1/25/2022 at 3:16 PM, the RD stated she was at the facility on 12/16/2021 and on 1/7/2022 and was aware of a 6 lb. weight loss (from 9/7/2021 - 12/16/2021). She stated she was not aware of the additional weight loss and had not made any new recommendations to prevent further weight loss for Resident #30. The RD stated .The Director of Nursing [DON] usually gives me a communication form for residents who have had weight loss. The communication form triggers the resident for weight loss program review . The RD could not recall if she had received a notification specifically regarding Resident #30 but had received the monthly and weekly weight forms of the residents in the facility. During a telephone interview on 1/26/2022 at 8:40 AM, the Medical Director stated he was aware of the weight loss on 12/9/2021 during a visit, .resident lost more weight than I like .usually add [high protein nutritional supplement beverage], or appetite stimulant for weight loss but did not add on 12/9/2021. Not sure why; did not write orders . Continued interview confirmed the Medical Director could not recall why he had not put new interventions in place to prevent further weigh loss for Resident #30. During an interview on 1/26/2022 at 9:41 AM, Certified Nursing Assistant (CNA) #5 reported Resident #30 was weighed on 1/26/2022 at 9:30 AM, with a lift scale, and weighed 160.0 lbs. The resident was reweighed on 1/26/2022 with a wheelchair scale and weighed 160.0 lbs. The CNA stated she reported the weight loss to the nurse assigned to the hall. Review of the medical record showed no documentation Resident #30's weight of 160.0 lbs. obtained on 1/26/2022 was recorded in the medical record. Continued review showed no documentation the RD or the Medical Director were notified of the weight and weight loss of an additional 12.5 lbs. from 1/10/2022 to 1/26/2022. Review of a Physician's Order dated 1/27/2022 showed a high protein nutritional supplement beverage was added 3 times daily with meals. Review of a Weekly Weight form dated 1/31/2022 for Resident #30 showed a weight of 159 lbs. Review of a Weekly Weight form dated 2/7/2022 for Resident #30 showed a weight of 157 lbs. Review of a Monthly Weight form dated 2/10/2022 for Resident #30 showed a weight of 159 lbs. (a loss of 41.3 lbs. or 20.6% in 5 months). Review of a Physician's Progress Note dated 2/10/2022 showed .Nursing staff reports no new issues with visualized feeding .Wt. [weight] 159 lbs .Past Vitals [vital signs] .12/09/2021 Wt. 177.5 lbs .Weight loss .Anorexia . The Progress Note showed weekly weights would continue for 3 weeks until trend turned around .I [Medical Director] believe he will regain weight slowly unless this is directly related to his mentation/dementia. If [weight] has been lost due to age related changes, anything short of feeding tube will only slow down process, Time will tell . Review of a Weekly Weight form dated 2/14/2022 for Resident #30 showed a weight of 158 lbs. During an observation on 2/14/2022 at 11:40 AM, Resident #30 was assisted with his meal in the dining room. Continued observation showed the resident consumed 100% of his lunch meal and high protein nutritional supplement beverage. Review of the meal intake records dated 12/16/2021 - 2/14/2022 showed Resident #30 consumed 0-25% of 12 meals, 26-50% of 42 meals, 51-75% of 29 meals, and 76-100% of 74 meals over the 60-day period. During a telephone interview on 2/14/2022 at 2:20 PM, the RD stated .I do not do an assessment that identifies what calorie, protein or fluid needs are for the resident, and I do not put it in my notes. I just ask the staff how they are eating .I don't compare estimated nutritional needs to actual intake. I do not do any nutritional analysis of individual menus .I have not charted on him [Resident #30] for February, he is still on my list to chart on. I am aware he [Resident #30] has had continued weight loss and should have been a priority when I was there on February 10th [2/10/2022]. I will not be back in the facility until March 7th . Continued interview showed the RD stated the resident was on an evening snack but was unable to specify the type of snack, how much the resident consumed, and whether the resident received it daily. The RD stated the resident's ideal body weight range was 159-189 lbs. The RD stated she reviewed monthly weights and reviewed the weights during quarterly and annual assessments.I do not review weekly weights. That is nursing responsibility .if they want to, they can call me .they haven't called me during the last 2 months . The RD further stated .I can put someone on weekly weights but nursing usually does that .the ADON reviews the weekly weights, and I am usually notified by the weight sheet on my next visit. It is up to nursing to notify the physician for him to order something or they can put in an intervention that does not require a physician's order such as snack or needs assist with eating .I'm not sure why I didn't do an intervention .[Resident #30s] weight [referring to weight on 1/10/2022] was not available when I did my January 7th visit [a weight on 12/2/2021 was 177.5 lbs., a loss of 24.5 lbs. in 90 days] . The RD stated nursing had identified him as having weight loss, .but I missed it .He should be discussed during the Weekly Weight Management meeting, but I don't know if he is or not. I don't participate in that meeting . Review of a meal tray card, undated (printed on 2/15/2022) showed Resident #30 had no dislikes, was on a pureed, no added salt diet, and regular liquids. The tray card showed the high protein nutritional supplement beverage or equivalent had been added. During an observation and interview with Resident #30 on 2/15/2022 at 7:50 AM, Resident #30, who had severe cognitive impairment, was seated in a Geri-chair slightly reclined in the dining room. The resident was assisted with his meal and consumed 100% of his food and drank 8 ounces of the high protein nutritional supplement beverage. The resident was questioned if he was hungry, and the resident replied .uh huh . indicating he was still hungry. Continued observation showed no other food was offered by the staff. During an interview on 2/15/2022 at 9:00 AM, Certified Nursing Assistant (CNA) #5 stated .[Resident #30] eats better for some CNA's than others .He drinks his high protein nutritional supplement beverage .he will eat 100% .sometimes I do well to get him to eat 50-75% .we try to pair him with the staff he will eat better for . Continued interview revealed she and CNA #4 obtained the weekly and monthly weights. After the weights were obtained and a weight loss of 3 lbs. or more was noted, she or CNA #4 notified the Assistant Director of Nursing (ADON) or the MDS Coordinator. CNA #5 further confirmed after an initial weight loss was identified and the ADON or MDS Coordinator were notified, she did not continue to communicate any additional weight losses noted on the same resident(s) because the weights were listed on the weekly or monthly weight forms. CNA #5 stated the forms were updated weekly. During an interview on 2/15/22 at 9:32 AM, the Assistant Director of Nursing (ADON) stated she was not aware of a document entitled weight loss notification form from the facility's 2017 Weight Management policy. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022-2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the MDS Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents, and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During a telephone interview on 2/15/2022 at 3:00 PM, the Medical Director stated he was notified of weight changes of residents by review of the weekly and monthly weights provided by the nursing staff on each visit to the facility. The Medical Director stated he usually visited the facility weekly except in December 2021 and January 2022, due to COVID outbreaks, and he had visited the facility twice during those two months. The Medical Director stated he was aware of Resident #30's initial weight loss from 9/2021 - 11/2021 and had attributed the weight loss to administration of diuretics and going from a heavy meat laden diet to a vegetarian diet. The Medical Director stated he was not concerned with the weight loss at the time due to the resident being over his ideal body weight and adjustment to a new diet. The Medical Director stated the resident was hospitalized for a week in November 2021 due to a bowel obstruction and the continued weight loss was attributed to the resident's hospitalization , the bowel obstruction, and the NPO (nothing by mouth) status during the hospitalization (11/23/2021-11/29/2021). The Medical Director stated after his assessment of Resident #30 on 12/9/2021, he implemented 1 on 1 visualized meals to determine what and how much food intake Resident #30 consumed during meals and to get an overall picture of the resident during the meals. The Medical Director stated he re-evaluated the resident's weight on 1/9/2022 and after interviewing the nursing staff, he ordered for Resident #30 to be fed all meals. Continued interview revealed after the MD was made aware of Resident #30's weight loss on 1/27/2021, a nutritional supplement was added to his diet. The Medical Director stated Resident #30 was at a good body weight (weight on 2/14/2022 was 158 lbs. and 1 lb. below the IBW) and confirmed no other nutritional interventions had been ordered since 1/27/2022. Facility Corrective Actions included: 1. The RD completed a Comprehensive Nutritional Assessment for Resident #30 on 2/16/2022. Director of Nursing (DON) #1 and Dietitian reviewed the assessment with the MD and recommendations were made. The ADON increased Resident #30's nutritional calories and the increase matched the meal tray card. The total calories for 3 meals added 1,937 calories. 2. The RD completed Comprehensive Nutrition Assessments on 2/16/2022 and 2/17/2022 for 11 residents who demonstrated weight changes including Resident #30. The RD's recommendation for Resident #30 included to continue the current diet and the high protein nutritional supplement beverage, assist with meals, and confer with Provider to rule out changes in medication that may cause drowsiness, and discontinue the No Added Salt Diet due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Medical Director was notified of Resident #30's weight loss on 1/27/2022. Resident #30 was examined by the Medical Director on 2/10/2022 and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director had implemented 1 on 1 visualized feeding on 1/9/2022 and high protein nutritional supplement beverage on 1/27/2022. 4. On 2/16/2022, the Administrator conducted a teachable moment with the RD concerning the completion of Comprehensive Assessments and assessments for change in weight in a timely manner. Assessments will be reviewed by the Administrator or designee weekly for 6 weeks and then monthly for 3 months. 5. Beginning 2/16/2022 and ending 2/18/2022, DON #1 and the Administrator conducted multiple mandatory in-services with all employees including Agency staff. The in-services included the implementation of the Stand-up meetings with the Department Heads, Monday thru Friday, and the establishment of Interdisciplinary Team (IDT) Clinical meetings, directed by the DON, with Clinical management staff daily, completing timely assessments when a resident's condition declined, and review of the Weight Management policies, and Assessment for change in condition. The in-services were conducted 1 on 1 in person or by telephone. Any staff who did not attend the in-services would not work until the education was received. Any staff who failed to comply with the points of the in-services would be further educated and/or progressively disciplined. 6. On 2/16/2022, an IDT meeting was held to establish the team (DON #1/#2, ADON, MDS, RD via phone or email, and in the absence of the RD, the MD will be notified, Dietary Manager or Designee, and Activities Director) and discussed meeting daily, the review of Resident #30's weight loss and to review the new Agenda. On 2/17/2022, an IDT meeting addressed the RD's recommendations, audited 100% of the medical charts for the nutritional care plans, and updated the care plans with any new interventions or recommendations. A Census of 42 residents were evaluated. Six residents were noted with weight loss (including Resident #30), 5 residents were noted with weight gains, and 2 residents were noted with significant weight changes (including Resident #30). The IDT meeting minutes will be taken by one of the IDT members present at the minute and put into a folder in the DON's office, and later into a binder. The DON or designee will be responsible for any follow up action taken in the IDT meetings. 7. All Residents were weighed 2/1/2022-2/4/2022 by the CNAs. DON #1 and the Dietitian reviewed the weights on 2/10/2022. The residents identified or who demonstrated significant weight changes which included any 5 lb. weight change, or more was verified by obtaining a reweight by the next day. Once the weights were verified, any significant change was reported to the MD. All weights will be reviewed in the daily IDT meetings indefinitely. 8. Starting 2/16/2022, newly admitted /readmitted residents' food preferences will be obtained by the dietary manager or designee within 72 hours of admission and entered in Dining Record for listing on the tray cards. Food preferences will be completed bi-annually and as needed for all residents. 