Every finding on record at Magnolia Healthcare and Rehabilitation Center

Based on policy review, observation, and interview, the facility failed to maintain the prevention and spread of infection during wound care, catheter care, and with Enhanced Barrier Precautions for 2 of 4 (Resident #16 and #24) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Infection Control Policy and Procedure, dated 2026, revealed .Require staff to follow hand hygiene practices consistent with accepted standards of practice.CMS [Centers for Medicare & Medicaid Services] recommends specialized training include the following.Principles of standard precautions.hand hygiene.use and care of indwelling urinary.catheters.wound management.The Facility shall develop and implement written policies and procedures for the provision of infection prevention and control.The use and care of urinary catheters.Wound care.Knowledge and skills pertaining to the IPSP's [Infection Prevention and Control Program] standards, policies and procedures are needed by all staff in order to follow proper infection control practices.Implementation of infection control practices for resident care such as but not limited to urinary catheter care, wound care.Staff must perform hand hygiene (even of gloves are used).Before performing an aseptic task.after removing.gloves.Gloves changed and hand hygiene before.during resident care.The Facility must prevent infections through indirect contact transmission. This requires.cleaning and/or disinfecting.resident equipment, medical devise, and the environment.Equipment or items in the resident environment likely to have been contaminated.must be handled in a manner so as to prevent transmission of infectious agents. Review of the undated facility policy titled, Hand Hygiene, revealed .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning [putting on] gloves, and immediately after removing gloves . Review of the facility policy titled, Indwelling Catheter Use and Removal, dated 11/30/2025, revealed .If an indwelling catheter is in use, the facility will provided appropriate care for the catheter in accordance with current professional standards. Review of the facility policy titled, Catheter Care, dated 11/25/2025, revealed .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Hemiplegia (paralysis affecting one side of the body), Adult Failure to Thrive, and Stage 3 Pressure Ulcer to Sacrum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Resident #16 was dependent on staff to perform activities of daily living (ADLs) and was assessed for a Stage 3 facility acquired pressure ulcer. Review of the Physician's Order dated 3/6/2026, revealed Cleanse Sacrum with Dakins [used to cleanse wounds to prevent infection], apply honey Alginate [used to promote healing of wounds], cover with foam dressing. Change every day and prn [as needed] soiling/dislodgement .for wound care. During an observation of wound care in the Resident room on 3/31/2026 at 10:16 AM, Licensed Practical Nurse (LPN) F did not perform hand hygiene before donning (putting on) a gown and gloves, prior to entering Resident #16's room. LPN F wiped the over the bed table with a Sani wipe, placed a barrier on the over the bed table, and set up wound care supplies. LPN F removed her gloves and donned a new pair of gloves without performing hand hygiene. LPN F removed the soiled dressing from Resident #16's sacrum and removed her gloves. LPN F donned a new pair of gloves, without performing hand hygiene, and cleansed the wound with Dakins solution and gauze. LPN F removed her gloves, donned a new pair of gloves without performing hand hygiene, applied the honey alginate dressing to the wound, then covered it with a foam dressing. LPN F gathered the trash and supplies and placed them into a biohazard bag, removed her gown and gloves, then left the room. LPN F performed hand hygiene after exiting the resident's room. During an interview on 3/31/2026 at 10:35 AM, LPN F was asked when should hand hygiene be performed. LPN F stated, .after patient care . During an interview on 4/1/2026 at 1:33 PM, the Director of Nursing (DON) was asked when should hand hygiene be done during wound care. She stated .after every glove change . The DON was then asked if she expected her nurses to perform hand hygiene during wound care. She stated .yes . 3. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Diabetes, and Neuromuscular Dysfunction of Bladder (nerve damage to bladder). Review of the quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Random observations in the resident's room on 3/30/2026 at 11:34 AM, revealed Resident #24's indwelling urinary catheter bag lying on the floor. During an interview on 3/30/2026 at 11:42 AM, the DON was asked if the urinary catheter bag should be on the floor. The DON stated, No, it should not. Observation and interview in the resident's room, on 4/1/2026 at 8:36 AM, revealed Resident #24's indwelling urinary catheter lying on the floor. LPN F was asked upon entering the room if she saw any issues with Resident #8's indwelling catheter bag. LPN F stated, The bag is on the floor. LPN F was asked if the indwelling catheter bag should be on the floor. LPN F stated, No, it should be in the bag [privacy bag] on side of the bed.he has UTI's [Urinary Tract Infection] and being on the floor is a risk for infection. During an interview on 4/1/2026 at 1:32 PM, the DON was asked if she would expect her nurses to observe and be aware if a resident had an indwelling catheter to check if the bag was lying on the floor. The DON stated, Yes, we addressed that yesterday. The DON was asked since it was addressed yesterday, would you expect the indwelling catheter bag to be lying on the floor again this morning. The DON stated, .I will be doing in-service and rounding.it is unacceptable for foley bag to be lying in the floor. During a random observation and interview outside of the resident's room on 3/30/2026 at 10:14 AM, revealed LPN B removing the Southeast Long Hall Medication Cart from Resident #92's room. An Enhanced Barrier Precautions (EBP) sign and Personal Protective Equipment (PPE) were observed on Resident #92's door. LPN B was asked if Resident #92 was on EBP. LPN B stated, Yes, ma'am she is. LPN B was asked the reason for Resident #92 being on EBP. LPN B stated, because of her peg-tube and sacral pressure ulcer. LPN B was asked should the medication cart be in the resident room. LPN B stated, No, it should not have been in the resident room . During an interview on 3/30/2026 at 10:16 AM, outside of Resident #92's room, the DON was asked should the medication cart be in a resident room with EBP. The DON stated, Absolutely not, I caught that myself. The DON was asked where the medication cart should be placed. The DON stated, The medication cart should stay on the hall and not in the resident room .

Based on facility policy review, observation, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions when unlabeled, undated, and expired food items were found stored, an empty soap dispenser was observed at the hand washing station, the inside of the microwave was splattered with dried food particles, the deep fryer had brown oil with food particles floating in it, there was a black build up on the floor, there was dried food particles on a metal pan, a layer of dust on a shelf of the drying rack, and the warming oven had a build up inside the doors. The facility had a census of 82 and 79 of the residents were served from the Kitchen. The findings include: Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, revealed .Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety.Food safety practices shall be followed throughout the facility's entire food handling process.Elements of the process include the following.Equipment used the handling of food, including dishes.other equipment that comes in contact with food.Employee hygienic practices.Facility staff shall inspect all food, food products.for safe transport and quality upon delivery/receipt and ensure timely and proper storage.Follow contract/vendor procedures when food arrives damaged or concerns noted.Remove these foods from use.Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen.discarded.Foods and beverages shall be distributed and served to residents in a manner to prevent contamination.Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.Staff shall wash hands according to facility procedures.Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs. Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, dated 3/6/2025, revealed .All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.The prepared food must be consumed by the resident within 3 days.If not consumed within 3 days food will be thrown away by facility staff. Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Staff will perform hand hygiene hand hygiene when indicated, using proper technique consistent with accepted standards of practice. During an observation on the initial tour in the Kitchen on 3/30/2026 at 10:10 AM, the Dietary Manager (DM) was present in the Kitchen. The following items were observed:a. No hand soap in the dispenser at the hand-washing station. b. The microwave had dried food particles splattered on the inside of the microwave door and throughout the sides and top of the microwave.c. 18 cartons of milk dated 3/28/2026 in a black crate on top of the standing cooler.d. Deep fryer with dark brown oil and large amounts of food particles floating in the oil.e. The floor underneath the deep fryer had thick black build up. During an interview in the Kitchen on 3/30/2026 at 10:15 AM, the DM was asked where staff are expected to perform hand hygiene. The DM stated, This is the only hand-washing station in the Kitchen. The DM was asked if there should be soap available. The DM stated, Yes, Housekeeping usually changes it. The DM was asked, if the milk in the black crate on top of the standing cooler should be discarded. The DM stated, No, the distributer picks up all expired milk on Wednesdays. The DM was asked how staff know not to use and serve to residents. The DM stated, Because they [milk] are on the outside of the cooler. During an observation in the Kitchen on 3/30/2026 at 10:35 AM, the following food items were in the walk-in refrigerator:a. 2 opened and undated 16 ounce packages of margarine. b.1-2 pack of tomatoes undatedc. 1- 4 pack of tomatoes undatedd. 1 gallon of apple juice concentrate with foam layer noted at the top of the juice, with a use by date 2/4/2026.e. 1 metal container of cooked spaghetti with a use by date of 3/27/2026.f. 1 plastic bag of boiled eggs with a used by date of 3/27/2026. g. 1 plastic bag of chopped cucumbers with a used by date of 3/27/2026 During an observation and interview in the Kitchen on 3/30/2026 at 10:46 AM, the DM was asked if the food items listed above in the walk-in refrigerator should be discarded. The DM stated, Yes, they should. During an observation in the Kitchen on 3/31/2026 at 8:34 AM, revealed the following:a. the microwave with splattered dried food particles on the inside of the microwave door and inside of the microwave.b. a metal muffin pan with dried food particles and thick dust build up on the bottom shelf of the drying rack. c. the warming oven with thick orange and brown build up on the inside of the oven doors. During an interview on 3/31/2026 at 9:03 AM, the DM was asked if the cookware on the drying rack was clean. The DM stated, Yes. The DM was asked if the metal muffin pan on the bottom shelf should have dried food particles and dust on it on if it is clean. The DM stated, No. We don't use it and we can throw it away. During an observation and interview in the Dry Storage Room on 3/31/2026 at 9:05 AM, the DM was asked what the process was for dented cans. The DM stated, I use them first. The DM was asked if she stored dented cans separately. The DM stated, I was told that it was ok to use them. During an observation in the Dry Storage Room on 3/31/2026 at 9:08 AM, revealed the following:a. 1 large box of bananas black in color with a white powdery substance growing on the bananas.b. 1 plastic bag of 10 biscuits with a green and white fuzzy substance on the biscuits, with a use by date of 3/13/2026. c. 2 boxes of undated croissants rolls. d. 1 opened and undated package of 6-inch flour tortillas. During an interview on 3/31/2026 at 9:10 AM, the DM was asked if food items in the Dry Storage should be discarded. The DM stated, Yes. The DM was asked who was responsible for checking food items for expiration. The DM stated, The cooks are responsible for checking them. During an interview on 3/31/2026 at 10:47 AM, the Registered Dietitian (RD) was asked what her role with the kitchen was. The RD stated, I have performed 1 audit with the Kitchen, and it was extensive and concerning. The RD was asked what the process for dented cans. The RD stated, Dented cans should be stored separately, labeled and placed for the distributor to pick up. The RD was asked if dented cans should be served. The RD stated, No. During an observation and interview on 3/31/2026 at 2:49 PM, Licensed Practical Nurse (LPN E) was asked if the following food items in the nutritional refrigerator should be labeled and dated. LPN E stated, Yes and should be discarded due to out of date or not labeled.a. 1 opened, undated and uncovered ice cream cake in the freezer.b. 1 box of [named fast food], unlabeled and undated. c. 1 plastic platter of toast, bacon, and a bowl of yellow substance, undated and unlabeled, from an outside restaurant.d. 1 swollen plastic container of salad, unlabeled and undated. e. 1 plastic container of pineapple, unlabeled and undated.f. 1 opened container of med pass (supplemental protein shake) dated 2/17/2026. g. 1 opened and undated bottle of water. During an interview on 3/31/2026 at 4:40 PM, the DM was asked how food items should be properly stored. The DM stated, Labeled with [an] opened date and [an] use by [date] 7 days later. The DM was asked when should cooked and prepared food items be discarded. The DM stated, Labeled and date use by 3 days later, and discarded by the use by date. The DM was asked when food items brought in by outside sources should be discarded. The DM stated, Within 3 days. The DM stated, No, ma'am. The Dietary Manager was asked if the microwave and oven should have thick orange-brown build up on the inside of the oven and dried food particles to the inside of the microwave. The DM stated, The oven has been like that since I came. The DM was asked if the floors underneath the deep fryer should have thick black build up. The DM stated, We will keep working on it until it comes up. The DM was asked if food items in the dry storage should be expired and have substances growing on them. The DM stated, There should be no expired, no molded, no dented cans, no opened and undated food items in the dry storage area.

Based on facility policy review, medical record review, observation and interview the facility failed to ensure the environment was free from accident hazards when sharps were found unattended and unsecured in the shared room of 2 of 82 (Residents #30 and #65) sampled residents observed. 1. Review of the facility's policy titled, Regulated [Biohazard] Medical Waste, dated 6/11/2025, revealed .It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State, and local guidance and regulations.Examples of regulated medical waste include.sharp items.Contaminated sharps will be placed in appropriate sharps containers located at the point of use. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Depression, and Hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Resident #30 required set-up assistance of staff with bathing. Review of the Resident #30's Care Plan dated 11/20/2024, revealed .The resident is on antiplatelet therapy. 3. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Deep Vein Thrombosis (a blood clot), Pneumonia, Malnutrition, and Asthma. Review of the admission MDS assessment dated [DATE], revealed Resident #65 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #65 required set-up assistance of staff to perform personal hygiene. Review of Physician's Order dated 2/28/2026, revealed Apixaban [used as a blood thinner to prevent blood clots] Oral Tablet 5 MG [milligram] Give 1 tablet by mouth every 12 hours. Observations in Residents #30 and #65's shared room on 3/30/2026 at 11:28 AM, 12:24 PM, and at 2:54 PM, revealed 3 navy disposable razors on the back of the shared pedestal sink. During an observation and interview in Resident #30 and #65's shared room on 3/30/2026 at 3:18 PM, Licensed Practical Nurse (LPN) G was asked if the 3 razors should be left unsecure and unattended in the Residents' room. LPN G stated, No. During an interview on 4/01/2026 at 9:59 AM, the Director of Nursing (DON) was asked if razors should be left unsecure and unattended in a resident's room. The DON stated, No, they should not.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medication was properly stored in 1 of 2 (South Short Hall) medication rooms and in 2 of 82 (Resident #8 and #24) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 3/31/2025, revealed .It is the policy of this facility to ensure all medications housed on our premise will be stored.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).back -up stock of Schedule III, IV and V medications are stored under double-lock and key. 2. Observation and interview in the Medication Room on the South Short Hall on 4/1/2026 at 8:48 AM, revealed 1 open and 2 unopen vials of Lorazepam (a Schedule IV controlled substance medication used to treat anxiety) 20 mg [milligram]/10 ml [milliliter] in a clear unlocked/unsecured box in the refrigerator. Licensed Practical Nurse (LPN) C attempted to lock the unsecured box with multiple keys and the keys did not fit the lock. LPN C was asked should narcotics be double-locked and secured. LPN C stated, Yes . LPN C was asked if Lorazepam is a narcotic, should it be double-locked, and secured. LPN C stated, Yes, it is a narcotic and should be locked and secured. LPN C was asked should she have a key to narcotic lock box. LPN C stated, I should have one, I tried every key . During an observation and interview in the Medication Room on the South Short Hall on 4/1/2026 at 9:38 AM, revealed LPN D Unit Manager (UM) was shown the refrigerator with the unlocked/unsecured box with the Lorazepam inside. LPN D attempted to lock the clear narcotic box with LPN C's keys and was unable to lock the narcotic box. LPN D was asked should the narcotic box be locked and secured in the refrigerator. LPN D stated, Yes, I don't know why it's [narcotic box] not locked but I will have to ask if it should be secured . During an interview on 4/1/2026 at 1:34 PM, the Director of Nursing (DON) was asked if Lorazepam should be locked and secured in a narcotic box when in the refrigerator. The DON stated, Yes, it will be in a locked box and secured. The DON was asked how the box is secured she stated, not moveable. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, and Opioid Dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact and had no impairment in Range of Motion to the upper extremities. During an observation in Resident #8's room on 3/30/2026 at 10:34 AM and at 2:56 PM, revealed 3 tubes of (Brand Name) arthritis gel at the resident's bedside unsecured and unattended. During an interview on 3/30/2026 at 5:44 PM, LPN B was asked if a resident should have unsecured medications at bedside. LPN B stated, I saw that in her room and told her we will have to put that up. During an interview on 4/1/2026 at 1:32 PM, the DON was asked where a resident's medication should be stored. The DON stated, Should be in the med [medication] cart. The DON was asked if a resident should have mediation at bedside. The DON stated, No, they should not. 4. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Diabetes, and Neuromuscular Dysfunction of Bladder (nerve damage to bladder). Review of the quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 15 on the BIMS assessment, which indicated he was cognitively intact and had no impairment in Range of Motion in Upper Extremities. Observation in Resident #24's room on 3/30/2026 at 11:34 AM and 4:30 PM, revealed 2 bottles of (Brand Name) wound cleanser was observed at bedside unsecured and unattended. During an observation and interview on 3/30/2026 at 4:34 PM, Registered Nurse (RN) C confirmed Resident #24 had 2 bottles of (Brand Name) wound cleanser at bedside. RN C was asked if it was acceptable for the wound cleanser to be at the bedside and unsecure. RN C stated, I have been here for just about a week and will get back to you. During an interview on 3/30/2026 at 4:47 PM, RN C stated, I was told it has to be left in the room since he is in isolation. RN C was asked should the wound cleanser be secured or left at beside. RN C stated, Secure. During an interview on 4/1/2026 at 1:32 PM, the DON was asked where should (Name Brand) wound cleanser be stored. The DON stated, .It should be put up in a cabinet or drawer.

Based on facility policy review, medical record review, and interview, the facility failed to ensure staff obtained daily weights for 1 of 6 (Resident #16) sampled residents reviewed for nutrition. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 4/9/2025, revealed .obtain and record vital signs.per physician orders. 2. Review of the medical record revealed Resident #16 was readmitted to the facility on [DATE], with diagnoses including Hemiplegia, Adult Failure to Thrive, and Abnormal Weight Loss. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the Physician's Order dated 1/29/2026, revealed .Weigh patient daily at 0600 [6:00 AM] in the morning. Review of the Medication Administration Record (MAR) dated January 2026, revealed daily weights were not obtained as ordered by the physician on the following date: a. 1/31/2026 at 6:00 AM Review of the MAR dated February 2026, revealed daily weights were not obtained as ordered by the physician on the following date: a. 2/14/2026 at 6:00 AM Review of the MAR dated March 2026, revealed daily weights were not obtained as ordered by the physician on the following dates: a. 3/2/2026 at 6:00 AM b. 3/6/2026 at 6:00 AM c. 3/8/2026 at 6:00 AM d. 3/10/2026 at 6:00 AM e. 3/11/2026 at 6:00 AM f. 3/15/2026 at 6:00 AM g. 3/18/2026 at 6:00 AM h. 3/21/2026 at 6:00 AM During an interview on 4/1/2026 at 1:33 PM, the Director of Nursing (DON) was asked if the physician has given an order to weigh a patient daily should there be blanks on the MAR. The DON stated .there should not be blanks on the MAR .the weights should have been done daily.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets and agency invoices, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 67 staff members (Licensed Practical Nurse (LPN) #1, Agency LPN #1, #2, #3, and #4, Certified Nursing Assistant (CNA) #1, #2, and #3, Agency CNA #1, #2, #4, #5 and #6, and Dietary Aide #1) failed to complete screening for the prevention and detection of COVID-19 prior to working on 3 of 3 days (5/28/2022, 5/29/2022 and 6/4/2022) reviewed and when 3 of 4 nurses (Registered Nurse (RN) #1, Agency LPN #5, and #6) failed to perform hand hygiene for 4 of 5 sampled residents (Resident #7, #34, #35, and #375) observed during medication administration. This had the potential to affect the 76 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the facility's policy titled, Coronavirus Surveillance, dated 11/15/2021, revealed .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness .Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include .screening visitors, staff, and residents .Staff who report or have signs and symptoms of a respiratory infection or COVID-19 shall not report to work .Screening is done electronically and monitored by the receptionist . Random observation on 6/15/2022 at 3:00 PM, revealed a sign posted at the front entrance, .Staff, Agency & [and] Family It is a policy of this facility for all [Named Facility] staff, including Agency Staff, and outside family members to check in on the [NAME] [access temperature sensor] temperature machine. Please screen in at the front desk . Review of the Employee Screening logs, employee time sheets, and Agency invoices, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 5/28/2022-LPN #1, CNA #1, Agency CNA #1, #2, and #3, and Dietary Aide #1. b. 5/29/2022-LPN #1, Agency LPN #1, #2, and #3, CNA #1, Agency CNA #1, and Dietary Aide #1. c. 6/4/2022-LPN #1, Agency LPN #3 and #4, CNA #2, and Agency CNA #2, #4, #5 and #6. During an interview on 6/15/2022 at 2:56 PM, the Interim Director of Nursing (DON) confirmed staff should screen in prior to working. The Interim DON stated, .they should take their temp [temperature] and answer the questions [screening for COVID-19] . Review of the facility's undated policy titled, Medication Administration, revealed .To administer all medications safely .Cleanse your hands before beginning and before contact with each resident .Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the medication . Observation outside the resident's room on 6/14/2022 at 11:32 AM, revealed RN #1 disinfected a glucometer with a bleach wipe, removed her gloves, reapplied clean gloves without hand hygiene, and entered Resident #375's room. RN #1 cleaned Resident #375's finger with an alcohol pad, obtained a blood sugar, removed her gloves, and reapplied clean gloves without performing hand hygiene. RN #1 proceeded to clean Resident #375's lower abdomen, administered [MEDICATION(S)] insulin subcutaneously, and removed her gloves. RN #1 walked to medication cart outside of the resident's room, and signed the medications administered without performing hand hygiene. Observation outside of the resident's room on 6/14/2022 at 2:14 PM, revealed Agency LPN #5 opened the medication cart drawer, moved the cart, touched a wheelchair, prepared enteral medications in a medication cup, entered Resident #35's room, and raised the head of the bed. Agency LPN #5 donned clean gloves without performing hand hygiene and administered enteral medications to Resident #35. Observation in the resident's room on 6/14/2022 at 4:05 PM, revealed Agency LPN #5 raised the resident's head of the bed, moved the over the bed table, handed the resident his phone, and put on clean gloves without performing hand hygiene. Agency LPN #5 administered eye drops to Resident #34's right eye, removed her gloves, walked out of the room, and signed the the medications administered, without performing hand hygiene. Observation outside of the resident's room on 6/15/2022 at 7:46 AM, revealed Agency LPN #6 was assisting another resident up in a wheelchair. Agency LPN #6 moved the medication cart toward the wall and proceeded to prepare oral medications without performing hand hygiene. Agency LPN #6 walked into Resident #7's room, assisted turning Resident #7 onto her back in the bed, and administered oral medications. Agency LPN #6 walked to medication cart and signed the medications administered, without performing hand hygiene. During an interview on 6/15/2022 at 4:55 PM, the Interim Director of Nursing confirmed hand hygiene should be performed before and after donning gloves, prior to medication administration, and before and after contact with each resident.