9. Beginning 2/16/2022, weights will be reviewed in the IDT Clinical Meetings daily, Monday thru Friday, and any recommendations from the RD concerning the residents are addressed at that meeting and the physician will be notified immediately. The Dietary Manager or designee is to report any nutrition concerns of residents with the group. The minutes of the IDT meetings will be maintained in the DON's office. This new process will replace the previous weight management procedure defined in the current weight management policy. That policy will be updated on 2/17/2022 to reflect the new process. On 2/18/2022, the surveyors validated the removal plan. The surveyors reviewed a Comprehensive Nutrition Assessment for Resident #30 which was completed on 2/16/2022. Review of the electronic medical record, the physician's order, and the meal tray card had been updated and matched. Observations of Resident #30 for 2 meals on 2/18/2022 showed additional foods of whole milk for breakfast and lunch, and 4 ounces (oz) ice cream, 4 oz pudding, and ½ cup fruit puree at lunch and dinner had been added. The tray card matched the observations and Resident #30 consumed 100% of the meals. On 2/18/2022, the surveyors validated the RD had completed the Comprehensive Nutritional Assessments on 2/16/2022 and 2/17/2022 on 11 residents (Resident #4, #9, #13, #14, #17, #23, #30, #32, #35, #90, and #91) and interventions had been implemented. The surveyors verified any recommendations noted on the Comprehensive Nutritional Assessments were updated on the electronic medical record, the physician was notified of any recommendations, and the care plans were revised, accordingly. The new Comprehensive Nutritional Assessments included the resident's name, date of birth, pertinent diagnoses, supplement orders, food allergies, oral intake and appetite, dining ability, chewing ability, adaptative equipment, swallowing ability, height, usual weight/IBW, weight trends, weight changes in 1 month, 3 months, and 6 months, the resident skin status, communication ability, pertinent nutrition related medications, laboratory results, energy needs, protein needs, fluid needs, and recommendations. The surveyors validated all the residents' weights were obtained (unless order to discontinue) 2/1/2022-2/4/2022 by review of the monthly weight form. The IDT Clinical staff reviewed the weights on 2/10/2022 and notified the RD/MD as needed, nutritional interventions were implemented, and the care plans and electronic medical records were revised. The surveyors validated the information by review of the electronic medical records and interviews conducted with the IDT members on 2/18/2022. On 2/18/2022, the surveyors validated the Medical Director had been notified of Resident #30's weight loss by the nursing staff. The Medical Director evaluated Resident #30 on 2/10/2022 and added new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors verified Resident #30 was scheduled for weekly weights beginning 1/27/2022 and the weights had been obtained weekly since 1/27/2022. The surveyors verified the high protein nutritional supplement beverage was added 3 times daily beginning 1/27/2022. Resident #30 was administered the high protein nutritional supplement beverage by the nursing staff, signed on the Medication Administration Records by the nursing staff as being given, and was on the meal tray card. Observations on 2/18/2022 of Resident #30 during 2 meals showed the resident received and consumed 100% of the high protein nutritional supplement beverage. On 2/18/2022, the surveyors validated the Administrator had conducted a teachable moment with the RD on 2/16/2022 regarding Comprehensive Assessments and Change in Weight Loss. Interview with the RD and the Administrator confirmed the education had been provided. The surveyors validated the content of the Comprehensive Nutrition Assessment to be completed by the RD which included pertinent resident information, oral intake, energy, protein, and fluid needs. On 2/18/2022, the surveyors reviewed the education and sign in sheets. The documentation showed all staff working on 2/18/2022 had been provided the education on nutrition, DON #1 and DON #2 roles and responsibilities, and weight loss policies. The surveyors validated all staff working on 2/18/2022, which included Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPN), 10 CNAs, 2 Maintenance staff, and 1 housekeeper had been educated and were knowledgeable about the new procedures related to nutrition and weight loss and person-centered care planning. The surveyors validated the division of DON #1 and DON #2 responsibilities by interview with DON #1, signed acceptance by DON #2, and review of the divided roles. The surveyors verified DON #1 responsibilities included staffing schedule, staffing issues, equipment needs, admissions and discharges, ensure the committees are meeting, in-services are conducted, and quality assurance. The DON #2 responsibilities included review of the doctor notes, psychiatric notes, RD notes, consultant notes, therapy notes, incident reports, weights, wounds, physician order reviews, narcotic reviews, medication administration process, review of pharmacy reports, review of labs, x-rays and other diagnostic reports, infection prevention, vaccinations, MDS review, and review of care plans. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 RN, 1 Agency RN, 4 Licensed Practical Nurses, 10 CNAs, 2 Maintenance staff, and 1 housekeeper. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. The nursing staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The Dietary Manager Designee was able to state her role and responsibilities regarding weight loss and communication, and participation during the IDT meetings. On 2/18/2022, the surveyors validated the IDT Meeting dated 2/17/2022 had been conducted and included chart audits by review of electronic medical records and interview. The surveyors validated, through interviews, the meeting was held with DON #1, the ADON, and the MDS Coordinator and the findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised accordingly. On 2/18/2022, the surveyors validated th [TRUNCATED]

Based on review of staff job descriptions, review of facility policy, medical record review, review of facility documentation, review of staffing schedules, review of staff time punches, and interview, the facility failed to employ a Registered Nurse (RN) acting as the Director of Nursing (DON) for 18 of 52 weeks and failed to provide RN coverage for 8 consecutive hours, 7 days per week in the facility for 4 of 30 days. The failure of the facility to provide an RN as a DON from 9/1/2021-2/18/2022 resulted in a failure to identify and implement interventions to prevent a severe weight loss for Resident #30, who experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure to have an RN as a DON placed the facility in an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited Immediate Jeopardy at F-637 (J), F-657 (J), and F-692 (J). The facility was cited at F-692 at a scope and severity of J level, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were validated by the surveyors onsite on 2/18/2022. The findings include: Review of facility documentation titled, Job Description Director of Nursing undated, showed .Qualifications .a Registered Nurse in the state of Tennessee . Review of the facility policy titled .Weight Management . dated 9/27/2017 revealed .Purpose: To provide a systematic, interdisciplinary approach to obtaining weights, intervention for 'true' significant weight loss and prompt identification of at risk residents .It is the policy to promptly .identify and track all weights and to intervene on any resident that .has experienced a significant weight loss .A significant weight loss is to be identified as 5% in one month or 7.5% in three months or 10% in six months .A resident that has experienced a significant weight loss will be placed on the Review Program .Weight loss will be documented on the Weight Loss Notification Form .Each resident will be discussed weekly in the Weight Management Meeting . Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #30's weight record showed the following recorded weights: - On 9/7/2021 200.5 pounds (lbs.) - On 10/7/2021 194.5 lbs., a 5.5 lb. weight loss or 2.99% weight loss in 30 days - On 11/3/2021 186.5 lbs., a 14 lb. weight loss or 6.98% weight loss in almost 60 days - On 11/29/2021 a re-admission weight to the facility from the hospital was 176.0 lbs., a 24.5 lb. or 12.2% weight loss - On 12/2/2021 177.5 lbs., a 23 lb. weight loss or 11.4% weight loss in almost 90 days - On 1/10/2022 172.5 lbs., a 28 lb. weight loss or 13.9% weight loss in 125 days - On 2/10/2022 159.0 lbs., a 41.3 lb. weight loss or 20.6% weight loss in 156 days - On 2/15/2022 158.0 lbs., a 42.3 lb. weight loss or 21.2% in 161 days Medical record review revealed on 12/9/2021 the physician documented in the progress notes Will direct visualized feeding assistance for Resident #30. Review of a Physician's Order dated 1/9/2022 showed .Feed Resident [Resident #30] . Medical record review revealed there were no other interventions put in place to address Resident #30's weight loss until a high protein nutritional supplement was ordered on 1/27/2022. Review revealed the facility had not identified and intervened to prevent continued weight loss for Resident #30. Review of a letter authored by the Administrator and dated 9/20/2021, showed .Effective September 1, 2021 .RN resigned as our Director of Nurses [DON] .Currently .LPN [Licensed Practical Nurse], our Assistant Director of Nursing [ADON] is serving as our Acting DON . Review of the RN schedules and time punches dated 12/1/2021 - 1/25/2022 showed the following dates without 8 consecutive hours of RN coverage in the facility: On 12/4/2021 and 12/29/2021 there were no recorded hours of RN coverage. On 12/18/2021 there was 2.75 hours of RN coverage (no coverage for 5.25 hours), and on 1/1/2022 there was 6.5 hours of RN Coverage (no coverage for 1.5 hours). During a telephone interview on 1/25/2022 at 3:16 PM, the Registered Dietitian [RD] stated she was at the facility on 12/16/2021 and on 1/7/2022 and was aware of a 6 lb. weight loss (from 9/7/2021 - 12/16/2021). She stated she was not aware of the additional weight loss and had not made any new recommendations to prevent further weight loss for Resident #30. The RD stated .The Director of Nursing [DON] usually gives me a communication form for residents who have had weight loss. The communication form triggers the resident for weight loss program review . The RD could not recall if she had received a notification specifically regarding Resident #30. During an interview on 1/26/2022 at 1:45 PM, the Administrator confirmed the facility had not employed an RN serving as the DON since 9/1/2021. Continued interview confirmed the facility had not provided 8 consecutive hours of RN coverage 7 days per week on 12/4/2021, 12/29/2021, 12/18/2021, and on 1/1/2022. During an interview on 2/15/22 at 9:32 AM, the ADON stated she was not aware of a document entitled weight loss notification form from the facility's 2017 Weight Management policy. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022 - 2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the Minimum Data Set (MDS) Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents, and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During an interview on 2/17/2022 at 1:42 PM, the MDS Coordinator stated there had been a lapse in communication related to weight loss, and weight loss meetings had not been held in the absence of the DON and recent vacation of the ADON from 1/7/2022 - 2/15/2022. Facility Corrective Actions included: 1. A facility RN accepted the position of DON on 2/16/2022 on a part-time basis (16-hours/week). A second RN accepted the position of DON on a part-time basis on 2/16/2022 (24 hours/week). The two RN's will cover the role of DON for a combined total of 40 hours/week. 2. The roles and responsibilities for both DON positions were identified and included in a revised job description. Both the DON's signed the job description documents on 2/16/2022. 3. The roles of each DON were reviewed by the Medical Director, Department Managers, Nursing Staff, and all facility staff to ensure understanding of how the responsibilities are shared on 2/16/2022. A copy of the responsibilities of each DON, as well as assigned workdays, was provided to the facility Medical Director, the Nursing Staff, and the Department Managers on 2/16/2022. 4. The facility had DON coverage at least 40 hours/week effective 2/16/2022. Oversight of the duties of DON #1 and DON #2 will be communicated by a written weekly report of issues addressed when each DON worked, the outcomes, and any follow up needed. The report will be shared with the other DON, the Administrator, and the nursing management team. On 2/18/2022, interviews with DON #1 and DON #2 validated the acceptance of part-time DON positions which combined provided 40 hours per week of RN DON coverage in the facility. The DONs were aware of their individual job responsibilities and roles. Review of the DON Division of Responsibilities validated the individual roles. The surveyors validated the division of DON #1 and DON #2 responsibilities by interview with DON #1, signed acceptance by DON #2, and review of the divided roles. The surveyors verified DON #1 responsibilities included staffing schedule, staffing issues, equipment needs, admissions and discharges, ensure the committees are meeting, in-services are conducted, and quality assurance. The DON #2 responsibilities included review of the doctor notes, psychiatric notes, RD notes, consultant notes, therapy notes, incident reports, weights, wounds, physician order reviews, narcotic reviews, medication administration process, review of pharmacy reports, review of labs, x-rays, and other diagnostic reports, infection prevention, vaccinations, MDS review, and review of care plans. On 2/18/2022, the surveyors reviewed and validated the education and sign in sheets, and the corrective action plans which were provided by the Administrator. The documentation showed all staff working on 2/18/2022 had been provided the education on the new DONs divided responsibilities. The surveyors validated all staff working on 2/18/2022 had been educated and were knowledgeable about the new procedures. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, ADON, Nurse Educator, MDS Coordinator, 1 RN, 1 Agency RN, 4 Licensed Practical Nurses, 10 Certified Nursing Assistants (CNAs), 2 maintenance men, and 1 housekeeper. The interviews showed the staff were educated on how the DON position had been split between 2 RN's and their responsibilities. The staff verbalized knowledge of the new plans. Noncompliance at F-727 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction. Refer to F-692

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency by failing to identify and implement interventions to prevent a severe weight loss for Resident #30. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the Administrator's office on 2/15/2022 at 6:48 PM. The facility was cited Immediate Jeopardy at F-637 (J), F-657 (J), F-692 (J), and F-727 (J). The facility was cited at F-692 (J) at a scope and severity of J level, which is Substandard Quality of Care. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. The corrective actions were verified onsite by the surveyors on 2/18/2022. Findings include: Review of the facility program .Quality Assurance Performance Improvement Program .Nursing Home Quality Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers. The facility employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time. The Facility's QAPI program is a collaborative and interdisciplinary approach. It is through this collaborative approach that the organization can plan, implement, and maintain an effective, ongoing, improvement program. The program demonstrates measured improvements in resident health outcomes and improves resident safety by using quality indicators or performance measures associated with improved health outcomes and by the identification and reduction of medical errors. The program measures, analyzes, and tracks quality indicators, adverse resident events, infection control and other aspects of performance that includes care and services furnished in the Facility . Record review showed Resident #30 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission weight on 9/7/2021 was 200.5 pounds (lbs.) and on 2/10/2022 the resident's weight was 159 lbs. (a loss of 41.3 lbs. or 20.6% in 5 months). Review of a letter authored by the Administrator and dated 9/20/2021, showed .Effective September 1, 2021 .RN [Registered Nurse] resigned as our Director of Nurses [DON] .Currently .LPN [Licensed Practical Nurse], our Assistant Director of Nursing [ADON] is serving as our Acting DON . During an interview on 1/26/22 at 12:39 PM, the Administrator stated the QAPI Committee team met monthly, and at least quarterly, and consisted of the Administrator, the Medical Director, the Assistant Director of Nursing (ADON), the Housekeeping Director, the Dietary Manager designee, the Maintenance Director, the Activity Director, the Social Services Director, and a secretary. The Administrator stated the previous Director of Nursing (DON #1), the Social Services Director, and the Dietary Manager had not attended the meetings for several months of the last year, and the committee had been reviewing resources needed to improve communications across the departments early last year. The Administrator stated the QAPI Committee, due to in-servicing on emergency transfers and other concerns, had not fully implemented or tracked the effectiveness of the communication improvement process. Continued interview revealed the QAPI committee had not discussed weight loss or nutrition issues and did not know about Resident #30's weight loss. The QAPI committee failed to identify concerns related the weight management process and reporting to the QAPI Committee for review. The Administrator stated he had not been involved in the weight loss meetings and relied on the clinical staff to monitor and report to him if any concerns were identified. The Administrator further confirmed the facility had not employed an RN to serve as the DON since 9/1/2021. During a telephone interview on 1/26/2022 at 1:18 PM, the Minimum Data Set (MDS) Coordinator confirmed she failed to follow the facility's Weight Management Policy to identify a significant change in Resident #30's condition when the resident was identified on the 12/21/2021 quarterly MDS assessment to have experienced a decline in 1 or more ADL care needs and an unplanned weight loss greater than 10%. Further interview revealed the failure to identify these declines and report them per policy to the QAPI Committee to investigate and put new interventions in place caused Resident #30's continued weight loss on 1/26/2022 of 12.5 lbs. (A total of 40.5 lbs., or 20.2% weight loss since admission on 9/7/2021). During an interview on 2/15/22 at 9:32 AM, the Assistant Director of Nursing (ADON) revealed she was a member of the QAPI Committee and had not attended the January 2022 meeting. The ADON stated she had been on vacation since 1/7/2022 (1/7/2022 - 2/15/2022) and was not aware of Resident #30's severe weight loss. The ADON further stated informal meetings with the MDS Coordinator were held after the scheduled care plan meetings each week to discuss any identified concerns with residents and Resident #30 had not been discussed. The ADON confirmed the facility had not been following their Weight Management Policy and the ADON was not familiar with the specifics of the policy and the processes related to the policy. The ADON further confirmed she did not know what process the staff had followed regarding weight loss in her absence. During an interview on 2/15/2022 at 6:15 PM, the Administrator stated the QAPI committee had not discussed nutrition or weight loss during the last year and had focused on other areas of concern. The Administrator stated nutrition or weight loss issues, including Resident #30's weight loss, had not been brought to his attention and the facility did not follow the facility's Weight Management Policy of reporting weight changes to the QAPI Committee. During an interview on 2/17/2022 at 1:42 PM, the MDS Coordinator stated there had been a lapse in communication related to weight loss and the weight loss meetings had not been held or discussed in QAPI in the absence of the DON and recent vacation of the ADON. Refer to F-637, F-657, F-692, and F-727 Facility Corrective Actions included: 1. The QAPI Committee met on 2/17/2022 to revise the Weight Management Policy to include a new process for weight management that includes an IDT meeting that meets daily Monday - Friday (M-F) to review weight changes and a process for finding weight changes faster and avoiding weight changes. The committee also approved a new tool to audit the Registered Dietitian (RD) assessments to ensure accurate completion and Resident #30's weight loss was reviewed. Other residents with weight change were reviewed as well. The QAPI committee includes the Medical Director, the DON, the Administrator, the Activities Director, the Housekeeping Supervisor, the Dietary Manager Designee, the Maintenance Director, a secretary, and invitees from non-managerial staff. 2. Beginning on 2/1/2022, all residents were weighed by Certified Nursing Assistants (CNA's). Weights were reviewed by the nursing team on 2/10/2022 to identify any weight loss and update the care plans. Residents who had significant weight changes (defined as 5% weight change in one month, 7.5% in three months, or 10% in six months) and are at risk were evaluated by the Physician and RD. 3. On 2/16/2022, DON #1 and the Administrator completed a root cause analysis for weight loss and found that Resident #30 lost significant weight because upon admission he was feeding himself independently, however, he was not feeding himself enough calories. He was falling asleep while eating, losing interest in eating, and combative when attempts were made to encourage him to eat. Interventions included putting Resident #30 on the assisted feeding list and increasing calories in his diet. 4. On 2/16/2022, the DON began weekly Interdisciplinary Team (IDT) Clinical meetings to include DONs, ADON, MDS, RD, Dietary Manager designee, and Activities Director to review falls, incidents, weight changes, pressure wounds, and all at-risk issues that will aid in communicating issues to care plan. On 2/16/2022, an agenda was designated for use in future meetings. Each participant will be assigned a topic to be responsible for reporting at meetings. Care Plans will be updated at each IDT meeting daily. 5. Beginning 2/16/2022, the Administrator began daily (M-F) Stand-up meetings with Department heads to review resident and facility issues. Members of the meeting was established, agenda reviewed, and location of meeting established. 6. The QAPI/QA process, using monthly and weekly weight tools, will ensure that residents with significant weight changes, reported by DON/ADON, are assessed, and addressed by RD and Physician. The DON/ADON will report to QAPI committee weekly until full compliance is met, after compliance is met will report monthly. 7. The QAPI/QA process will ensure that residents with significant weight changes are addressed. The DON or ADON will report all significant weight changes to the QAPI Committee. If concerns are found the Administrator will investigate to ensure that the Weight Management Policy was followed. If failures are discovered, the DON(s) and the Administrator will perform a root cause analysis and suggest solutions. These causes and solutions will be brought back to the QAPI Committee and a Plan of Correction (POC) will be developed for the specific failure. The Administrator or his designee will then provide visual monitoring on a weekly basis for 4 weeks to see that the failure was properly addressed. If the failure is not corrected within that time, further interventions will be considered by the QAPI Committee and repeated monitoring until the process is operating successfully. 8. Beginning 2/16/2022 and ending 2/18/2022, DON #1 and the Administrator conducted multiple mandatory in-services with all employees including agency staff concerning the split roles of the DON position. Education covered Stand-up meetings with Department Heads Monday through Friday, establishment of IDT Clinical meetings directed by DON with Clinical management staff, completing assessments when resident's condition declines, and review of the Weight Management policies. These in-services were either in-person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressively disciplined as indicated. As of 2/18/2022, all staff were educated. On 2/18/2022, the surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Administrator. The documentation showed all staff working on 2/18/2022 had been provided the education on nutrition, DON #1 and DON #2 roles and responsibilities, and weight loss policies. The surveyors validated all staff working on 2/18/2022 had been educated and were knowledgeable about the new procedures related to nutrition and weight loss and person-centered care planning. On 2/18/2022, the surveyors validated the corrective actions onsite through interviews with the Administrator, Assistant Director of Nursing, Nurse Educator (DON #1), MDS Coordinator, 1 Registered Nurse (RN), 1 Agency RN, 4 Licensed Practical Nurses (LPNs), 10 Certified Nursing Assistants (CNAs), 2 Maintenance staff, and 1 housekeeper. The interviews showed the staff were educated on how to communicate weights and aid residents with assisted feedings, recording of the amounts of intake of foods, liquids, and snacks, and implementing person centered care plans for each resident that required assisted feeding. Staff verbalized knowledge of the new plan for nutrition and weight loss reporting, and how to assess residents to determine person centered needs/interventions. The surveyors validated by interview with the Dietary Manager Designee on 2/18/2022 the understanding of obtaining food preference upon admission and/or readmission to the facility, bi-annually, and as needed. The Dietary Manager designee was able to state her role and responsibilities regarding weight loss and communication and participation during the IDT meetings. On 2/18/2022, the surveyors validated IDT Meetings occurred 2/16/2022, 2/17/2022, and 2/18/2022 and included chart audits. The surveyors validated by interviews the IDT meeting was held with DON #1, the ADON, and the MDS Coordinator. The findings were communicated to the Administrator. The surveyors validated the nutrition care plans had been revised accordingly. On 2/18/2022, the surveyors validated the Weight Management Policy had been revised on 2/17/2022. Noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on review of facility policy, review of Centers for Disease Control (CDC) guidance, medical record review, observation, and interview, the facility failed to ensure staff utilized the proper Personal Protective Equipment (PPE) during a Coronavirus (COVID-19) outbreak for 1 (Resident #31) of 8 COVID-19 positive residents. The findings include: Review of the facility policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy and Protocol dated 11/23/2020, showed .Isolation Precautions .Residents with suspected or confirmed COVID-19 will be placed in isolation immediately .The type of isolation used is Standard Precautions, Contact Precautions, Airborne Precautions and Eye Protection . Review of CDC guidance, titled Interim Infection Prevention and Control [IPC] Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing Homes, updated 9/10/2021 showed .nursing homes .must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP [health care personnel] in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death .Personal Protective Equipment [PPE] .HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent .gown, gloves, and eye protection . Review of the CDC guidance, titled Infection Prevention and Control Guidance, updated 1/21/2022, showed the recommended routine infection prevention and control practices during the COVID-19 pandemic included: .NIOSH-approved N95 or equivalent or higher-level respirator OR .well-fitting face mask . Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #31 tested positive for COVID-19 on 1/21/2022 and was placed on contact and droplet isolation precautions. During an interview on 1/24/2022 at 12:07 PM, the Administrator stated the housekeeping staff who cleaned a transmission-based precaution room was not required to wear goggles in the rooms because they were not providing direct care and their encounter with the COVID-19 positive resident was brief. During an observation and interview on 1/24/2022 at 2:32 PM, Housekeeper #1 was observed donning PPE to enter COVID-19 positive Resident #31's transmission-based precaution room. Housekeeper #1 wore a gown and a surgical mask. The Housekeeper stated he was not wearing eye protection when he entered Resident #31's room and was not informed to wear eye protection. During an interview on 1/25/2022 at 8:15 AM, the Administrator stated he did not recall the latest CDC guidance regarding the use of PPE during a COVID-19 outbreak in a facility. The Administrator stated he was not aware of the CDC guidance. During a telephone interview on 1/26/2022 at 8:50 AM, the Medical Director stated he had been made aware of the COVID-19 outbreak in the facility and had advised the Administrator on the quarantining of the residents. The Medical Director stated it was his expectation for the facility staff to implement the use of N95 mask, face shields or goggles, and to limit the number of staff who entered a COVID positive room.