Based on policy review, review of the interdisciplinary Care Plan meeting sign in sheets, medical record review, and interview, the facility failed to ensure residents were involved in developing the Care Plan and making decisions about his or her care and failed to include direct care staff in the Interdisciplinary Care Planning for 3 of 3 sampled residents (Residents #20, #35, and #65) reviewed for Care Plan meetings. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 4/2022, revealed .the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The IDT may include .Attending Physician .registered nurse who has responsibility for the resident .nurse aide who had responsibility for the resident .member of food and nutrition services .Social Services staff member .Therapy services staff members .resident and the resident's legal representative . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CARE PLAN CONFERENCE SUMMARY, dated 2/22/2022, revealed .No concerns @ [at] this time .ATTENDEES .RN [Registered Nurse] .[Named Social Service Assistant] .Act Dir [Activity Director] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 5, indicating he was severely cognitively impaired. The facility was unable to provide documentation of a quarterly Care Plan Conference with the IDT team for 4/2022 or 5/2022. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CARE PLAN CONFERENCE SUMMARY, dated 11/4/2021, revealed .ATTENDEES .[Activity Director] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #35 had a BIMS score of 3, indicating she was severely cognitively impaired. The facility was unable to provide documentation of a quarterly Care Plan Conference from 12/2021 - 5/2022. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CARE PLAN CONFERENCE SUMMARY, dated 11/9/2021, revealed .ATTENDEES .Act.Dir [Activity Director] . Review of the CARE PLAN CONFERENCE, dated 2/16/2022, revealed attendees were the Social Service Assistant, Activity Director, a Registered Nurse, and the Guardian. Review of the CARE PLAN CONFERENCE, dated 5/17/2022, documented attendees were the Social Service Assistant, Resident #65, a Licensed Practical Nurse, and an Activity Assistant. Review of the quarterly MDS assessment dated [DATE], revealed Resident #65 had a BIMS score of 12, indicating she was moderately cognitively impaired. During an interview on 6/14/2022 at 2:42 PM, the Social Service Assistant was asked how often should the Care Plan conference meetings be scheduled. The Social Service Assistant stated, .I was told yearly . The Social Service Assistant confirmed the Care Plan Conference should include the IDT team members (Social Service, Dietary, Therapy, Nurse, MDS Nurse, Activity Director, direct care staff, and the Director of Nursing). During an interview on 6/14/2022 at 3:02 PM, the MDS Coordinator confirmed the Care Plan Conference should be completed quarterly and include the IDT members.

Based on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 6 of 6 sampled residents (Resident #19, #28, #42, #57, #375, #376) reviewed for nutrition. The findings include: Review of the facility's policy titled, Nutritional Assessment, revised 10/2017, revealed .The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .and as indicated by a change in condition that places the resident at risk for impaired nutrition .As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition . Review of the facility's policy titled, Weight Management, revised 8/2021, revealed .residents that are new/readmissions or identified as high risk are placed on weekly weights .New or readmissions will be evaluated for at least 4 weeks if weight is stabilized resident may be weighed in two weeks or put on regularly monthly weights. Residents who are put on weekly weights due to high risk nature will be evaluated until weight stabilization and then be placed back on monthly weights . Review of the medical record, revealed Resident #19 was admitted to to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change in status Minimum Data Set (MDS) dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment, and required extensive assistance from staff for all activities of daily living (ADL's). Review of the medical record, revealed Resident #19 did not have a nutritional assessment on 10/13/2021, 1/13/2022, and 4/13/2022. During an interview on 6/15/2022 at 8:38 AM, the Interim Director of Nursing (DON) was shown Resident #19's last nutritional assessment dated [DATE] and was asked how often nutritional assessments should be done. The Interim DON stated, .I think quarterly . During a telephone interview on 6/15/2022 at 10:21 AM, the Registered Dietician (RD) was asked about how often the Resident's nutritional assessments should be done. The RD stated, .there is a lot of catch up that needs to happen .on the quarterly assessment . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #28's BIMS score was 15, indicating intact cognition, and required extensive assistance of staff for ADL's. Review of the Resident #28's medical record dated 4/19/2022, revealed an admission weight of 171 pounds. The facility was unable to provide documentation of Resident #28's weekly weights after admission. Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS dated [DATE], revealed Resident #42 had a BIMS score of 15, indicating intact cognition and required extensive assistance of staff for ADL's. Review of Resident #42's medical record, revealed no admission weight was documented. The facility was unable to provide documentation of weekly weights from 5/6/2022 through 5/20/2022. Review of the medical record, revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of significant change in status MDS dated [DATE], revealed Resident #57's BIMS score was a 4, indicating severe cognitive impairment, and required extensive assistance of staff for ADL's. Review of Resident #57's medical record, revealed no admission weight was documented. Review of the medical record,revealed Resident #375 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #375's BIMS score was 15, indicating intact cognition, and required limited assistance of staff for ADL's. Review of Resident #375's medical record, revealed no admission weight was documented. Review of the medical record dated 6/3/2022, revealed Resident #375 had a weekly weight of 181 pounds. The facility was unable to provide documentation of Resident #375's weekly weights from 6/9/2022 through 6/15/2022. Review of medical record, revealed Resident #376 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #376's medical record dated 6/8/2022, revealed no admission weight was documented. The facility was unable to provide documentation of Resident #376's weekly weights from 6/8/2022 through 6/15/2022. During an interview on 6/15/2022 at 9:00 AM, the Interim Director of Nursing confirmed resident's weights should be completed on the day of admission to the facility and then completed weekly for 4 weeks.

Based on policy review, medical record review, and interview, the facility failed to ensure 6 of 16 sampled residents (Resident #13, #28, #42, #52, #56, and #376) had alternative food and menu choices. The findings include: Review of the facility's undated policy titled, .RESIDENT RIGHTS AND RESPONSIBILITIES, revealed .Recognize each resident's individuality and provide services in a person-centered manner .promotes .resident's quality of life . Review of the facility's undated policy titled, RESIDENT FOOD PREFERENCES, revealed .Dietary Manager, or designee with regards to obtaining food preferences and conducting an initial visit to the resident .this visit should occur within 72 hours from admitted .important that these preferences .be honored . Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], Nausea, and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. During an interview on 6/13/2022 at 3:14 PM, Resident #13 was asked about the facility's food. Resident #13 stated, .we eat what they give us, we don't have menus and don't know what is being served . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur, [CONDITION(S)], and [CONDITION(S)]. Review of the admission MDS dated [DATE], revealed Resident #28 had a BIMS score of 15, which indicated intact cognition. During an interview on 6/13/2022 at 11:43 AM, Resident #28 was asked about the facility's food. Resident #28 stated, .I don't know what food is coming until it gets here, haven't seen any menus .they haven't even asked my food likes or dislikes .I don't have choices if I don't like the food . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Diabetes, [CONDITION(S)], and [CONDITION(S)]. Review of the admission MDS dated [DATE], revealed Resident #42 had a BIMS score of 15, which indicated intact cognition. During an interview on 6/14/2022 at 9:41 AM, Resident #42 was asked, what was being served for lunch today. Resident #42 stated, I don't ever know what we are having. Review of the medical record, revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)], End Stage Renal Disease, and Hypertension. Review of the quarterly MDS dated [DATE], revealed Resident #52 had a BIMS score of 14, which indicated intact cognition. During an interview on 6/13/2022 at 3:37 PM, Resident #52 was asked about the facility's food. Resident #52 stated, .We don't have any menus, or told before hand what's coming from the kitchen .the staff don't know what food is coming at meal times when we ask them . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Cerebral Infarction, Hypertension, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #56 had a BIMS score of 15, which indicated intact cognition. During an interview on 6/13/2022 at 10:30 AM, Resident #56 was asked about the facility's food. Resident #56 stated, .I have no idea what food we are having before each meal .we don't have menus choice of food .no one has ever asked me my food choices . Review of the medical record, revealed Resident #376 was admitted to the facility on [DATE] with diagnosis of Fracture of Right Hip, [CONDITION(S)], Diabetes, and Hypertension. During an interview on 6/13/2022 at 2:48 PM, Resident #376 was asked about the facility's food. Resident #376 stated, .we do not receive menus, whatever is there is what I get .I have not been asked about my preferences . During an interview on 6/15/2022 at 2:01 PM, the Dietary Manager confirmed the preference choices were not completed on admission and a change in plans for menus and preferences will be implemented.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 16 of 27 sampled residents (Resident #7, #8, #13, #15, #19, #20, #21, #26, #28, #32, #35, #37, #47, #53, #56, and #65) reviewed for Advanced Directives. The findings include: Review of facility's undated policy titled, Resident Rights and Responsibilities, revealed .all Residents have the right to participate in their health care decisions and to make Advance Directives .and [Named Facility] respects and upholds those rights . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of Resident #7's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #8 had a BIMS score of 0, which indicates severe cognitive impairment. Review of Resident #8's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #13 had a BIMS score of 11, which indicated moderate cognitive impairment. Review of Resident #13's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change of status MDS dated [DATE], revealed Resident #15 had a BIMS score of 2, which indicated severe cognitive impairment. Review of Resident #15's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change of status MDS dated [DATE], revealed Resident #19 had a BIMS score of 0, which indicated severe cognitive impairment. Review of Resident #19's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #20 had a BIMS score of 5, which indicated severe cognitive impairment. Review of Resident #20's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #21 had a BIMS score of 3, which indicated severe cognitive impairment. Review of Resident #21's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #26 had a BIMS score of 12, which indicated cognitively intact. Review of Resident #26's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #28 had a BIMS score of 15, which indicated cognitively intact. Review of Resident #28's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #32 had a BIMS score of 15, which indicated cognitively intact. Review of Resident #32's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #35 had a BIMS score of 3, which indicated, which indicated severe cognitive impairment. Review of Resident #35's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #37 was rarely/never understood, with short and long term memory problems. Review of Resident #37's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #47 had a BIMS score of 15, which indicated cognitively intact. Review of Resident #47's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #53 had a BIMS score of 15, which indicated cognitively intact. Review of Resident #53's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #56 had a BIMS score of 15, which indicated cognitively intact. Review of Resident #56's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #65 had a BIMS score of 12, which indicated moderate cognitive impairment. Review of Resident #65's medical record, revealed there was no documentation the resident or their legal representative was informed of or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 6/14/2022 at 3:20 PM, the Administrator confirmed the residents did not have Advanced Directives offered to them on admission. The Administrator stated, .prior to the new form we just used POST forms .