Based on facility policy review, medical record review, interview, and review of an electronic mail (e-mail) correspondence, the facility failed to document the needs that could not be met for 1 hospitalized resident (Resident #2) of 3 residents reviewed for readmission to the facility after a hospitalization . The findings include: Review of the facility's policy titled Hospital Transfer of a Resident, last revised 7/28/2021, revealed .Procedures .Notify the resident's family or Responsible party of resident's transfer to the hospital . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospital on 5/14/2021. Review of Admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had moderate cognitive impairment, was delusional, and required assist of 1 staff member for bathing, was independent with ambulation, transfer, bed mobility, and eating. Further review of a Discharge MDS assessment dated [DATE] revealed resident discharged with return not anticipated. Medical record review of a Health Status note dated 5/14/2021 revealed .Resident found by Sheriff up by fire station across from nursing home. Sent to ER [emergency room ] for evaluation and placement for incident, Hit CNA [Certified Nursing Assistant] on the head with Pill Crusher and then broke window out . Further review showed no documentation the resident's responsible party was notified the resident was transferred to the ER. During an interview on 7/26/2021 at 3:47 PM, the Administrator stated the facility would not take the resident back after discharge from the hospital because he was a safety risk to himself and others. Medical record review showed no documentation by the physician to indicate the reason why the facility was unable to meet the needs of Resident #2. Review of an e-mail correspondence dated 7/29/2021 at 2:20 PM from the Administrator to the State Surveyor revealed .We find no documentation in the medical record to the effect that we would not take the Resident back. We always knew that he was our resident and there was a possibility that we may be forced to take him back. However, we resisted bringing him back because we were very concerned that he was a danger to himself and others because he had already demonstrated that he was .

Based on facility policy review, medical record review, facility reported incident review, observations, and interviews, the facility failed to prevent neglect for 1 resident (Resident #1) of 5 sampled residents. The facility failed to ensure a safe environment by identifying that Resident #1 was a risk for elopement and implementing interventions to prevent an elopement. After the resident eloped, the facility failed to implement interventions to prevent future elopements. Resident #1 eloped from the facility 3 separate times and the facility was unaware the resident had left the facility 2 of the 3 times. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance 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, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 5/20/2021 at 11:30 AM, in the sunroom. The facility was cited F-600 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 5/3/2021 - 5/20/2021 and was removed on 5/21/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The findings included: Review of the facility policy Preventing Resident Abuse, not dated, showed .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc . Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect .Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Wandering Risk Scale dated 4/16/2021 showed a score of 9, which indicated he was at risk to wander (scale 0-8 no risk, 9-10 at risk for wandering, 11 and above at high risk). Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #1 had mood symptoms of little interest or pleasure in doing things, feeling down, depressed, or hopeless, and feeling bad about himself 12 to 14 days during the assessment period, and experienced delusions. No other behaviors were identified during the assessment period. Review of a facility's reported incident for 5/3/2021, showed Resident #1 was out of the building on 5/3/2021 at approximately 11:30 AM. Certified Nursing Assistant (CNA) #5 was delivering lunch trays and could not find the resident. The resident was located at 11:50 AM, by the Administrator, 3,559 feet from the facility. The facility investigation showed maintenance was performing generator checks outside the east wing doors that exit to the fenced-in patio. The east wing exit doors and the gate leading from the fenced-in patio were unlocked. Resident #1 eloped a second time on 5/3/2021 at approximately 3:00 PM (this elopement was not documented until 5/20/2021). The facility was unable to determine which door the resident exited. The resident was located 393.6 feet from the west wing exit door and 204 feet from the front door. Review of Resident #1's Behavior Progress Note dated 5/3/2021 at 6:52 PM, showed .Resident has wandered all over nursing home . Observation of Resident #1 on 5/13/2021 at 10:30 AM, in the front lobby, showed the resident was seated on a sofa. No aggressive, agitated or exit seeking behaviors were observed. During an observation with the Administrator on 5/13/2021 at 10:45 AM, the Administrator demonstrated the facility's presumed route Resident #1 had followed during his first elopement. Upon exiting the East wing doors and the fenced patio directly behind the facility, it was densely wooded with a creek running along the road. He then traveled along a gravel road for a short distance. The road turned into a paved road. The presumed route had multiple areas of dense trees and underbrush with scattered housing. During an interview with Licensed Practical Nurse (LPN) #2 on 5/13/2021 at 11:15 AM, she stated I didn't know he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . I didn't know he had eloped from the hospital until after he eloped here on 5/3/2021 . LPN #2 stated the staff were discussing Resident #1's care plan after the resident returned to the facility. That was when the DON said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON on 5/13/2021 at 4:30 PM, he stated .I did not inform the admitting nurse [Resident #1] was at risk for elopement .The staff was not monitoring him for being at risk for elopement. If the staff had known they would have more closely supervised and possibly prevented the elopement .Anything is possible. He could have gotten in the woods. He could have fallen off the bridge or fallen in the creek . Review of Resident #1's Incident Note dated 5/14/2021 at 2:48 AM, showed Resident jumped out the window (that he had broken) by the front entrance, and ran away from facility . On 5/14/2021, Resident #1 eloped from the facility at 12:56 AM. Resident #1 exited the facility by climbing through a window he had broken by the front entrance. The resident was located by the Sheriff's Department on facility grounds at 1:50 AM, approximately 542 feet from the facility, near the fire station behind a barn. During an interview with CNA #5 on 5/17/2021 at 1:00 PM, she stated . we normally receive an email from the DON when we are getting an admission. Sometimes there is information about the resident, but with [Resident #1], I don't recall receiving an email .[DON] has an in-service about 2:00 PM [daily or when needed] and gives us updates and some of 2nd shift [staff] should be in the in-services .I recall [DON] saying something about [Resident #1] running to the elevator in the hospital, but that is all I recall . During an interview with Training Nurse Assistant (TNA) #1 on 5/17/2021 at 1:30 PM, she stated .I was never notified that he was at risk for elopement . During an interview with LPN #3 on 5/17/2021 at 3:05 PM, she stated .I was not informed he was at risk for elopement . During an interview with CNA #7 on 5/17/2021 at 3:40 PM, she stated . [On 5/3/2021] I was in another resident's room on the east wing assisting a resident. I looked out the window and saw [Resident #1] outside walking around to the side of the building. It was between 3:00 PM and 4:00 PM [Resident's second elopement on 5/3/2021]. I told the Social Worker. I told her to call somebody and I ran out the front door. I go around the corner of the building and he was on the grass beside the little bridge. I said 'hey [Resident #1] where are you going,' and he stopped and said he was just going for a walk. I didn't see where the Administrator came from, but he was on the sidewalk by the patio. I hollered at [Resident #1] and we walked toward him .and he came back into the building with us . During observation and interview with CNA #7 on 5/17/2021 at 4:00 PM, CNA #7 showed where Resident #1 was on 5/3/2021 between 3:00 PM-4:00 PM, the resident's second elopement on 5/3/2021. Resident #1 was found on the east side of the building. The CNA stated he was in a grassy area, walking toward the foot bridge leading to the pavement, behind and east of the facility. During an interview with Social Worker #1 on 5/17/2021 at 4:20 PM, she stated somewhere around 3:00 PM, [CNA #7] told me she saw [Resident #1] outside .I told the Administrator [Resident #1] was outside and he went outside and got him and brought him back in through front door During an interview with the DON on 5/17/2021 at 4:30 PM, he stated he had received information during a phone conversation with the hospital Social Worker, Resident #1 had 24-hour sitters in the hospital, and he had considered Resident #1 as being at risk for elopement. He stated he had not informed the facility staff of Resident #1 being at risk for elopement. The DON confirmed the facility failed to implement interventions to prevent elopement prior to Resident #1's first elopement on 5/3/2021 and did not implement interventions after the second elopement on 5/3/2021 to prevent a reoccurrence. During an interview with CNA #8 on 5/18/2021 at 12:30 PM, she stated .When he was admitted he was confused and he was asking where he was .I found out [Resident #1] was at risk for elopement 5/3/2021 the day he got out . During an interview with CNA #11 on 5/18/2021 at 2:15 PM, she stated .I was not aware he was at risk for elopement until after his incident on 5/3/2021 . During an interview with the Administrator on 5/18/2021 at 2:45 PM, when questioned about Resident #1's second elopement on 5/3/2021, he stated .My theory is on the second elopement was the doors beep for 5 seconds. We have signs on all the doors to be sure that no one follows you out. I am sure he went out of the building behind someone .I just figured it was in with the other [first elopement on 5/3/2021] . Observation from the facility entrance door on 5/19/2021 at 5:45 AM, showed a security light in the front parking lot and a security light in the distance at the campus fire station. The rest of the grounds were unlit. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The Removal Plan presented to the survey team documented the following immediate corrective actions implemented: The DON and ADON reviewed and/or updated all wander/elopement assessments on all residents on 5/20/2021. Five residents were found to be high risk for wandering and placed on the Wandering Resident Monitoring System. The comprehensive plan of care was updated to reflect the implementation of the wandering residents monitoring system. Stars were placed on the door nameplates and medical records. Resident #1 was currently out of facility for treatment. Resident #1 has been assessed for Elopement Risk and there is a comprehensive plan of care in place to include interventions to mitigate the risk of elopement. One-on-one will be provided if needed upon return to facility. The Administrator, DON, and Maintenance Supervisor educated all staff on 5/20/2021. No staff member will return to work without being in-serviced regarding: facility elopement policy, remaining with vulnerable resident until help arrives, Abuse and Neglect policy, documentation of 1:1 (one-to-one) care, every 15-minute checks, and Wandering Resident Monitoring System and procedure. Five residents were found to be high risk for wandering. Of the 5 at risk, 2 were not at risk for elopement, 2 were at low risk, and Resident #1 was currently out of the building. All 5 residents were placed on the Wandering Resident Monitoring System. Elopement policy and Abuse/Neglect policy will be taught upon hire, annually and periodically by using Relias Learning online training platform. Contract staff must show proof of facility policy education prior to working in the facility. A copy of all education was sent to the contract agency for delivery to contract nurses. The DON or Designee will initiate a QAPI (Quality Assurance Performance Improvement) program related to elopement that will include at a minimum: Review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full QAPI to determine if the issue has been resolved or if the initiative should continue. 100% of all new admissions will be reviewed weekly for four weeks, then monthly for 3 months to determine if Elopement Risk Assessments were conducted and if a plan of care is initiated for those at risk. The results of the review will be presented to the full QAPI to determine if the issue has been resolved or if the initiative should continue. 100% of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to the Elopement policy and Abuse/Neglect policy. The results of the review will be presented to the full QAPI to determine if the issue has been resolved or if the initiative should continue. 100% audit of Residents receiving 1:1 care or every 15-minute checks to determine if the care has been delivered and documented. The results of the review will be presented to the full QAPI to determine if the issue has been resolved or if the initiative should continue. The DON will audit the provisions and documentation of the Removal Plan weekly for 4 weeks and then monthly for 3 months to ensure compliance with the Removal Plan. The DON will also deliver education to the Administrative team as needed. The DON will report findings of the Administrative Audits to the full QAPI committee and the President of the company to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors confirmed 100% completion of the wander/elopement assessments and reviewed the 5 residents identified as at risk and their updated care plan. The DON was interviewed on 5/21/2021 at 4:00 PM. He confirmed the re-education of the facility's elopement policy, remaining with vulnerable resident until help arrives, Abuse and Neglect policy, documentation of 1:1 care, every 15-minute checks, and Wandering Resident Monitoring System and procedure. The surveyors reviewed the employee sign-in sheets on the re-education. Nine staff members had not received education. The DON confirmed the remaining employees must receive the above stated in-services prior to returning to work. During an interview on 5/21/2021 at 12:10 PM, CNA #12 confirmed she had participated in the Abuse/Neglect in-service, and voiced understanding of the in-services, new policies, and procedures to follow in the event of a resident elopement. During an interview with CNA #13 on 5/21/2021 at 12:15 PM, she stated she had attended the Abuse/Neglect in-service and confirmed understanding of the in-service, new policies, and procedures to follow for a missing resident. On 5/21/2021 the surveyors interviewed 2 LPN's and 3 CNA's to confirm they had received education on the Elopement policy, Abuse/Neglect policy, documentation of 1:1 care, every 15-minute checks, and Wandering Resident Monitoring System and procedures. All staff members were able to confirm understanding of the in-services, new policies, and procedures to follow for a missing resident. Noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, facility reported incident review, observation, and interview, the facility failed to report possible neglect (elopement) to local and state agencies for 1 (Resident #1) of 5 sampled residents. Resident #1 eloped a second time from the facility on 5/3/2021 at approximately 4:00 PM, and the facility failed to report the elopement to the State Survey Agency. The facility's failure to report Resident #1's elopement from the facility on 5/3/2021 placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance 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, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 5/20/2021 at 11:30 AM, in the sunroom. The facility was cited F-609 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective 5/3/2021 - 5/20/2021 and was removed on 5/21/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The findings included: Review of the facility policy Preventing Resident Abuse, not dated, showed .Abuse Reporting .It is the policy of this facility that all personnel promptly report any incident or suspected incident of resident abuse, including injuries of unknown sources .Any alleged violations involving mistreatment, neglect, or abuse including injuries of an unknown source and misappropriation of resident property, must be reported to the administrator .Reporting Abuse to Facility Management .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .Reporting Abuse to State Agencies and Other Entities/Individuals .All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law .Should a suspected violation or substantiated incident of mistreatment, neglect .be reported, the facility administrator, or his/her designee, will promptly notify the following .(verbally and written as appropriate) of such incident: a. State licensing/certification agency responsible for surveying/licensing the facility . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility reported incident dated 5/3/2021, showed Resident #1 had eloped from the facility at approximately 11:30 AM on 5/3/2021, and was found outside 3,559 feet from the facility. Review of Resident #1's Behavior Progress Note dated 5/3/2021 at 6:52 PM, showed .Resident has wandered all over nursing home. He got out earlier in the day and was on close watch [15-minute checks] this evening . There was no documentation of any other elopements on 5/3/2021. During interview with Certified Nursing Assistant (CNA) #7 on 5/17/2021 at 3:40 PM, she stated .I was in another resident's room on the east wing assisting a resident. I looked out the window and saw [Resident #1] outside walking around to the side of the building. It was between 3:00 PM and 4:00 PM. I told the Social Worker. I told her to call somebody and I ran out the front door. I go around the corner of the building and he was on the grass beside the little bridge. I said 'hey [Resident #1] where are you going,' and he stopped and said he was just going for a walk. I didn't see where the Administrator came from, but he [the Administrator] was on the sidewalk by the patio. I hollered at [Resident #1] and we walked toward him .and he came back into the building with us . Observation and interview with CNA #7 on 5/17/2021 at 4:00 PM, showed on 5/3/2021 between 3:00 PM-4:00 PM, Resident #1 was found on the east side of the building in a grassy area walking toward the foot bridge leading to the pavement, behind and east of the facility. During an interview with Social Worker #1 on 5/17/2021 at 4:20 PM, she stated somewhere around 3:00 PM, [CNA #7] told me she saw [Resident #1] outside .I told the Administrator [Resident #1] was outside and he went outside and got him and brought him back in through front door During an interview with the Administrator on 5/18/2021 at 2:45 PM, when questioned about Resident #1's second elopement on 5/3/2021, he stated .My theory is on the second elopement was the doors beep for 5 seconds. We have signs on all the doors to be sure that no one follows you out. I am sure he went out of the building behind someone .I just figured it was in with the other [first elopement on 5/3/2021] and I did not report it [to State Agency] .In hindsight we would have looked at the situation, but it didn't occur to me to turn it [the 2 separate elopements] into 2 incidents .So, no I didn't .report it [the second elopement on 5/3/2021] . An acceptable Removal Plan which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The Removal Plan presented to the survey team documented the following immediate corrective actions implemented: The facility reviewed Resident #1's elopement incidents, with additional interventions implemented, and updated the care plan. On 5/20/2021, the facility reported Resident #1's second elopement on 5/3/2021 at 3:00 PM, to the State Survey Agency. On 5/20/2021, the President of the company conducted a teachable moment with the Administrator concerning reporting of alleged violations. On 5/20/2021 and 5/21/2021, the Administrator, DON, and Maintenance Supervisor educated all staff regarding Abuse and Neglect including Reports of alleged violations. Elopement policy and Abuse/neglect policy including reporting will be taught upon hire, annually and periodically, by using Relias Learning online training platform. Contract staff must show proof of facility policy education prior to working in the facility. A copy of all education was sent to the contract agency for delivery to contract nurses. The DON will audit past 24-hour reports from 4/16/2021 to present for missed allegations not reported. The DON or his designee will audit 24-hour shift reports each week times four weeks for missed, or potentially missed, required reporting. The Administrator or his representative will report all allegations of abuse to local/state agencies as required. The DON was interviewed on 5/21/2021 at 4:00 PM, and confirmed the re-education of the facility's Elopement policy, Abuse/Neglect policy, documentation of 1:1 (one-to-one) care and every 15-minute checks, and the Wandering Resident Monitoring System and procedures. The surveyors reviewed the employee sign-in sheets on the re-education. Nine staff members had not received education, however, would not be allowed to return to work until the education was completed. The Administrator was interviewed on 5/21/2021 at 4:15 PM and confirmed he had received a teachable moment from the company President related to reporting allegations of abuse/neglect. This was also confirmed by the Administrator's signature. During an interview with CNA #12 on 5/21/2021 at 12:10 PM, CNA #12 confirmed she had participated in the Abuse/Neglect in-service, and voiced understanding of the in-services, new policies, and procedures to follow in the event of a resident elopement. During an interview with CNA #13 on 5/21/2021 at 12:15 PM, she stated she had attended the Abuse/Neglect in-service and confirmed understanding of the in-service, new policies, and procedures to follow for a missing resident. On 5/21/2021 the surveyors interviewed 2 LPN's and 3 CNA's to confirm they had received education on the Elopement policy, Abuse/Neglect policy, documentation of 1:1 care, every 15-minute checks, and Wandering Resident Monitoring System and procedures. All staff members were able to confirm understanding of the in-services, new policies, and procedures to follow for a missing resident. Noncompliance at F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-600.

Based on facility policy review, medical record review, facility reported incident review, review of weather data, interview, and observation, the facility failed to implement interventions to prevent elopement and failed to investigate incidents of elopement and implement interventions to prevent future elopements for 1 resident (Resident #1); and failed to follow facility policy for wandering residents and implement interventions to prevent elopement for 3 residents (Resident #1, Resident #2, Resident #3) of 5 sampled residents. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). Resident #1 eloped from the facility 3 times, twice in 1 day. Resident #1 eloped from the facility on 5/3/2021, was discovered missing at approximately 11:30 AM, and was found 3,559 feet from the facility. Resident #1's second elopement occurred on 5/3/2021 at approximately 4:00 PM and he was located on the east side of the building, 393.6 feet from the west wing door and 204 feet from the facility front door. This second elopement was not documented or investigated. Resident #1's third elopement from the facility occurred on 5/14/2021 at 12:58 AM and he was located behind a barn across from the facility at 1:50 AM, by the Sheriff's Department, 542 feet from the facility. The Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 5/20/2021 at 11:30 AM. The facility was cited F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective 5/3/2021 - 5/20/2021 and was removed on 5/21/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The findings included: Review of a facility policy Accidents/Incidents, not dated, showed .Reporting of accidents or incidents .an Accident/Incident Form must be completed on the shift that the accident/incident occurred .The charge nurse shall conduct an immediate investigation of the accident or incident. The report must be completed within 24 hours of an accident/incident .Reporting/Investigating Resident Accidents/Incidents .The resident's representative (sponsor), attending physician and medical director will be promptly notified when the resident is involved in an accident/incident .All accidents/incidents involving residents will be thoroughly investigated by management and the findings of such investigation will be recorded in the resident's medical record .The investigation of the accident/incident will focus on the root causes of the event or occurrence .Accidents and Incidents-Investigating and Reporting .All accidents/incidents are investigated with interventions identified and implemented to reduce the likelihood of reoccurrence . Review of a facility policy Elopement Prevention Policy, not dated, showed .attempt to prevent an occurrence of elopement and if one occurs, to know the steps to return the resident to the safe environment of the nursing home in the quickest time possible .Definition: The act of leaving a safe area unsupervised and unnoticed and entering into harm's way . Review of a facility policy Wandering Resident Monitoring System, not dated, showed .An incident report needs to be created if a resident elopes .All assessed at risk wanderers will be identified by: a. A star on the nameplate at their room b. Care planned c. A star sticker on the chart .The wandering program will be placed in the plan of care .A quarterly and yearly assessment of need will be done on those placed on the wandering system .Conduct Annual Elopement Exercise . Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction due to Embolism, Dementia without Behavioral Disturbance, [CONDITION(S)], [CONDITION(S)] Disorder, and [CONDITION(S)]. Review of Resident #1's Wandering Risk Scale dated 4/16/2021 showed a score of 9, which indicated he was at risk to wander (risk scale 0-8 low, 9-10 at risk to wander, 11 and above at high risk). Review of Resident #1's comprehensive care plan dated 4/26/2021, showed .The resident high elopement risk r/t [related to] History of leaving facility unattended .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Resident prefers .Monitor location every 60 min. [minutes]. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The care plan did not include the wandering program that was in the Wandering Resident Monitoring System policy. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. No wandering behaviors were identified during the assessment period. Review of Resident #1's Nurse Progress Note dated 5/3/2021 at 11:30 AM, showed .CNA [Certified Nursing Assistant] reported they could not find resident to serve him his lunch tray . Review of a facility's reported incident dated 5/3/2021, showed on 5/3/2021 at approximately 11:30 AM, CNA #5 was delivering lunch trays and could not find the resident. The resident was located at 11:50 AM, by the Administrator 3,559 feet from the facility. The facility investigation showed maintenance was performing generator checks outside the east wing doors that exit to the fenced-in patio. The east wing exit doors and the gate leading from the fenced-in patio were unlocked. The resident was brought back into the facility at 11:55 AM. Review of the AccuWeather application for the weather in [NAME], TN on 5/3/2021, showed the temperature ranged from 66 degrees Fahrenheit to 79 degrees Fahrenheit. Review of Resident #1's care plan showed it was revised on 5/3/2021 with interventions .15-minute checks .Maintenance in-serviced to post staff at door during generator checks . The care plan was not updated with interventions from the facility's Wandering Resident Monitoring System. Review of Resident #1's Behavior Progress Note dated 5/3/2021 at 6:52 PM, showed .Resident has wandered all over nursing home . Review of Resident #1's Nurse Progress Note dated 5/7/2021 at 9:30 AM, showed .has been ambulating through halls and standing by doors since beginning of shift . Review of Resident #1's Behavioral Progress Note dated 5/7/2021 at 9:01 PM, showed .he woke up about 2:30 PM, and has been ambulating all through the nursing home . Review of Resident #1's Behavior Progress Note dated 5/8/2021 at 3:47 AM, showed .Resident has been up all this shift ambulating up and down the hallway, going to door, twisting on doorknobs, exit seeking . Review of Resident #1's Behavior Progress Note dated 5/8/2021 at 8:38 PM, showed .Resident has been exit seeking. Followed one person around from end of hall to the other end. Banged on door to outside and kicked at it one time. Has a bag packed and carrying it around the nursing home . During an interview with the Administrator on 5/13/2021 at 8:45 AM, he stated on 5/3/2021 at approximately 11:30 AM .[CNA #1] came in and told me we had a resident missing .when I found him .He was just walking on the road .I asked him to get in the car .When we got back, he saw the building and recognized it. He said 'I don't belong here,' and he started walking the other way .[Licensed Practical Nurse (LPN) #2] came out and started talking to him. He came back in the building .He had been observed at approximately 10:50 AM. On the camera he turned left and went down the east hall. The door and the gate were unlocked .his name should be on the door, there should be a star on the door and there should be a star on the medical record [to indicate the resident is a wanderer] . Observation and interview with the Administrator confirmed there was not a star on Resident #1's door or medical record as required by the facility's Wandering Resident Monitoring System. During an interview with Maintenance Assistance #1 on 5/13/2021 at 9:30 AM, he stated on 5/3/2021 .we were testing the emergency generator .the fire doors release until the generator starts .I went immediately to the mechanical room to turn the generator on. [Maintenance Assistant #3] was in the hall still watching the doors .at that point we both went out the door to the generator to record the information on the generator we needed. When we completed writing the information we came back in and everyone was looking for the resident .We did not see him on the patio, and we did not see him exit the door . During observation of Resident #1 on 5/13/2021 at 10:30 AM, the resident was in the front lobby seated on a sofa. During interview with Resident #1 in the front lobby, he stated he was doing okay. When questioned about leaving the facility he stated That wasn't me. It could have been someone impersonating me, but it wasn't me. I just got here today. I am just visiting. I have some family that need care, so I am checking out all options. It is a little far from where I live, but it isn't bad here. During the interview the resident was asked if someone wanted to leave the facility how would they do that, and he stated, you have to have a code and someone has to let you out. During observation with the Administrator on 5/13/2021 at 10:45 AM, the Administrator showed the facility's presumed route Resident #1 had followed during his elopement the morning of 5/3/2021. Upon exiting the East wing doors and fenced-in patio, directly behind the facility, it was densely wooded with a creek running along the road. Resident #1 then traveled along a gravel road for a short distance and the road turned into a paved road. The presumed route had multiple areas of dense trees and underbrush with scattered housing. During an interview with CNA #2 on 5/13/2021 at 11:05 AM, she stated .I worked with [Resident #1] prior to his elopement and I still work with him. He continuously walks the hallways and walks up to the doors .He does watch people come in and out . During an interview with LPN #2 on 5/13/2021 at 11:15 AM, she stated I didn't know he had a history of elopement. What I read in the hospital notes was that he left AMA [against medical advice]. I didn't know he had eloped from the hospital until after he eloped here on 5/3/2021 .We were discussing his care plan after he was returned to the facility [following his elopement and being brought back to the facility] . It was during that discussion the DON told LPN #2 that Resident #1 had a history of elopement from the hospital and had 24-hour sitters while in the hospital, prior to being admitted to the facility. Review of Resident #1's Behavior Progress Note dated 5/13/2021 at 1:27 PM, showed .Resident continues to wander hallways, exit seeking . During observation with LPN #1 on 5/13/2021 at 2:25 PM, Resident #1's name was not on the nameplate outside of his room and no star was on the nameplate to indicate Resident #1 was a wanderer. Observation of Resident #1's medical record showed there was no star. During an interview with CNA #3 on 5/13/2021 at 2:45 PM, she stated .I have taken care of [Resident #1] since he was admitted . I normally work night shift and he is often is awake all night and goes to bed between 4:00 AM and 5:00 AM .He is observant though and he watches everyone . During an interview with CNA #4 on 5/13/2021 at 2:55 PM, she stated .I work 8:00 AM to 4:00 PM and I have worked with [Resident #1] since he has been here. I see him watching people as they go in and out .I was here the day he got out [5/3/2021]. I saw him about 10:00 AM. He was in the front lobby .I did not see him after 10:00 AM .we were passing trays on his hall about 11:15 AM, and couldn't find him . During an interview with CNA #1 on 5/13/2021 at 3:05 PM, she stated .I saw him at about 10:15 AM [on 5/3/2021]. He was on the short hall close to the dining room. [CNA # 5] took his tray in and he was not in the room . During an interview with the DON on 5/13/2021 at 4:30 PM, he stated .I did not inform the admitting nurse [Resident #1] was at risk for elopement .The staff was not monitoring him for being at risk for elopement. If the staff had known they would have more closely supervised and possibly prevented the elopement .Anything is possible. He could have gotten in the woods. He could have fallen off the bridge or fallen in the creek . During the interview, the DON stated it was his responsibility to inform the staff Resident #1 was at risk for elopement. The admitting nurse was responsible for placing the star on the chart. Review of Resident #1's Nurse Progress Note dated 5/13/2021 at 8:12 PM, showed .resident extremely agitated this shift, wandering hallways and exit seeking, redirection ineffective . Review of the facility incident report for 5/14/2021 showed Resident #1 eloped from the facility on 5/14/2021 at 12:56 AM. Resident #1 exited the facility by climbing through a window he had broken by the front entrance. The resident was located by the Sheriff's Department on facility grounds at 1:50 AM, approximately 542 feet from the facility, near the fire station behind a barn. The resident was sent to the hospital for evaluation. No injuries were observed. Review of Resident #1's Incident Note dated 5/14/2021 at 2:48 AM, showed .Resident jumped out the window (that he had broken) by the front entrance, and ran away from facility . Review of the AccuWeather application for the weather in [NAME], TN on 5/14/2021 showed the average temperature for that time of morning was 54 degrees Fahrenheit. During an interview with CNA #5 on 5/17/2021 at 1:00 PM, she stated .I went in the room to take him his lunch tray [on 5/3/2021] at approximately 11:25 AM, and he wasn't in the room. The last time I physically saw him was around 10:00 AM. I checked the bathroom and hollered at [CNA #1] 'do you know where [Resident #1] is' . During an interview with CNA #6 on 5/17/2021 at 2:15 PM, she stated .he was my resident on Wednesday the 12th. He was not in my section before then. That morning he was following the nurse around. He kept close to her. He was watching the doors as we would walk out . During an interview with LPN #3 on 5/17/2021 at 3:05 PM, she stated .I was not aware he was at risk for elopement . LPN #3 stated she had been made aware of Resident #1's elopement occurring on 5/3/2021 at approximately 11:30 AM, but she was not aware of any other elopements on 5/3/2021. During interview with CNA #7 on 5/17/2021 at 3:40 PM, she stated . [on 5/3/2021] I was in another resident's room on the east wing assisting a resident. I looked out the window and saw [Resident #1] outside walking around to the side of the building. It was between 3:00 PM and 4:00 PM. I told the Social Worker. I told her to call somebody and I ran out the front door. I go around the corner of the building and he was on the grass beside the little bridge. I said 'hey [Resident #1] where are you going,' and he stopped and said he was just going for a walk. I didn't see where the Administrator came from, but he [the Administrator] was on the sidewalk by the patio. I hollered at [Resident #1] and we walked toward him .and [Resident #1] came back into the building with us . During observation and interview with CNA #7 on 5/17/2021 at 4:00 PM, CNA #7 indicated where Resident #1 was located on 5/3/2021 between 3:00 PM-4:00 PM. Resident #1 was found on the east side of the building in a grassy area, walking toward the foot bridge leading to the pavement, behind and east of the facility. During an interview with the Social Services Worker on 5/17/2021 at 4:20 PM, she stated .somewhere around 3:00 PM [on 5/3/2021], [CNA #7] told me she saw [Resident #1] outside .I told the Administrator [Resident #1] was outside and he went outside and got him and brought him back in through front door . During medical record review and review of incident reports, there was no documentation of Resident #1's second elopement from the facility on 5/3/2021 between 3:00 PM and 4:00 PM. During an interview with the DON on 5/17/2021 at 4:30 PM, he stated he had received information during a phone conversation with the hospital Social Worker that Resident #1 had 24-hour sitters in the hospital, and he had considered Resident #1 as being at risk for elopement. He stated he had not informed the facility staff of Resident #1 being at risk for elopement. He confirmed the facility failed to implement interventions to prevent an elopement prior to Resident #1's first elopement on 5/3/2021 and did not implement interventions after the second elopement on 5/3/2021 to prevent a reoccurrence. He confirmed the facility failed to provide Resident #1 with adequate supervision to prevent him from eloping from the facility 3 times. During an interview with CNA #8 on 5/18/2021 at 12:30 PM, she stated .I don't know of any other time he got out except that morning [first elopement on 5/3/2021] . During an interview with CNA #11 on 5/18/2021 at 2:15 PM, she stated .I was not aware he was at risk for elopement until after his incident on the morning [of 5/3/2021] .I don't know anything about him getting out later on the 3rd [5/3/2021]. I didn't see anything, and I wasn't told anything . During an interview with CNA #9 on 5/18/2021 at 2:30 PM, CNA #9 confirmed she was working the night shift on 5/13/2021 (into 5/14/2021) when the resident eloped from the facility the third time. CNA #9 stated she heard CNA #10 scream and went to see what was wrong. Resident #1 had hit CNA #10. The CNA's went down the hallway to locate the nurse. The CNA's did not see Resident #1 break the window. During an interview with the Administrator on 5/18/2021 at 2:45 PM, when questioned about Resident #1's second elopement on 5/3/2021, he stated .My theory is on the second elopement was the doors beep for 5 seconds. We have signs on all the doors to be sure that no one follows you out. I am sure he went out of the building behind someone .I just figured it was in with [included as part of] the other [first elopement on 5/3/2021] and I did not report it .In hindsight we would have looked at the situation, but it didn't occur to me to turn it [the 2 separate elopements] into 2 incidents . Observation from the facility entrance door on 5/19/2021 at 5:45 AM, showed a security light in the front parking lot and a security light in the distance at the campus fire station. The rest of the grounds were unlit. During an interview with LPN #4 on 5/19/2021 at 5:50 AM, she stated on night shift 5/13/2021 - 5/14/2021 (Resident #1's third elopement), Resident #1 had been up all evening pacing. He would go to the door and look out but did not attempt to open the door. She was in a resident room when she heard CNA #10 yelling for her. CNA #10 reported to her the resident had hit her. LPN #4 and the CNA's returned to the nurses' station where the resident was, and told him he could not hit anyone. He picked up a chair like he was going to hit her with it. The resident then ran toward the front broken window, jumped out, and ran into the darkness. LPN #4 stated she was unaware the window had been broken until she saw the resident running toward the window. The nurse stated no one followed him for fear of the resident becoming aggressive with them. CNA #10 called 911. During an interview with CNA #10 on 5/19/2021 at 6:05 AM, she stated she was seated at a table beside the nurses' station observing Resident #1's behavior on 5/14/2021. She stated the resident was not agitated, he was just pacing back and forth. The CNA did not realize Resident #1 had hit her. She thought a shelf had fallen on her. When she stood up, she realized it was the resident that had hit her. The CNA stated she thought the resident looked as if he was going to hit her again and she ran down the hallway to find the nurse. The CNA reported she did not know what the resident had hit her with until the Sheriff's Department discovered a pill crusher lying in the grass in front of the broken window. Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Restlessness and Agitation. Review of Resident #2's Wandering Risk Scale dated 4/25/2021 showed a score of 13, indicating the resident was at high risk for elopement (score of 11 or higher is at high risk to wander). Review of Resident #2's annual MDS assessment dated [DATE], showed a BIMS score of 4, indicating severe cognitive impairment, and the resident had behaviors of wandering daily during the review period. Review of Resident #2's comprehensive care plan dated 4/30/2019, showed the resident was care planned for elopement risk/wandering related to history of attempts to leave facility unattended. Observation on 5/18/2021 at 12:00 PM, showed Resident #2's nameplate beside the room door did not have a star posted to indicate the resident was at risk for wandering. Observation on 5/18/2021 at 12:05 PM, of Resident #2's medical record showed there was no star on the medical record to indicate the resident was at risk for wandering. LPN #5 was working on Resident #2's hall on 5/18/2021. During an interview with LPN #5 on 5/18/2021 at 12:15 PM, he stated residents were identified as at risk for elopement by observations, and it would be documented in the chart. If it were determined by observations a resident needed to be watched the resident would have a sheet on a clip board to check the resident every 15 minutes. LPN #5 stated he did not have anyone identified as at risk on his hall. Observation and interview with Resident #2 on 5/13/2021 at 12:40 PM, in her room, showed the resident seated on the side of her bed and the resident was confused. Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, and Anxiety. Review of Resident #3's comprehensive care plan dated 11/2/2020, showed the resident was care planned for wandering. Review of Resident #3's quarterly MDS dated [DATE], showed a staff assessment was completed for mental status. The resident had short and long-term memory problems and had behaviors of wandering daily during the review period. Review of Resident #3's Wandering Risk Scale dated 5/4/2021, showed a score of 15, indicating he was at high risk for wandering. Observation on 5/18/2021 at 12:00 PM, showed Resident #3's nameplate beside the room door did not have a star posted to indicate the resident was at risk for wandering. Observation on 5/18/2021 at 12:05 PM, of Resident #3's medical record showed there was no star on the medical record to indicate the resident was at risk for wandering. Observation and interview with Resident #3 on 5/13/2021 at 1:00 PM, in his room, showed the resident standing looking out of the window and the resident was unable to answer questions appropriately. LPN #2 worked on Resident #3's hall on 5/18/2021. During an interview with LPN #2 on 5/18/2021 at 12:30 PM, she stated if a resident was identified as at risk for elopement, it would be shared by staff during change of shift report. LPN #2 stated she did not have anyone identified as at risk on her hall. During an interview with the DON on 5/18/2021 at 2:15 PM, he stated he did not have any residents currently in the facility that were at risk for elopement. The DON stated his definition of at risk for elopement was .exit seeking behavior equals elopement risk. Just walking around does not . The DON confirmed the facility failed to implement the facility policy for Wandering Resident Monitoring System. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on-site by the surveyors on 5/21/2021. The Removal Plan presented to the survey team documented the following immediate corrective actions implemented. The DON and Assistant Director of Nursing (ADON) reviewed and updated all wander/elopement assessments on all residents on 5/20/2021. Five residents were found to be high risk for wandering and placed on the Wandering Resident Monitoring System and the comprehensive plan of care was updated. Stars were placed on the door nameplates and medical records. The gate leading out of the fenced-in patio to the open facility property had been secured on 5/20/2021 with a locking device. The lock will be checked weekly to ensure it is secure by maintenance. Resident #1 was currently out of the facility for treatment. Resident #1 was assessed as at risk for elopement. The facility has developed a comprehensive plan of care to implement interventions to mitigate the risk of elopement. Supervision will be provided if needed upon return to facility. On 5/21/2021 the facility implemented procedures if a resident was at risk for wandering and exit seeking, the charge nurse would assess the resident and may implement 15-minute checks or one-on-one (1:1) observation. The Administrator, DON, and Maintenance Supervisor educated staff on 5/20/2021-5/21/2021 regarding facility Elopement policy, Abuse/Neglect policy including reports of alleged violations, documentation of 1:1 care and every 15-minute checks, and Wandering Resident Monitoring System and procedures. In-services were either in a classroom setting or 1:1 in person or by telephone. Nine staff members were unavailable for the in-services and will not be eligible to return to work until they receive the education. 100% of all new admissions will be reviewed weekly for four weeks, then monthly for 3 months to determine if Elopement Risk Assessments were competed and identified on the plan of care. The results of the review will be presented to the full Quality Assurance Performance Improvement (QAPI) committee to determine if the issue has been resolved or if the initiative should continue. 100% of all education sign-in sheets were reviewed to ensure that all staff had been properly educated related to the Elopement policy and Abuse/Neglect policy (9 staff members were identified as not receiving the education and will be required to complete the education prior to returning to work). The results of the review will be presented to the QAPI committee to determine if the issue has been resolved or if the initiative should continue. 100% audit of residents receiving 1:1 care or every 15-minute checks to determine if the care had been delivered and documented. The results of the review will be presented to the QAPI committee to determine if the issue has been resolved or if the initiative should continue. The DON and Assistant Director of Nursing (ADON) reviewed and updated all wander/elopement assessments on all residents on 5/20/2021. Five residents were found to be high risk for wandering. Of the 5 at risk, 2 were identified as at risk for wandering but not at risk for elopement, 2 were identified at low risk for elopement, and Resident #1 was currently out of the building. All 5 residents were placed on the Wandering Resident Monitoring System. Stars were present on the door nameplates and the medical records of 5 residents identified at risk. The DON will audit the provisions and documentation of the Removal Plan weekly for 4 weeks and then monthly for 3 months to ensure compliance with the Removal Plan. The DON will also deliver education to the administrative team as needed. The DON will report findings of the audits to the QAPI committee and the President of the company to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors confirmed 100% completion of the wander/elopement assessments and reviewed the 5 residents identified as at risk and the updated care plans. All 5 residents were placed on the Wandering Resident Monitoring System. Stars were present on the door nameplates and the medical records of all 5 residents identified at risk. The DON was interviewed on 5/21/2021 at 4:00 PM, and confirmed the re-education of the facility's Elopement policy, Abuse/Neglect policy, documentation of 1:1 care and every 15-minute checks, and the Wandering Resident Monitoring System and procedures. The surveyors reviewed the employee sign-in sheets on the re-education. Nine staff members had not received education, however, will not be allowed to return to work until the education is completed. On 5/21/2021 the surveyors observed the outside gate to ensure it was secured by a locking device. During an interview with CNA #12 on 5/21/2021 at 12:10 PM, CNA #12 confirmed she had participated in the Abuse/Neglect in-service, and voiced understanding of the in-services, new policies, and procedures to follow in the event of a resident elopement. During an interview with CNA #13 on 5/21/2021 at 12:15 PM, she stated she had attended the Abuse/Neglect in-service and confirmed understanding of the in-service, new policies, and procedures to follow for a missing resident. On 5/21/2021 the surveyors interviewed 2 LPN's and 3 CNA's to confirm they had received education on the Elopement policy, Abuse/Neglect policy, documentation of 1:1 care, every 15-minute checks, and Wandering Resident Monitoring System and procedures. All staff members were able to confirm understanding of the in-services, new policies, and procedures to follow for a missing resident. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, review of facility incident investigations, and interview, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to investigate 3 elopements as adverse events in order to determine the root cause, systemic failures, and necessary corrective actions for 1 resident (Resident #1) of 5 sampled residents. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Resident #1 eloped from the facility 3 times between 5/3/2021 - 5/14/2021, with 2 elopements occurring in one day. The Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 5/20/2021 at 11:30 AM. The facility was cited Immediate Jeopardy at F-600, F-609, F-689, F-867, and F-943. The facility was cited F-600, F-609, and F-689 at a scope and severity of J, which constitutes Substandard Quality of Care. The IJ was effective 5/3/2021 - 5/20/2021 and was removed on 5/21/2021. An acceptable removal plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, in the sunroom and the corrective actions were verified onsite by surveyors on 5/21/2021. The findings included: Review of the facility policy Corporate QAPI Plan dated 2018 showed .The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autotomy, choice, and quality of daily life for residents and family by ensuring our data collection tool and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. We will utilize the best available evidence (e.g. data, national benchmarks, published best practices, clinical guidelines) to define and measure our goals . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Wandering Risk Scale dated 4/16/2021 showed a score of 9, indicating the resident was at risk for wandering (0-8 no risk, 9-10 at risk for wandering, 11 and above at high risk). Review of a facility investigation report showed Resident #1 eloped from the facility on 5/3/2021 through either an unlocked gate on the fenced-in patio, or by climbing over the fence. The resident was noted to be missing at 11:30 AM. The facility was unaware of the exact time the resident eloped from the building. The resident was found on the facility property 3,559 feet from the facility at 11:50 AM. Review of a facility investigation report showed Resident #1 eloped a second time on 5/3/2021 at approximately 4:00 PM. A Certified Nursing Assistant (CNA) saw the resident walking outside, in front of the building, and the resident continued to walk out of sight around the East end of the building. The CNA exited the facility through the front door and located the resident at the East end of the building. The facility was unable to determine where the resident exited the facility. If the resident exited through the West wing door, he would have traveled 393.6 feet. If the resident exited through the front door, he would have traveled 204 feet. The facility did not document or investigate this second elopement until 5/20/2021. Review of a facility investigation report showed Resident #1 eloped from the facility a third time on 5/14/2021 at 12:58 AM, by breaking a windowpane by the front entrance. He was located behind a barn across from the facility at 1:50 AM, by the Sheriff's Department. During an interview with the Administrator on 5/18/2021 at 2:30 PM, he reported the last QAPI committee meeting was held on 5/12/2021 and Resident #1's 2 elopements that occurred on 5/3/2021 were not discussed. The facility did not complete a root cause analysis to determine how the resident got out of the facility and if the facility needed to implement additional interventions to prevent further elopements. Interview with the Administrator on 5/18/2021 at 2:45 PM, confirmed the Administrator did not consider the second elopement on 5/3/2021 as a separate incident, but instead considered it a continuation of the first elopement earlier that same day. The facility did not treat it as a second elopement and did not complete a separate incident report or investigate the elopement to implement interventions to prevent further elopements. Review of the facility's QAPI program showed the facility did not conduct a QAPI committee meeting to discuss the adverse events of Resident #1's three elopements from the facility between 5/3/2021 and 5/14/2021, with 2 elopements occurring on 5/3/2021, until 5/20/21, 17 days after the first 2 elopements. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were validated on site by the surveyors on 5/21/2021. On 5/20/2021 the President of the company re-educated the Administrator on the QAPI process and reporting allegations of abuse to state and local agencies. On 5/20/2021 all minutes from QAPI meetings held 12/2020 and 3/2021 were reviewed by the Administrator, DON, and the QAPI Coordinator for trends and opportunity to improve processes. On 5/20/2021 the Administrator conducted an emergency QAPI committee meeting and provided re-education on the QAPI process, reviewed Resident #1's three elopements, performed root cause analysis, and developed and approved audit tools. The committee determined a QAPI meeting would be conducted weekly times 4 weeks, then monthly thereafter. Review of the QAPI sign in sheet dated 5/20/2021 confirmed the meeting was conducted. The meeting consisted of the Administrator, DON, Maintenance Assistant, Housekeeping Supervisor, and the Social Services Worker. Interview with the Administrator on 5/21/2021 at 11:15 AM, confirmed the meeting had been conducted and re-education was provided on the QAPI process, on what information should be brought to QAPI meeting, and how/when to conduct a root cause analysis. Noncompliance for F865 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-600, F-609, and F-689.