Based on medical record review and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 3 of 19 sampled residents (Resident #42, #57 and #75) reviewed. The findings include: Review of the medical record, revealed Resident #42 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #42 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. A Comprehensive Care Plan was initiated on 5/11/2022. During an interview on 6/15/2022 at 4:11 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #42 did not have a Baseline Care Plan completed within 48 hours of admission. Review of the medical record, revealed Resident #57 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #57 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. A Comprehensive Care Plan was initiated on 5/18/2022. During an interview on 6/15/2022 at 3:55 PM, the MDS Coordinator confirmed the facility did not complete Baseline Care Plan and a Baseline Care Plan should have been initiated for Resident #57 prior to 5/18/2022. Review of the medical record, revealed Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #75 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. A Comprehensive Care Plan was initiated on 5/18/2022. During interview on 6/15/2022 at 3:14 PM, the MDS Coordinator confirmed resident #75 did not have a Baseline Care Plan completed within 48 hours of admission.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were administered as ordered for 2 of 2 sampled residents (Resident #47 and #65) reviewed. The findings include: Review of the facility's undated policy titled, MEDICATION ADMINISTRATION Missed Medication Dose, revealed .Licensed nurse is to administer medications per physicians order. If a medication is not administered at the prescribed time due .the nurse will notify the physician or physical extender of the missed dose or possible need to change the medication administration time .Physician .to determine if further monitoring or an alternative therapy is required . Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 6/3/2022, 6/6/2022, and 6/9/2022 revealed .Orders .Administration Note Text: [MEDICATION(S)] Liquid Apply to entire body topically one time a day every 3 day(s) for [CONDITION(S)] unable to locate . During an interview on 6/15/2022 at 9:41 AM, Licensed Practical Nurse (LPN) #6 confirmed she could not find Resident #47's [MEDICATION(S)]. During an interview on 6/15/2022 at 10:53 AM, the Nurse Practitioner (NP) was asked about the missing doses of [MEDICATION(S)] Liquid. The NP stated .I was notified today that Resident #47's [MEDICATION(S)] was not in .I went to [Named Store] today to pick it [[MEDICATION(S)]] up . During an interview on 6/15/2022 at 12:54 PM, the Interim Director of Nursing (DON) confirmed that the [MEDICATION(S)] Liquid should have been administered as ordered. Review of the medical record, revealed Resident #65 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet 800 MG [milligrams] Give 1 tablet by mouth four times a day . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #65 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the 6/2022 MAR, revealed the [MEDICATION(S)] 800 mg was coded as a 9 (see progress notes) for the 10:00 AM and 2:00 PM doses on 6/14/2022. Review of the Progress Notes dated 6/14/2022 at 9:06 AM, revealed .[MEDICATION(S)] .800 MG .four times a day .pharmacy awaiting hard script . Review of the Progress Notes dated 6/14/2022 at 2:19 PM, revealed .[MEDICATION(S)] .800 MG . four times a day .awaiting delivery .Pharmacy notified . Observation in the resident's room on 6/14/2022 at 5:21 PM, revealed Resident #65 was lying in bed eating dinner and stated, .I have not gotten my [MEDICATION(S)] today . During an interview on 6/14/2022 at 5:56 PM, the NP was asked what the process was for missed doses of mediations. The NP stated .they should have alerted me .I was here at 1:30 [PM] .I wrote a hard script .I write a month supply .I prefer the nurses to tell me 7 days ahead of time so they [the residents] will not run out of the medication .when first notified .I was told just needed a script .this morning at 9:05 AM .I got a text .I didn't know the resident [Resident #65] was completely out [of the [MEDICATION(S)]] .I was not aware .if she was out I would have called the pharmacy myself with an order . During an interview on 6/15/2022 at 8:13 AM, the Interim DON confirmed the residents should not run out of medications.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plan interventions were followed to prevent falls for 1 of 1 sampled resident (Resident #20) reviewed for falls. The findings include: Review of the facility's policy titled, FALL PREVENTION AND MANAGEMENT, revised 10/2021, revealed .All residents will be assessed for risk of falling using the 'Long Term Care Fall Risk Assessment Form' .The assessment will be competed up on admission, quarterly, annually, and/or if a change in condition requiring completion of a new MDS [Minimum Data Set] .Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Intracerebral Hemorrhage, Falls, Diabetes, and Obesity. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive deficits, he required extensive assistance from staff for activities of daily living, and had no limitations in range of motion. Review of the Care Plan revised 1/28/2022, revealed the following additional interventions had been added to the Care Plan, .1/28/22 [2022] Verbally remind resident not to attempt to transfer or ambulated without staff .2/12/21 [2021] continue to encourage .to call for assistance .mats at bedside .3/30/21 [2021] Moxi [therapeutic support surface] cover to bed .bed rolls to be placed between bed frame and mattress .Dycem [non-slip mats and gripping aids] to top and bottom of w/c [wheelchair] cushion .Fall 9/20/2020-Dycem to W/C [wheelchair] . Review of the Morse Fall Scale dated 2/9/2022, revealed Resident #20 was a high risk for falling. Review of the Incident Report dated 3/9/2022, revealed .Un-witnessed .CNA [Certified Nursing Assistant] reported approx. [approximately] 1245 [12:45 PM] this shift Pt [patient] lying in floor, Pt lying on right side at end of bed, w/c sitting at Pt's [patient's] head, Pt attempted to transfer self to be unassisted . Review of the Morse Fall Scale dated 4/7/2022, revealed Resident #20 was a high risk for falling. Review of the quarterly MDS assessment dated [DATE], revealed Resident #20 had a BIMS score of 5, which indicated the resident had severe cognitive deficits, he required extensive assistance from staff for activities of daily living, and had no functional limitations in range of motion. Observation in the resident's room on 6/14/2022 at 3:56 PM, with the Interim Assistant Director of Nursing (ADON), revealed Resident #20 did not have fall mats at the bedside, no Dycem mat on top of the wheelchair cushion, there was a balled up Dycem mat under the wheelchair cushion, no Moxi cover, and no bed rolls were in place between the bed frame and mattress. During an interview on 6/14/2022 at 4:49 PM, the Interim Assistant Director of Nursing (ADON) confirmed the resident should have interventions in place according to the Care Plan. During an interview on 6/15/2022 at 8:20 AM, the Interim Director of Nursing (DON) confirmed Resident #20 should have interventions in place according to the Care Plan.

Based on policy review, medical record review, and interview, the facility failed to administer the prescribed medication for 1 of 3 sampled residents (Resident #5) reviewed for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Review of the facility's undated policy titled, .Medication Administration, revealed .Medications shall be administered in a safe and timely manner .The individual administering the medication must initial the resident's electronic MAR (Medication Administration Record) on the appropriate line after giving the medications . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 40 milligram (mg) two times a day. 2. [MEDICATION(S)] inject 15 units one time a day. Review of the July 2021 MAR, did not reflect Resident #5 received her 6:00 AM medication of [MEDICATION(S)] 15 units on 7/3/2021, 7/4/2021, and 7/5/2021 and did not reflect Resident #5 received her 6:00 AM medication of [MEDICATION(S)] 40mg on 7/10/2021, 7/11/2021, 7/21/2021, 7/22/2021, and 7/26/2021. During a telephone interview on 8/30/2021 at 10:49 AM, the Director of Nursing (DON) confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .should have their initials .

Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served under sanitary conditions when dietary staff members (Dietary Aide #1, #2, #3, #4, Cook #1 and Cook #2) were observed preparing and serving food without properly wearing a mask and failed to perform appropriate hand hygiene. This had the potential to affect the 82 residents that received a tray from the Kitchen. The findings include: Review of the facility's policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy and Protocol, revised 7/1/2021, revealed .all staff members are required to wear a mask throughout their entire shift unless on a break while eating . Review of the facility's policy titled, COVID-19 Visitation Compliance Plan, dated 5/28/2021, revealed .Fully vaccinated HCP (Health Care Professionals) should continue wear source control while at work .Face covering or mask (covering mouth and nose) . Observation of the Kitchen during meal service on 7/20/2021 at 11:50 AM, Dietary Aides #1 and #2 were working the tray line with their masks under their chins, Cook #1 was serving food with her mask under her nose, and Dietary Aide #3 was preparing drinks with his mask under his nose, resting on his top lip. Observation of the Kitchen during meal service on 7/20/2021 at 12:00 PM, revealed Dietary Aide #1 touched her mask to pull the mask up from under her nose and continued setting up trays for the tray line, without performing hand hygiene. Observation of the Kitchen on 7/20/2021 at 2:30 PM revealed Cook #2 and Dietary Aide #4 working in the Kitchen, wearing their masks under their noses. During an interview on 7/20/2021 at 2:33 PM, the Dietary Manager was asked should staff be wearing masks covering their mouth and nose while in the Kitchen. The Dietary Manager stated, I'm not 100 percent sure about that. The three in there now have been vaccinated. The ones at lunch had been vaccinated except [named Dietary Aide #1] . During an interview on 7/20/2021 at 2:44 PM, the Dietary Manager confirmed Dietary staff should wear masks while working in the Kitchen.

Based on review of the facility Time Clock reports, Daily Assignment sheets, a facility e-mail, and interview, the facility failed to ensure a Registered Nurse (RN) was on duty at least 8 hours a day, 7 days a week for 3 of 104 days (5/9/2021, 6/20/2021, 6/27/2021, 7/3/2021, and 7/4/2021) reviewed. The findings include: Review of the facility's Time Clock Plus Generated Report dated 4/4/2021-7/2/2021, revealed there was 6.2 hours of RN coverage on 5/9/2021, 5.45 hours of RN coverage on 6/20/2021, and no RN coverage on 6/27/2021. Review of the facility's Daily Assignment sheets and Time Clock Plus Generated Report dated 7/3/2021 -7/16/2021, revealed there was no RN coverage on 7/3/2021 and a RN worked 4 hours on 7/4/2021. During an interview on 7/20/2021 at 4:05 PM, the Director of Nursing (DON) confirmed that there was no RN coverage on 7/3/2021 and she worked 4 hours. The DON stated, .I came in to help out [Named Staff Member) .I didn't realize there was not another RN in the building. The DON was asked how many hours of RN coverage the facility should have each day. The DON stated, Eight, I believe. During an interview on 7/20/2021 at 5:45 PM, the Administrator confirmed there should be 8 hours of RN coverage each day. During an interview conducted on 7/20/2021 at 5:51 PM, the Business Office Manager confirmed there was no RN coverage on 7/3/2021, and only 4 hours of RN coverage on 7/4/2021. An e-mail from the Business Office Manager on 7/21/2021 at 3:14 PM, confirmed there was not 8 hours of RN coverage on 5/9/2021, 6/20/2021 and 6/27/2021.

Based on policy review, medical record review, and interview, the facility failed to develop and implement comprehensive Care Plans and interventions that are person-centered that address the needs of 13 of 14 sampled residents (Resident #1, #2, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed for wandering behaviors and falls. The facility's failure placed Resident #1, #2, #6, #7, #8, #9, #11, #12, #13, #14, and #15 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). Resident #2, a vulnerable resident with Dementia, eloped from the facility through a window, and staff responded immediately. Two months later, Resident #1, a confused vulnerable resident, eloped from the facility through a window from an unoccupied resident room. Resident #1 walked down a steep hill, across the driveway, and was found sitting under a pavilion, next to an integrity impaired fence with an unsecured gate, near a creek with swift moving water. The facility staff were unaware Resident #1 was missing from the facility for 9 minutes and the resident was outside alone and unattended for an additional 8 minutes, after he was located by the facility staff who left him unattended outside. The facility's failure to develop and implement Comprehensive Care Plans resulted in Immediate Jeopardy and actual Harm when Resident #1 had a fall that resulted in a hematoma (collection of blood between the layers of tissue) to his forehead and lacerations (cuts or tears through the skin) that required repair (stitches) and Resident #7 fell and suffered a sacral (large triangular bone at the bottom of the spine) fracture and displaced fractures of the pelvis. The facility's failure to develop and implement Comprehensive Care Plans resulted in Immediate Jeopardy for Resident #6, #8, #9, #11, #12, #13, #14, and #15 when these residents were at increased risk for falls and wandering, and the facility failed to have a Comprehensive Care Plan with interventions that were person-centered to address these risks. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-656 on 2/22/2021 at 10:00 AM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-656. The Immediate Jeopardy for F-656 was effective from 11/13/2020-2/22/2021. An acceptable Removal Plan for F-656, which removed the immediacy of jeopardy, was received on 2/23/2021 at 3:00 PM, and was validated onsite by the surveyors on 2/23/2021 through observations, review of in-service records, audits, and meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Care Plans-Comprehensive, showed, .A person-centered 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 Nurse/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the resident Assessment Instrument .The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment .Care plans are ongoing and revised as information about the resident and the resident's condition change .The care plan should reflect the current status of the resident and be updated with changes in the resident's status . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 10, which indicated Resident #1 was moderately cognitively impaired. Resident #1 required extensive assist for transferring and bed mobility. Review of the Nursing Admission assessment dated [DATE], showed, .Motor control unsteady gait, history of falling/recent fall . Review of the Fall Risk assessment dated [DATE], showed Resident #1 scored a 40 which indicated the resident was at moderate risk of falling. Review of Resident #1's Incident Note dated 1/9/2021, showed, .Nurse heard a noise and upon entering pt's (patient's) room, pt was found to be rising from the floor. Urine was in the floor and appears pt slipped causing him to sit in the floor .no injuries observed . There was no Fall Risk Assessment completed after this fall. Review of the Nurses' Notes dated 1/13/2021 at 7:58 PM, showed, .witness (witnessed) fall by nurse and CNA (Certified Nursing Assistant). Resident (Resident #1) witnessed ambulating unassisted in the hallway when he lost his balance and fell face first into the floor. Head to toe assessment performed, dark purple bruising to the forehead and eyes noted. Resident noted to be more confused, combative to staff and unsteady for his baseline .order transfer to ER (emergency room ) . Review of Resident #1's Emergency Department Note dated 1/13/2021 at 10:22 PM, showed, .small hematoma forehead .fell forward hitting his forehead .(symbol for positive) contusion (bruise) .dx (diagnosis): head contusion (bruise) .return to nursing home . During an interview on 2/7/2021 at 9:56 AM, the Medical Records Nurse confirmed the Comprehensive Care Plan did not address Resident #1's fall risk after the falls that occurred on 1/9/2021 and 1/13/2021. Review of the facility's video camera footage on 1/24/2021 at 1:44 PM, showed Resident #1 standing at the North Hall exit door looking out the window. At 1:44 PM, Resident #1 walked from the exit door into an unoccupied resident room. At 1:46 PM, Resident #1 walked down a steep hill, grabbed onto a tree trunk to steady himself, then walked across the driveway to an integrity impaired (the fence was bent at the top of the fence and the bottom was bent with a crawling space underneath the fence) chain linked fence with an unsecured gait, near a creek with swift moving water. He propped against the fence then walked down the fence line frequently stopping and pushing on the fence. At 1:50 PM, he pushed on the fence and faced the creek. At 1:52 PM, he reached over the fence toward the creek and attempted to pull a tree branch and raised his left leg and propped his leg on the fence. At 1:54 PM, Resident #1 walked to the pavilion and sat on the picnic table bench under the pavilion. At 1:55 PM, a car came in view of the camera from the side of the building toward the pavilion and three staff members (Dietary Aide #1, Dietary Cook #1, and the Receptionist) got out of the car and walked to Resident #1. After these three staff interacted with Resident #1, at 1:55 PM, two employees (Dietary Aide #1 and Dietary Cook #1) got back in the car and drove away. The third employee (Receptionist) walked away and into the building. Resident #1 was left alone and unsupervised outside under the pavilion. At 1:56 PM, the car drove out of the camera view. At the North Entrance at 2:03 PM, Resident #1 and two staff members (Certified Nursing Assistant (CNA) #1 and CNA #7) returned and entered the building in the basement area. Review of Resident #1's Incident Note dated 1/27/2021 at 9:30 AM, showed, .staff found pt lying in hallway by nurses station with moderate amount of bleeding from mouth .all pt could tell us he think (thinks) he got dizzy when fell .laceration of lip .pt had knocked front tooth out with gold cap, had a laceration with moderate amount of bleeding noted from mouth .sent to ER . Review of the Emergency Department record dated 1/27/2021, showed, .he (Resident #1) knocked out his right upper central incisor, and he has multiple large lacerations involving his lower lip .has a history of Dementia and baseline confusion .there were 4 total lacerations repaired (requiring stitches) .sent back to facility . Review of the Comprehensive Care Plan dated 1/28/2021, showed the Comprehensive Care Plan did not address the resident's [DIAGNOSES REDACTED]. to the cognitive deficits, elopement/wandering risk, or the falls on 1/9/2021, 1/13/2021, or 1/27/2021. Interventions or Care area concerns for wandering/elopement risk were not initiated until 1/28/2021. During an interview on 2/7/2021 at 9:56 AM, the Medical Records Nurse confirmed Resident #1's Care Plan was not comprehensive, did not include the resident's risk of falling, and impaired cognitive function The facility's failure to ensure a resident at risk for falls had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #1 suffered a hematoma to his forehead and lacerations that required stitches. Review of the medical record, showed Resident #2 was admitted to the facility 6/17/2020 with [DIAGNOSES REDACTED]. Review of the Nurses' Notes dated 11/3/2020 at 2:53 AM, showed, .(Resident #2) pacing up and down halls most of night would not get in bed .said he wanted to go home and told him it was middle of night and he could talk to someone in am (morning) about going home, he was satisfied and cont (continued) to pace . Review of the Comprehensive Care Plan dated 6/18/2020 to present, showed there was not a Comprehensive Care Plan which addressed the elopement/wandering risk. Review of the quarterly MDS assessment dated [DATE], showed Resident #2 had a BIMS score of 6, which indicated Resident #2 was severely cognitively impaired. Resident #2's activities of daily living needs showed he required supervision-oversight, encouragement, or cueing. Review of the Nurses' Notes dated 11/13/2020 at 9:00 PM showed, CN (Charge Nurse) was notified via (by) CNA (Certified Nursing Assistant) from South Hall, patient had been seen busting out glass from window and climbing out. Upon assessing situation, room [ROOM NUMBER]'s window glass was busted out and patient (Resident #2) was not in the room. Patient (Resident #2) was located sitting on the bench in front of entrance door .had no visible injuries .Administrator was contacted and did return to center to discuss situation with patient. Patient did agree to return to room [ROOM NUMBER] and would not attempt to escape building again. NP (Nurse Practitioner) notified by CN of incident . Review of the Comprehensive Care Plan dated 6/18/2020 to present, showed the Comprehensive Care Plan did not address the resident's elopement attempt on 11/13/2020. Review of the medical record, showed Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] (the most recent Fall Assessment completed), showed Resident #7 scored a 75, which indicated high risk for falls. Review of the quarterly MDS assessment dated [DATE], showed Resident #7 was assessed to have a BIMS score of 7 which indicated severe cognitive impairment. Resident #7's activities of daily living needs ranged from limited assistance to extensive assistance. She required a wheelchair and a walker for mobility. Review of Resident #7's Comprehensive Care Plan dated 3/3/2020 to present, showed the care area concern for mobility did not address the resident's use of a wheelchair for mobility and the Care Plan for high risk for falls initiated on 3/3/2020 had no interventions for fall prevention until 1/8/2021. Review of the Significant Change in Condition MDS assessment dated [DATE], showed Resident #7 was assessed to have a BIMS score of 5 which indicated severe cognitive impairment. Resident #7's activities of daily living needs ranged from limited assistance to total dependence. She required a wheelchair for mobility. Review of the Incident Report dated 1/8/2021, showed, .found patient (Resident #7) in her bed call light next to her .Resident stated she tried to stand up and her legs went one way and her body went the other. She said she hit her head and got back in bed .Immediate Action taken .Resident reinforced to please use call light when needing assistance (Resident #7 had a BIMS of 5) .Patient is a one-person assist cannot walk . Review of the Incident Report dated 2/10/2021, showed .Resident (Resident #7) attempted to go to bathroom without asking for help and lost balance and fell flat of her back .Immediate Action Taken: educated on use of call light (Resident #7 had a BIMS of 5) . Review of the Nurses' Notes dated 2/10/2021, showed, .(Resident #7) sent back to (named hospital) r/t (related to) the fall in resident room. Pain in back and left hip .educated on the use of the call light and encouraged to use it whenever she needed anything (Resident #7 had a BIMS of 5) . Review of the hospital Discharge Documentation dated 2/10/2021, showed, .Significant Findings .IMPRESSION: 1. Vertical left sacral fracture along the SI (sacroiliac) joint .2. Comminuted (Break or splintered bone into more than 2 pieces) displaced fractures (broken bones that are not lined up) involving the left superior and inferior pubis rami (pelvis) . The facility's failure to ensure a resident at risk for falls had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #7 fell and suffered a sacral fracture and displaced fractures of the pelvis. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], showed Resident #6 was assessed to have a BIMS score of 12, which indicated Resident #6 was moderately cognitively impaired. Resident #6's activities of daily living needs ranged from being independent to supervision. She required a wheelchair for safe mobility and required continuous oxygen by nasal cannula. Observation at the exit door on the Southeast Hall on 2/7/2021 at 12:55 PM, showed Resident #6 was seated in a wheelchair with a group of other residents. Resident #6 stated, Waiting to go smoke. Observation and interview in the resident's room on 2/8/2021 at 11:58 AM, showed Resident #6 was alert and oriented. She ambulated in her room with an unsteady gait, holding to the furniture. She used supplemental oxygen by nasal cannula. When asked if she had experienced a fall Resident #6 stated, Falls at home. Many times, I fell . Review of the medical record, showed Resident #6 had a [DIAGNOSES REDACTED]. There were no interventions implemented to prevent or manage falls. Review of the Comprehensive Care Plan dated 1/19/2021, showed the Comprehensive Care Plan did not address the resident's [MEDICAL CONDITION] with oxygen therapy, pain management, risk of falling, use of a wheelchair for mobility, or smoking. During an interview on 2/8/2021 at 3:10 PM, the Medical Records Nurse was asked if she had a Comprehensive Care Plan for Resident #6. She stated, That's all there is. It's (Comprehensive Care Plan) not complete. I try to help with the Care Plan, but I've been working the floor too. It's not complete. Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #8 had a score of 105, which indicated high risk of falling. Review of the quarterly MDS assessment dated [DATE], showed Resident #8 was assessed to have a BIMS score of 2, which indicated severe cognitive impairment. Resident #8's activities of daily living needs ranged from limited assistance to extensive assistance. She used a rolling walker device for mobility. Resident #8 had experienced a fall since the prior MDS assessment. Observation at the end of the South Hall on 2/7/2021 at 11:40 AM, showed Resident #8 was using a rolling walker, wandering down the hall toward the Southeast Hall. She was alert and did not answer questions appropriately. Observation in the resident's room on 2/7/2021 at 12:15 PM, showed Resident #8 was sitting on the side of her bed. A fall mat was on the floor to the right side of the bed. Review of Resident #8's Comprehensive Care Plan dated 4/1/2020 to present, showed the Comprehensive Care Plan did not address the resident's use of a rolling walker for mobility and the Care Plan for high risk for falls did not address the intervention of a fall mat. Review of the medical record, showed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] (the most recent Fall Risk completed), showed Resident #9 score a 55, which indicated high risk of falling. Review of the Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed Resident #9 scored a 17 which indicated a high risk for wandering. Observation in the Front Lobby on 2/6/2021 at 11:33 AM, showed Resident #9 wandering aimlessly at the Receptionist Desk and then toward the North Hall. She was alert and did not answer questions appropriately. Review of the Comprehensive Care Plan dated 9/25/2020 to present, showed the Comprehensive Care Plan did not address the resident's [DIAGNOSES REDACTED]. There were no interventions to prevent falls until 11/3/2020 and there were no interventions for wandering/elopement risk until 2/3/2021. During an interview on 2/6/2021 at 10:50 AM, the Medical Records Nurse confirmed Resident #9's Care Plan was not comprehensive and did not address [MEDICAL CONDITION] or [MEDICAL CONDITION], and did not address the fall risk until 11/3/2020, or the wandering/elopement risk until 2/3/2021. Review of the medical record, showed Resident #11 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan dated 6/13/2018 to present, showed the Comprehensive care Plan did not address the resident's elopement risk or the wanderguard. Review of the quarterly MDS assessment dated [DATE], showed Resident #11 was assessed with [REDACTED]. Review of the Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed a score of 10 moderate risk for wandering. Resident #11 was readmitted [DATE] from the hospital, without orders for a wanderguard and the Comprehensive Care Plan was not updated. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], showed Resident #12 had a score of 90, which indicated a high risk for falls. Review of the Physical Therapy Evaluation dated 1/15/2021, showed, .partial/moderate assistance for chair to bed transfer, sit to stand, bed mobility sit to lying and lying to sitting on side of bed, walk 10 feet . Review of the medical record, showed a Comprehensive Care Plan had not been developed for Resident #12 by 2/4/2021 (21 days after admission). Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed the resident had a score of 6, which indicated a moderate risk for wandering. Review of the admission MDS assessment dated [DATE], showed Resident #13 was assessed to have a BIMS score of 3, which indicated Resident #13 was severely cognitively impaired. Resident #13's activities of daily living needs showed supervision-oversight, encouragement or cueing. Review of the physician's orders [REDACTED].wanderguard due to risk for elopement . Review of the Comprehensive Care Plan dated 10/19/2020 to present, showed the Comprehensive Care Plan did not address the resident's [DIAGNOSES REDACTED]. Review of the medical record, showed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], showed Resident #14 was assessed to have a BIMS score of 8, which indicated moderate cognitive impairment. Resident #14's balance during transition and walking was not steady but able to stabilize without staff assistance. Review of the physician's orders [REDACTED].#14 had a wanderguard. Review of the medical record showed, Resident #14 had a fall on 10/22/2020 with no injuries, on 10/27/2020 with an open area to the forehead, and 10/31/2020 with no injuries. Review of medical record showed, Resident #14 did not have a Fall Risk Assessment on admission, quarterly, or after the falls. Resident #14 did not have a Wandering Risk Assessment on admission or quarterly. Review of Resident #14's Comprehensive Care Plan dated 11/2/2020 to present, showed the Comprehensive Care Plan did not address the resident's risk for falls or the resident's wandering/elopement risk. (Resident #14 had 3 falls in 10/2020, and wore a wanderguard). Review of the Significant Change in Condition MDS assessment dated [DATE], showed Resident #14 was assessed to have a BIMS score of 6, which indicated severe cognitive impairment. Resident #14's balance during transition and walking was not steady but able to stabilize without staff assistance. Review of the medical record, showed Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Care Plan dated 6/26/2019 to present, showed the intervention/task for fall prevention documented, Be sure the resident's call light is within reach . Observation and interview in the resident's room on 2/22/2021 at 11:16 AM, showed Resident #15 was alert and oriented. There was no call light for her room. When asked where the call light was located, Resident #15 stated, I don't have one. During an interview on 2/22/2021 at 4:25 PM, the Administrator was asked about a call light not being present in Resident #15's room. The Administrator stated, I do not know how long the call light was out .Should have one. The facility's failure to develop and implement Comprehensive Care Plans resulted in Immediate Jeopardy for Resident #1, #2, #6, #7, #8, #9, #11, #12, #13, #14, and #15 when these residents were at increased risk for falls and wandering, and the facility failed to have a Comprehensive Care Plan with interventions that were person-centered to address these risks. Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurses' Note dated 1/24/2021, showed, .Physical altercation with resident in (named Room number, a former roommate) . Review of a Social Worker Note dated 1/27/2021, showed, Late entry: pt (patient) was in a physical altercation with another resident on 1/24/2021 . Review of the Comprehensive Care Plan dated 8/5/2020 to present, showed the Comprehensive Care Plan did not address the resident's physical aggression, or the [DIAGNOSES REDACTED]. Review of the medical record, showed Resident #10 was admitted [DATE] on and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of a Patient Encounter note by the Acute Care Nurse Practitioner dated 11/30/2020 showed, .Chief Complaint: Depression, refusing medications .She (Resident #10) continues to refuse medications from multiple nurses .She no longer gets out of bed and has had periods of violent outbursts. Her last violent outburst was 11/19/20 (2020), when police were called to facility. Pt (patient) (Resident #10) refuses all medications at this time . Review of the Comprehensive Care Plan dated 6/22/2020 to present, showed the Comprehensive Care Plan did not address the resident's behaviors that included refusal of medications, violent outbursts, Major [MEDICAL CONDITION], or Hypertension. The surveyors verified the Removal Plan by: 1. On 2/22/2021, licensed nursing staff will complete assessments on all residents with 100% completion of all residents assessed by 2/24/2021. The DON, MDS Nurse, and the Nurse Consultant will review assessments completed, medications list, and environment to ensure a comprehensive plan of care is completed with 100% of all residents affected with oxygen therapy, wandering/exit seeking behaviors, and falls, non-ambulatory residents with mobility, and will review to ensure residents have revised Care Plans by 3/3/2021. The surveyors reviewed the documentation, Care Plans, assessments, and interviewed staff on all shifts. 2. On 2/3/2021, Fall Assessments were completed by nursing management team to determine risk factors and this is ongoing. The Interdisciplinary Team (IDT) began reviewing assessments and updating for appropriate interventions to address risk factors and this will be completed by 3/3/2021. The surveyors reviewed the lists, forms, assessments, Care Plans, and interviewed staff on all shifts. 3. On 2/22/2021, an admission checklist was created by the DON to assist the Admission Nurse in completing admission assessments (including fall risk assessments), appropriate fall interventions are implemented, and initiation of a 48 hour Care Plan. The surveyors reviewed the forms, checklists, and interviewed staff on all shifts. 4. Beginning 2/22/2021, the DON or designee initiated staff education on comprehensive Care Planning and the role that all staff members play in contribution of interventions and resident care, and importance of following the plan of care. 100% completion of all staff will be completed by 3/3/2021. This will be ongoing and included in the orientation process. This will be included in all orientations. All staff education that was initiated by DON and Unit Manager was the following: a) Fall investigation process and intervention implementation. b) Comprehensive Care Plan process and following plan of care. c) Neurological status and assessments. d) Care of residents with behaviors and behavior management techniques. e) Fall Risk Assessment (how to; score and what to do next). f) Root cause analysis. g) Wandering Risk Assessments and what to do next The surveyors reviewed the education sign-in sheets and interviewed staff on all shifts. 5. All staff members will be required to attend mandatory in-servicing as well as education prior to start of any future shifts if on leave or Family Medical Leave Act (FMLA). All staff members not attending initial in-service will be educated upon return and will not be permitted to work until education is completed. The surveyors interviewed staff and the DON. 6. On 2/3/2021, Wander Risk Assessments were completed per Nursing Management staff and comprehensive Care Plans were initiated with ongoing plan of care updates and appropriate interventions implemented as needed for individualized plan of cares with 100% completion of all residents by 3/3/2021. The surveyors reviewed the risk assessments, lists, interventions, and interviewed the DON and staff. 7. All new admits will be reviewed by the IDT team in morning meeting to ensure completion of Fall Risk Assessments, accuracy of the 48 hour Care Plan, and review of the current fall interventions. The surveyors reviewed the IDT team morning checklist and interviewed staff on all shifts. 8. The IDT team will review all falls and current plan of care in the morning meeting to ensure appropriate interventions are in place. The surveyors reviewed the IDT meeting check list and interviewed members of the IDT. 9. The IDT team will conduct at risk meetings weekly to address falls, wandering behaviors, and review of comprehensive Care Plans. The surveyors reviewed the morning meeting agenda tool and interviewed the DON. 10. A second MDS Coordinator position is now open and facility is seeking a full time MDS Coordinator to assist with ensuring compliance with comprehensive Care Plans. A part-time MDS Coordinator started with the hiring process on 2/22/2021 and is to start on 2/24/2021. A full time MDS Coordinator has been offered a position and he has accepted the position and has initiated a 30 day notice at current employment. The surveyors interviewed the Administrator and the DON. 11. On 2/22/2021, the Nurse Consultant will conduct an education session with the MDS Coordinator to review key components in a comprehensive Care Plan per facility policy, format of a comprehensive Care Plan, 48 hour Care Plan, and frequency of updates required by regulation. The surveyors interviewed the Nurse Consultant and MDS Coordinator. 12. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will report findings of the administrative audits to the full Quality Assurance Performance Improvement (QAPI) committee and the President of the company to determine if the issues have been resolved. The surveyors reviewed the audits, and interviewed the Nurse Consultant and the Administrator. 13. The DON will complete a Performance Improvement project for comprehensive Care Plans utilizing the assessments completed for falls, wandering, behaviors, oxygen therapy, and all other assessments to create a comprehensive Care Plan that will be monitored by the QAPI committee monthly until 100% compliance is obtained or recommendations from the QAPI committee to resolve ongoing (TRUNCATED)

Based on policy review, video camera footage review, National Weather Service statistics, medical record review, observation, and interview, the facility failed to ensure a safe environment, provide adequate supervision to prevent elopement, and failed to investigate elopement incidents for 2 of 10 sampled residents (Resident #1 and #2) reviewed with wandering behaviors and elopement. The facility's failure to ensure a safe environment, provide adequate supervision to prevent elopement, and failure to investigate elopement incidents resulted in Immediate Jeopardy when Resident #2, a vulnerable resident with Dementia, exited the facility through a window, staff responded immediately after he eloped, but did not investigate this incident. Then, 2 months later, Resident #1, a confused vulnerable resident, exited the facility through a window in an unoccupied resident room. Resident #1 was near a creek with swift moving water. Facility staff were unaware Resident #1 was missing from the facility for 9 minutes and the resident was outside unattended for an additional 8 minutes, after being found by staff who left him unattended outside. In addition the facility failed to ensure residents at risk for falls were assessed, adequately supervised, and had appropriate interventions implemented to prevent falls for 7 of 11 sampled residents (Resident #1, #7, #3, #6, #8, #9, and #14) reviewed for falls, which resulted in Immediate Jeopardy Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Actual Harm occurred when Resident #1 suffered a hematoma (collection of blood between the layers of tissue) to his forehead and lacerations (cuts or tears through the skin) that required stitches, and when Resident #7 suffered a sacral (large triangular bone at the bottom of the spine) fracture (broken bone) and displaced fractures of the pelvis. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 2/6/2021 at 3:45 PM and on 2/22/2021 at 10:00 AM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-689. F-689 was cited at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/13/2020 through 2/22/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy for F-689 was received on 2/8/2021 at 2:50 PM. The corrective actions were validated onsite by the surveyors on 2/9/2021-2/10/2021 through observation, review of audits and meeting minutes, and staff interviews. An acceptable Removal Plan, which removed the immediacy of the jeopardy for F-689 was received on 2/23/2021 at 3:00 PM. The corrective actions were validated onsite by the surveyors on 2/23/2021 through observation, review of audits and meeting minutes, and staff interviews. The findings include: The facility's policy titled, Elopement Action Items, Missing Resident, dated 5/2016 showed, .Review camera footage if available .Begin interviewing ALL staff on duty to get statements include visitors if applicable .Complete an event and thorough assessment in event manager (computer program) .Begin investigation to determine root cause analysis and schedule ad hoc (as needed) QA (Quality Assurance) meeting within 24 hours to discuss findings .Audit all patient's elopement assessments to assure accurate and no other patient at risk .Elopement books to be updated with all changes .All residents to be assessed for risks of elopement on admission, condition change, quarterly and annual. Those at risk will be placed in elopement risk binders on each unit and care plans developed to address individual safety needs .An ad hoc QA meeting should be held as soon as possible with IDT (Interdisciplinary Team) members and the MD (Medical Doctor) and Medical Director to review findings of the investigation, RCA (root cause analysis) and .action plan . Review of the facility's undated policy titled, Elopement/Wandering, showed, .An elopement/wandering assessment will be completed upon admission .and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services and kept at nurses' stations. Updates will be done at least quarterly . Review of the facility's undated policy titled, Falls, showed, .It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries .All residents will have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions (measures implemented to reduce the risk of falls) will be implemented and evaluated as indicated by assessment .A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient .Interventions are to be revised as indicated by the assessment .If a fall occurs the following actions will be taken .Assess resident including neuro checks .Assess resident each shift for 72 hours .Neuro checks will be completed on residents that experience an unwitnessed fall .Document assessment, pertinent acts and incident .Begin investigation .Interdisciplinary Team (IDT) to determine root cause of fall if possible .Update care plan .IDT/MDS (Minimum Data Set)/ADON (Assistant Director of Nursing) Reviews revises care plan as appropriate quarterly and as needed .Falls will be a standing agenda item for facility QAPI (Quality Assurance Performance Improvement) Committee . Review of the facility's undated policy titled, Neurological Evaluation/Monitoring, showed, .Guideline Steps: Neurological evaluations are indicated: following an unwitnessed fall, following a fall or other accident/injury involving head trauma, when indicated by resident's condition .Neuro checks will be performed using the Neurological Evaluation Flow Sheet for a full 72 hours and placed in the medical record: every 15 minutes times four checks, every 30 minutes times four checks, every 1 hour times four checks, every 4 hours times four checks, every 8 hours until completed . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], showed Resident #1 was assessed to have a Brief BIMS score of 10, which indicated Resident #1 was moderately cognitively impaired. Review of a Nursing Admission assessment dated [DATE], showed, .Motor control unsteady gait, history of falling/recent fall . Medical record review showed no documentation of a Wandering Risk Assessment. A Fall Risk Assessment was not completed for the 12/4/2020 admission. Review of the Fall Risk assessment dated [DATE], showed Resident #1 scored a 40, which indicated a moderate risk of falling. Review of Resident #1's Incident Note dated 1/9/2021, showed, .Nurse heard a noise and upon entering pt's (patient's) room, pt was found to be rising from the floor. Urine was in the floor and appears pt slipped causing him to sit in the floor .no injuries observed . Review of Resident #1's medical record, showed there were no fall interventions, neurological checks, or Fall Risk Assessment completed after the unwitnessed fall on 1/9/2021. During an interview on 2/7/2021 at 9:56 AM, the Medical Records nurse confirmed there was no documentation of fall interventions, neuro checks, or a Fall Risk Assessment for Resident #1's fall on 1/9/2021. Review of the Nurses' Notes dated 1/13/2021 at 7:58 PM, showed, .witness (witnessed) fall by nurse and CNA (Certified Nursing Assistant). Resident (Resident #1) witnessed ambulating unassisted in the hallway when he lost his balance and fell face first into the floor. Head to toe assessment performed, dark purple bruising to the forehead and eyes noted. Resident noted to be more confused, combative to staff and unsteady for his baseline .order transfer to ER (emergency room ) . Review of Resident #1's Emergency Department Note dated 1/13/2021 at 10:22 PM, showed, .small hematoma forehead .fell forward hitting his forehead .(symbol for positive) contusion .dx (diagnosis): head contusion (bruise) .return to nursing home . Review of the medical record, showed there was no documentation of fall interventions, neuro checks, an incident report, or a Fall Risk Assessment for the 1/13/2021 fall. During an interview on 2/7/2021 at 9:56 AM, the Medical Records nurse confirmed there was no documentation of fall interventions, neuro checks, incident report, or a Fall Risk Assessment for Resident #1's fall 1/13/2021. Review of the facility's video camera North Hall footage with a timestamp of 1/24/2021 at 1:44 PM, showed Resident #1 standing at the North Hall exit door looking out the window. At 1:44 PM, Resident #1 walked from the exit door into an unoccupied resident room. At 1:46 PM, Resident #1 walked down a steep hill, grabbed onto a tree trunk to steady himself, then walked across the driveway to an integrity impaired (the fence was bent at the top of the fence and the bottom was bent with a crawl space underneath the fence) chain linked fence with an unsecured gait, near a creek with swift moving water. He propped against the fence then walked down the fence line frequently stopping and pushing on the fence. At 1:50 PM, he pushed on the fence and faced the creek. At 1:52 PM, he reached over the fence toward the creek and attempted to pull a tree branch and raised his left leg and propped his leg on the fence. At 1:54 PM, Resident #1 walked to the pavilion and sat on the picnic table bench under the pavilion. At 1:55 PM, a car came in view of the camera from the side of the building toward the pavilion and three staff members (Dietary Cook #1, Dietary Aide #1, and the Receptionist) got out of the car and walked to Resident #1. After staff interaction with Resident #1, at 1:55 PM, two employees (Dietary Cook #1 and Dietary Aide #1) got back in the car and drove away. The third employee (Receptionist) walked away and into the building. Resident #1 was left alone and unsupervised outside under the pavilion. At 1:56 PM, the car drove out of the camera view. At the North Entrance at 2:03 PM, Resident #1 returned to the building with staff assistance (CNA #1 and CNA #7). Review of the National Weather Service records showed, the recorded temperature on 1/24/2021 at 2:00 PM was 50 degrees Fahrenheit with light rain. Review of the facility's investigation of the elopement (on 1/24/2021) of Resident #1, showed the facility failed to interview all staff that were involved when the elopement occurred. There were no interviews of other staff on duty, Dietary Cook #1, Dietary Aide #1, Receptionist, or staff working previous shifts. The facility did not review the video camera footage. Review of Resident #1's medical record, showed no vital signs or assessment were documented after his elopement and there were no interventions documented on the 7:00 PM shift after Resident #1 eloped on 1/24/2021. Review of Resident #1's Incident Note dated 1/27/2021 at 9:30 AM, showed, .staff found pt lying in hallway by nurses station with moderate amount of bleeding from mouth .all pt could tell us he think (thinks) he got dizzy when fell .laceration (a cut or tear through the skin) of lip .pt had knocked front tooth out with gold cap, had a laceration with moderate amount of bleeding noted from mouth .sent to ER . Review of Resident #1's Emergency Department record dated 1/27/2021, showed, .he knocked out his right upper central incisor, and he has multiple large lacerations involving his lower lip .has a history of Dementia and baseline confusion .there were 4 total lacerations repaired (stitched) .sent back to facility . Review of the medical record, showed there was no documentation of fall interventions, neuro checks, or a Fall Risk Assessment for the 1/27/2021 fall. During an interview on 2/5/2021 at 12:48 PM, the Medical Records nurse confirmed Resident #1 did not have an admission Wandering Risk Assessment or a Fall Risk Assessment. She stated, .It is not there . During an interview on 2/7/2021 at 9:56 AM, the Medical Records nurse confirmed there was no documentation of fall interventions, neuro checks, or Fall Risk Assessment for Resident #1's 1/27/2021 fall. The facility's failure to ensure a resident at risk for falls was assessed, adequately supervised, and had appropriate interventions in place and implemented to prevent falls resulted in actual Harm for when Resident #1 suffered a hematoma to his forehead and lacerations that required stitches. Observations on 2/3/2021 at 1:54 PM of random resident room windows showed, the following openings: room [ROOM NUMBER] window slid open 21 inches room [ROOM NUMBER] window slid open 31 3/4 inches room [ROOM NUMBER] window slid open 12 inches During interviews on 2/3/2021 beginning at 1:00 PM, with different department staff which included 8 CNAs, 5 LPNs, 1 RN, 5 dietary, 2 therapy, 4 housekeeping, and 2 maintenance, showed the staff were not aware of a wandering/elopement notebook or where the notebook was located. All staff interviewed stated that they were not aware there was a notebook. During an interview on 2/3/2021 at 1:54 PM, the Director of Maintenance confirmed the windows were not secured. He stated, .No, I don't check the windows. They slide open . The Director of Maintenance was asked if any elopement drills were completed after the elopement 1/24/2021. He stated, .No, have not had a drill since 11/30 (2020) . During an interview on 2/3/2021 at 4:07 PM, Dietary Cook #1 stated, .I was in my car and driving around to the back of the building on the way to the grocery (store) and I saw a man beside the fence looking at the creek. I said to (named Dietary Aide #1), 'that is one of our patients'. I drove back around to the front of the building, went into the front door looking for a nurse. I couldn't find one, so I told the Receptionist a patient is down by the river. The Receptionist got in the car with us and we drove back around to the back of the building. The Receptionist confronted him (Resident #1) and he (Resident #1) grabbed him (Receptionist) .He (Receptionist) left and went back into the building through the basement door to get somebody. I and (named Dietary Aide #1) left and went to the store .No, I didn't stay with the resident (either time when first found or after Receptionist left) .He (Resident #1) was left out there at the picnic table .We didn't stay with him, left him alone . During an interview on 2/3/2021 at 4:20 PM, Dietary Aide #1 confirmed Dietary Cook #1's statement. She stated, .After the Receptionist went into the building me and (Named Dietary Cook #1) left to go to the store .Yes, we left him (Resident #1) alone .it was cold outside . During a telephone interview on 2/4/2021 at 10:00 AM, the Receptionist stated, .A lady (Dietary Cook #1) came in the front door and said a resident was outside in the back. I jumped in her car and we drove around. He (Resident #1) was sitting under the pavilion .I walked up and asked him to come back inside and he grabbed me by the shirt. I finally got loose and went back in the building .I paged overhead nurse to lobby ASAP (as soon as possible) .people (CNA #1 and CNA #7) came to the lobby and went out the front door .I saw him (Resident #1) walking, looking like going for the fence toward the creek . During an interview on 2/4/2021 at 10:33 AM, CNA #1 stated, .I was taking care of (named Resident #1) that day (1/24/2021). He had been lying down in his room .Someone said a resident was outside, so I looked out the window and saw him. I went down the elevator and went outside. I sat beside him and told him it's cold out here we need to go in. I noticed grass stain on his knee but there was no injury .Me and (Named CNA #7) escorted him (Resident #1) back into the building. Once inside I cut the heat on because he said he was cold .changed his clothes and he went to sleep . During a telephone interview on 2/4/2021 at 11:46 AM, Licensed Practical Nurse (LPN) #2 stated, .I worked 1/24 (2021) 7:00 PM shift after his (Resident #1's) elopement .they gave me report at shift change but no instructions of any interventions, like it was not a serious thing .no, we did not do one on one .it was the next night (1/25/2021) when he (Resident #1) got one on one, I thought that was odd because the night (1/24/2021) after it happened earlier that afternoon (1/24/2021) they didn't do any interventions . During a telephone interview on 2/4/2021 at 12:00 PM, the Medical Director stated, .No one from the facility talked directly to me .I don't remember .I do remember discussing with (named Nurse Practitioner) later about it (the elopement) . During a telephone interview on 2/4/2021 at 12:10 PM, LPN #1 stated, .When I went outside to help it was cold and had started drizzling rain pretty good. Once we got Mr. (Named Resident #1) back in the building, I assessed him. He had no injuries just dirt on the knee of his pants. He had on gray jogging pants, gray t-shirt short sleeves and tennis shoes. He said he was cold and tired, and he laid down to sleep .His history was he wandered all the time and would go to the doors . During an interview on 2/4/2021 at 1:18 PM, the DON and Medical Records Nurse confirmed the facility did not have an incident report for the elopement on 1/24/2021, and no documentation or evidence of interventions during the 7:00 PM - 7:00 AM shift on 1/24/2021-1/25/2021. Observation in the North Hall on 2/4/2021 at 1:37 PM, showed Resident #1 ambulating down the hall with an unsteady gait, holding onto the wall and/or chair rail for balance. He walked toward the exit door, looking in every room, if the door was closed, he would attempt to push the resident room door open as he walked by. He pushed on the door to room [ROOM NUMBER] without success, then proceeded to room [ROOM NUMBER], the door opened, and he walked in. CNAs were alerted and as the door was opened, Resident #1 was standing at the window. Resident #1 was redirected out into and down the hall. During an interview on 2/4/2021 at 4:22 PM, the Nurse Practitioner was asked if she was notified of Resident #1's elopement. She stated, .I was off 1/24 (2021) and I did not find out until the afternoon of 1/25 (2021) .My company sends out a 24 hour report and that is how I found out about it .The facility did not call or text me .I had no communication with the Medical Director at all about this elopement .since they did not notify any medical professional it was an environmental type thing . During an interview on 2/4/2021 at 5:21 PM, the MDS Coordinator stated, .I was interim DON on 1/24 (2021) .No, I did not come in nor did the Administrator come in after the elopement (1/24/2021) .No one from Administration came into the facility after the incident . During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if a thorough investigation was conducted on the elopement. He stated, .I failed at this one .I see it .I should have known . During an interview on 2/5/2021 at 2:00 PM, the Administrator confirmed the facility's video camera footage was never reviewed. Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #2 was assessed to have a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #2 was severely cognitively impaired for decision making. Resident #2's activities of daily living needs showed the resident required supervision-oversight, encouragement, or cueing. Review of the Nurses' Notes dated 11/13/2020 at 9:00 PM showed, CN (Charge Nurse) was notified via (by) CNA from South Hall, patient had been seen busting out glass from window and climbing out. Upon assessing situation, room [ROOM NUMBER]'s window glass was busted out and patient (Resident #2) was not in the room. Patient was located sitting on the bench in front of entrance door .had no visible injuries .Administrator was contacted and did return to center to discuss situation with patient. Patient did agree to return to room [ROOM NUMBER] and would not attempt to escape building again. NP (Nurse Practitioner) notified by CN of incident . Review of the National Weather Service records, showed the recorded temperature on 11/13/2020 at 6:00 PM was 54 degrees Fahrenheit. Review of the medical record, showed Resident #2 had no documentation of a skin assessment, no documentation of interventions implemented after the elopement, no incident report completed, no documentation of an assessment after the elopement, and no Wander Risk Assessment on admission, quarterly or after the incident. During an interview on 2/4/2021 at 12:43 PM, the Medical Records Nurse confirmed Resident #2's medical record contained no documentation of a Wander Risk Assessment on admission, quarterly or after the incident. There was no documentation of an incident report or investigation, and no documentation of a skin assessment, any wandering risk assessments or interventions after the elopement. During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if the facility had any elopements prior to the elopement of Resident #1 on 1/24/2021. He stated, .well four months prior (was two months prior) Mr. (Named Resident #2) broke a window .our interventions were every 15 minute checks and medication review .I didn't do an investigation . During an interview on 2/5/2021 at 10:00 AM, the Administrator was asked for the documentation of the interventions of the incident with Resident #2. He stated, .I have no interventions and I did not do an investigation . During a telephone interview on 2/5/2021 at 2:10 PM, Contract CNA #3 stated, .The incident occurred at shift change after 7:00 PM .