Based on facility policy review, medical record review, review of facility incident reports, observations, interviews, and review of employee records, the facility failed to implement abuse training for 2 of 5 employees reviewed, failed to provide education for all staff on the Wandering Resident Monitoring Program, and failed to conduct annual performance of an elopement exercise. Resident #1 eloped from the facility 3 times between 5/3/2021 - 5/14/2021. The facility's failures placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Three residents (Resident #1, Resident #2, and Resident #3) of 5 sampled residents did not have the Wandering Resident Monitoring Program implemented. The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 5/20/2021 at 11:30 AM, in the sunroom. The facility was cited Immediate Jeopardy at F-600, F-609, F-689, F-867, and F-943. The facility was cited F-600, F-609, and F-689 at scope and severity of J, which constitutes Substandard Quality of Care. The IJ was effective 5/3/2021 - 5/20/2021 and was removed on 5/21/2021. An acceptable removal plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, and the corrective actions were verified on site on 5/21/2021. The findings included: Review of the facility policy Abuse/ Neglect, Misappropriation of Funds Protocol revised date 1/2013, showed .Training: All new employees will be trained as part of General Orientation .and ongoing training sessions to include but not limited to the following: 1) Definition of abuse, neglect, involuntary seclusion or misappropriation of resident property, to include the facility policy that protects them from reprisal . Review of the facility policy Wandering Resident Monitoring System undated, showed .An incident report needs to be created if a resident elopes .All assessed at risk wanderers will be identified by: a. A star on the nameplate at their room b. Care planned c. A star sticker on the chart .The wandering program will be placed in the plan of care .A quarterly and yearly assessment of need will be done on those placed on the wandering system .Conduct Annual Elopement Exercise .Elopement has NOT occurred if resident is off the property but is within eyesight . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Wandering Risk Scale dated 4/16/2021 showed a score of 9, indicating the resident was at risk for wandering (0-8 no risk, 9-10 at risk for wandering, 11 and above at high risk). Review of Resident #1's comprehensive care plan dated 4/26/2021, showed .The resident high elopement risk r/t [related to] History of leaving facility unattended . Review of a facility incident report showed Resident #1 eloped from the facility on 5/3/2021 through either an unlocked gate on the fenced-in patio, or by climbing over the fence. The resident was noted to be missing at 11:30 AM. The facility was unaware of the exact time the resident eloped from the building. The resident was found on the facility property 3,559 feet from the facility at 11:50 AM. Review of a facility incident report showed Resident #1 eloped a second time on 5/3/2021 at approximately 4:00 PM. A Certified Nursing Assistant (CNA) saw Resident #1 walking outside in front of the building, and the resident continued to walk out of sight around the East end of the building. The CNA exited the facility through the front door and located the resident at the East end of the building. The facility was unable to determine where the resident exited the facility. If the resident exited through the West wing-door, he would have traveled 393.6 feet. If the resident exited through the front door, he would have traveled 204 feet. The facility did not document or investigate the second elopement that occurred on 5/3/2021 until 5/20/2021. Observation with Licensed Practical Nurse (LPN) #1 on 5/13/2021 at 2:25 PM, showed Resident #1's nameplate beside his door and his medical record did not have a star to indicate he was at risk for wandering or elopement. Review of a facility incident report showed Resident #1 eloped from the facility a third time on 5/14/2021 at 12:58 AM, by breaking a windowpane by the front entrance. He was located behind a barn across from the facility at 1:50 AM by the Sheriff's Department, 542 feet from the facility. The temperature was approximately 54 degrees. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Wandering Risk Scale dated 4/25/2021 showed a score of 13, indicating the resident was at high risk for elopement (score of 11 or higher is at high risk to wander). Review of Resident #2's annual MDS assessment dated [DATE], showed a BIMS score of 4, indicating severe cognitive impairment, and the resident had behaviors of wandering daily during the review period. Review of Resident #2's comprehensive care plan dated 4/30/2019, showed the resident was care planned for elopement risk/wandering related to history of attempts to leave the facility unattended. Observation on 5/18/2021 at 12:00 PM, showed Resident #2's nameplate beside the room door did not have a star posted to indicate the resident was at risk for wandering. Observation on 5/18/2021 at 12:05 PM, of Resident #2's medical record, showed there was no star on the medical record to indicate the resident was at risk for wandering. LPN #5 was working on Resident #2's hall on 5/18/2021. During an interview with LPN #5 on 5/18/2021 at 12:15 PM, he stated residents were identified as at risk for elopement by observations, and it would be documented in the chart. If it were determined by observations a resident needed to be watched the resident would have a sheet on a clip board to check the resident every 15 minutes. LPN #5 stated he did not have anyone identified as at risk on his hall. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's comprehensive care plan dated 11/2/2020, showed the resident was care planned for wandering. Review of Resident #3's quarterly MDS dated [DATE], showed a staff assessment was completed for mental status. The resident had short and long-term memory problems and had behaviors of wandering daily during the review period. Review of Resident #3's Wandering Risk Scale dated 5/4/2021, showed a score of 15, indicating he was at high risk for wandering. Observation on 5/18/2021 at 12:00 PM, showed Resident #3's nameplate beside the room door did not have a star posted to indicate the resident was at risk for wandering. Observation on 5/18/2021 at 12:05 PM, of Resident #3's medical record, showed there was no star on the medical record to indicate the resident was at risk for wandering. LPN #2 worked on Resident #3's hall on 5/18/2021. During an interview with LPN #2 on 5/18/2021 at 12:30 PM, she stated if a resident was identified as at risk for elopement, it would be shared by staff during change of shift report. LPN #2 stated she did not have anyone identified as at risk on her hall. Review of Registered Nurse (RN) #1 and CNA #10 employee records on 5/18/2021, showed no documentation of abuse training. During an interview with the DON on 5/18/2021 at 2:00 PM, he confirmed there was no documentation of Abuse training for RN #1 and CNA #10. During an interview with the DON on 5/18/2021 at 2:15 PM, he stated the facility did not currently have any residents at risk for elopement. The DON stated his definition of at risk for elopement was .exit seeking behavior equals elopement risk, just walking around does not equal elopement risk . The DON confirmed the facility failed to train staff on the policy Wandering Resident Monitoring System and had not conducted an annual elopement exercise for 2020 or 2021. Review of the electronic training history for RN #1 and CNA #10 on 5/19/2021, showed no documentation of abuse training. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/21/2021 at 5:00 PM, in the sunroom, and the corrective actions were validated on-site by the surveyors on 5/21/2021. On 5/20/2021 the Administrator and the DON reviewed the facility Abuse/Neglect policy to include the training be added to each employee's on-line training during orientation and annually. The facility implemented an audit to ensure this was completed and reported in each QAPI committee meeting conducted. On 5/20/2021 - 5/21/2021 the facility staffing coordinator provided education for staff on facility policies for Abuse/Neglect and the Wandering Resident Monitoring System. There were 9 employees that were unavailable for the training and those employees will receive education before being allowed to return to work. On 5/20/2021 the DON and ADON reassessed all residents for elopement risk. The facility identified 5 residents at risk for elopement and implemented the placement of stars posted on the resident's nameplates beside their doors and on their medical records, and initiated every 15-minute checks on 2 of the 5 residents identified at high risk. On 5/20/2021 the facility conducted an elopement exercise on the evening shift with all staff that were present. The facility plans to conduct 1 elopement exercise on each shift of the 3 shifts, and 1 on the weekend, with the facility Safety Officer, over the next 4 weeks, and then conduct an elopement exercise every 6 months thereafter. Review of the revised 5/21/2021 Abuse policy showed the facility would provide Abuse/Neglect training on orientation and annually. Review of the in-service sign-in sheets dated 5/20/2021 and 5/21/2021, the facility policy Abuse/Neglect (revised date 5/20/2021) and the Wandering Resident Monitoring System were reviewed and validated by the surveyors. Observation with the DON on 5/21/2021 at 12:00 PM, showed the 4 resident's nameplates and medical records had a star placed on them. Resident #1 was included in the facility list of 5 residents identified as being at risk. Review of a sign in sheet dated 5/20/2021, the facility conducted an elopement exercise with facility staff that were present on the second shift (2:00 PM - 10:00 PM). During an interview with CNA #12 on 5/21/2021 at 12:10 PM, CNA #12 confirmed she had participated in the Abuse/Neglect in-service and confirmed understanding of the in-service, new policies, and procedures to follow in the event of a resident elopement. During an interview with CNA #13 on 5/21/2021 at 12:15 PM, she stated she had attended the Abuse/Neglect in-service and confirmed understanding of the in-service, new policies, and the procedures to follow for a missing resident. Non-compliance at F-943 continues at a scope and severity of D for monitoring of the effectiveness of the Removal Plan. The facility is required to submit a Plan of Correction. Refer to F-600, F-609, and F-689.