(Named Contract Licensed Practical Nurse (LPN) #6) husband saw it, he was parked at the front entrance waiting in the car to pick her (Contract LPN #6) up .he called (Named Contract LPN #6) on the cell phone and told her someone was breaking out a window .then he called her back and said someone is climbing out the window .I ran (from South Hall Nursing Station) out the front entrance and he (Resident #2) had already got out the window and was standing in front of the building (facility) .I stayed out there with him .He (Resident #2) did not want to come back in the building .It was cold outside but I don't remember what he was wearing . During a telephone interview on 2/5/2021 at 2:30 PM, Contract LPN #6 stated, .I got a call from the person who was picking me up and he said someone broke the glass out of the window .He was parked near the front entrance .He then called back and said a man was coming out the window .I went out the front entrance and saw Mr. (Named Resident #2) outside the window .I think he was upset because he was COVID positive and they had put him in isolation unit . Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #7 was assessed to have a BIMS score of 7 which indicated severe cognitive impairment. Resident #7's activities of daily living needs ranged from limited assistance to extensive assistance. She required a wheelchair and walker for mobility. Review of the Fall Risk assessment dated [DATE], showed Resident #7 scored a 75, which indicated high risk for falls. Review of the Significant Change in Condition MDS assessment dated [DATE], showed Resident #7 had a BIMS score of 5, which indicated severe cognitive impairment. Resident #7's activities of daily living needs ranged from limited assistance to total dependence. She required a wheelchair for mobility. Review of the Incident Report dated 1/8/2021, showed, .found patient (Resident #7) in her bed call light next to her .Resident stated she tried to stand up and her legs went one way and her body went the other. She said she hit her head and got back in bed .Immediate Action taken .Resident reinforced to please use call light when needing assistance (Resident #7 had a BIMS of 5) .Patient is a one-person assist cannot walk . Review of the Incident Report dated 2/10/2021, showed .Resident (Resident #7) attempted to go to bathroom without asking for help and lost balance and fell flat of her back .Immediate Action Taken: educated on use of call light (Resident #7 had a BIMS of 5) . Review of the Nurses' Notes dated 2/10/2021, showed, .(Resident #7) sent back to (named hospital) r/t (related to) the fall in resident room. Pain in back and left hip .educated on the use of the call light and encouraged to use it whenever she needed anything (Resident #7 had a BIMS of 5) . Review of the hospital Discharge Documentation dated 2/10/2021, showed, .Significant Findings .IMPRESSION: 1. Vertical left sacral fracture along the SI (sacroiliac) joint .2. Comminuted displaced fractures involving the left superior and inferior pubis rami (pelvis) . During an interview on 2/6/2021 at 2:40 PM, the Medical Records nurse was asked if Resident #7 had a Fall Risk Assessment completed quarterly and after any fall. She stated, That's (Fall Risk Assessment completed 11/11/2019) all I got . Observation in the resident's room on 2/7/2021 at 12:30, showed Resident #7 was lying on her bed wearing street clothes and no socks. Resident #7 was alert and could not answer questions appropriately. A large fading dark purple bruise was below Resident #7's left eye and a fading yellow bruise under her right eye. Observation in the resident's room on 2/22/2021 at 10:55 AM, showed Resident #7 lying in bed wearing a hospital gown and no socks. She was alert, oriented to self only. The call light was lying on the floor. There was one fall safety mat on the floor to the right side of the bed. The facility's failure to ensure a resident at risk for falls was assessed, adequately supervised, and had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #7 suffered a vertical left fracture and comminuted displaced fractures involving the left superior and inferior pelvis. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was discharged from the facility on 12/29/2020. Review of the Emergency Visit Note dated 12/17/2020 (included in the admission information prior to admitting to the facility), showed, .Patient (Resident #3) certainly would need a walker or someone to walk with him to prevent any falls . Review of a Nurses' Progress Note dated 12/20/2020, showed, .ambulates with a slow unsteady gait r/t (related to) weakness and fatigue . Review of Physical Therapy Evaluation and Plan of Treatment dated 12/21/2020, showed, .Fall Risk Assessment .Patient (Resident #3) presents with generalized weakness and he needs to hold on to wall rail . Review of the admission MDS assessment dated [DATE], showed Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #3's activities of daily living (ADLs) needs ranged from limited to extensive assistance. Review of Resident #3's Incident Note dated 12/22/2020, showed, .resident found sitting on the floor in the middle of his bedroom .Resident was very upset with staff that he had fallen. Resident is alert and oriented to person, place and time but is confuse (confused) .resident sustained [REDACTED].Notes .Resident ambulates with an unsteady gait and requires assistance of staff x (symbol for times) 1 and use of rolling walker r/t weakness and fatigue .Predisposing Environmental Factors assistive device not in use . Review of the medical record showed, neurological checks were not completed after the unwitnessed fall on 12/22/2020, and a Fall Risk Assessment had not been completed. During an interview on 2/4/2021 at 4:40 PM, the Medical Records nurse stated, .There is no admission assessment. No Falls Risk Assessment . During an interview on 2/8/2021 at 11:02 AM, the DON was asked when she expected a Fall Risk Assessment to be completed. The DON stated, .A Fall Risk Assessment (should be completed) on a new resident, with a change in condition, after a fall, and quarterly. The DON confirmed Resident #3 had no admission assessment or Fall Risk Assessment. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], showed Resident #6 had a BIMS score of 12, which indicated Resident #6 was moderately impaired cognitively. Resident #6's activities of daily living needs ranged from being independent to supervision. She required a wheelchair for safe mobility and required continuous oxygen by nasal cannula. Observation in Resident #6's room on 2/8/2021 at 11:58 AM, showed Resident #6 was alert and oriented. She ambulated in her room with an unsteady gait, holding to furniture. When asked if she had experienced a fall, Resident #6 stated, .Falls at home. Many times, I fell . Review of the medical record, showed Resident #6 was not assessed upon admission to determine fall risk. There were no interventions implemented to prevent or manage falls. Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], showed Resident #8 had a score of 105, which indicated high risk for falling. Review of the Incident Report dated 10/9/2020, showed, Resident #8 had a fall with no injuries and documented, .Immediate intervention is educated resident to ask for assistance with all transfers and visual aide on closet door to call for assistance . Resident #8's BIMS was 2 which indicated severe cognitive impairment Review of Resident #8's Nurses' Progress Note dated 10/9/2020, showed, .cna (CNA) knocked on door to room and barely opened door to room resident was noted to be laying on right side on floor behind door cna (CNA) notified this nurse went immediately to room resident noted to be behind door to room in front of closet . Review of the quarterly MDS assessment dated [DATE], showed Resident #8 had a BIMS score of 2, which indicated severe cognitive impairment. Resident #8's activities of daily living needs ranged from limited assistance to extensive assistance. She used a rolling walker device for mobility. <(TRUNCATED)

Based on policy review, employee and contract employee personnel file review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure licensed nurses had the knowledge and skills necessary to provide care and assure safety for 14 of 15 sampled residents (Resident #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed at risk of falls and/or wandering/elopement. The facility's failure to assess residents, complete fall risk assessments, complete neurological checks, implement appropriate interventions, develop comprehensive Care Plans, and provide care for residents with behaviors resulted 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) for Resident #1, #7, #2, #3, #6, #8, #9, #11, #12, #13, #14, and #15. These failures resulted in Immediate Jeopardy and actual Harm when Resident #1 suffered a hematoma (collection of blood between the layers of tissue) to his forehead and lacerations (cuts or tears in the skin) that required repair (stitches) and when Resident #7 fell and suffered a sacral (large triangular bone at the bottom of the spine) fracture (broken bone) and displaced fractures of the pelvis. Resident #2, a vulnerable resident with Dementia, exited the facility through a window. Then, 2 months later, Resident #1, a confused vulnerable resident, exited the facility through a window in an unoccupied resident room. Resident #1 was missing from the facility for 17 minutes and the resident was outside unattended for 9 minutes. Resident #1 was next to an integrity impaired (broken) fence with an unsecured gate, near a creek with swift moving water. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-726 on 2/22/2021 at 10:00 AM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy was effective from 11/13/2020-2/22/2021. An acceptable Removal Plan for F-726, which removed the immediacy of jeopardy, was received on 2/23/2021 at 3:00 PM, and was validated onsite by the surveyors on 2/23/2021 through observations, review of education provided, audits, and meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Elopement/Wandering, showed, .An elopement/wandering assessment will be completed upon admission .and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering . Review of the undated facility's policy titled, Falls, showed, .All residents will have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition . Review of the undated facility's policy titled, Neurological Evaluation/Monitoring, showed, .Neurological evaluations are indicated: following an unwitnessed fall, following a fall or other accident/injury involving head trauma, when indicated by resident's condition . Review of employee personnel files for Registered Nurse (RN) #1, #2, and #3, Licensed Practical Nurse (LPN) #1, #2, #3, and #4, and Contract LPN #1, #2, #3, #4 and #5 showed the employees had no documentation of a competency evaluation to ensure they had knowledge related to the care of residents with dementia, care of residents with behaviors such as wandering/exit seeking, fall prevention safety, or nursing assessment skills. There was no documentation the nurses were determined to be competent to provide care for the residents in the facility. Review of Resident #1's medical record and video camera footage, showed the following: There was no documentation of a Fall Risk Assessment or Wandering Risk Assessment completed and there was no documentation of a Fall Risk Assessment for the admission on 12/4/2020. Resident #1's Fall Risk Assessment completed on 1/7/2021, showed Resident #1 was at moderate risk for falls. Review of the Incident Notes and Nurses' Notes showed the following falls: Resident #1 fell on [DATE] with no injuries. Resident #1 fell on [DATE] with a hematoma to his forehead. Resident #1 fell on [DATE] with lacerations to his lip requiring stitches. There were no Fall Risk Assessments completed after the falls and no interventions for falls on the Care Plan. The facility's video camera North Hall footage on 1/24/2021, showed Resident #1 exited the facility. The Comprehensive Care Plan dated 1/28/2021, did not include Resident #1's risk for falling, impaired cognition function/dementia or impaired thought processes related to dementia, elopement/wandering risk. A Care Plan for wandering/elopement risk was not initiated until 1/28/2021. The facility's failure to ensure a resident at risk for falls was assessed and had a Comprehensive Care Plan with appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #1 suffered a hematoma to his forehead and lacerations that required stitches. Review of Resident #7's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #7 scored a 75, which indicated high risk for falls. Resident #7's Comprehensive Care Plan dated 3/3/2020 to present, showed the Care Plan for high risk for falls had no interventions for fall prevention until 1/8/2021. The Incident Report dated 1/8/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to reinforce to use call light when needing assistance and the resident was severely cognitively impaired. The Incident Report dated 2/10/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to educate on use of call light and the resident was severely cognitively impaired. The Nurse's Notes dated 2/10/2021, showed, Resident #7 fell and suffered a sacral fracture and displaced fractures to the pelvis. The facility's failure to ensure a resident at risk for falls had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #7 fell and suffered a sacral fracture and displaced fractures of the pelvis. Review of Resident #2's medical record, showed the following: The Comprehensive Care Plan dated 6/18/2020 to present, did not include the Resident #2's elopement/wander risk or any interventions to address a risk of wandering. The Nurses' Notes dated 11/3/2020 at 2:53 AM, showed, Resident #2 was pacing up and down the halls most of the night, would not get in bed, and said he wanted to go home. The Comprehensive Care Plan dated 6/18/2020 to present, showed there was not a Comprehensive Care Plan which addressed the elopement/wandering risk. The Nurses' Notes dated 11/13/2020, showed Resident #2 broke a window and exited the facility, and was located immediately by staff The Comprehensive Care Plan dated 6/18/2020 to present, did not include interventions for the elopement attempt on 11/13/2020. There was no Wandering Risk Assessment completed on admission, quarterly, or after the elopement attempt. Review of Resident #3's medical record, showed the following: There was no Fall Risk Assessment completed on admission of 12/20/2020. The Incident Note dated 12/22/2020, showed Resident #3 fell with a small skin tear to his elbow. There was no Fall Risk Assessment completed after the fall. Review of Resident #6's medical record, observation, and interview, showed the following: Observation at the exit door on the Southeast Hall on 2/7/2021 at 12:55 PM, showed Resident #6 was seated in a wheelchair with a group of other residents. Resident #6 stated, Waiting to go smoke. Observation and interview in the resident's room on 2/8/2021 at 11:58 AM, showed Resident #6 was alert and oriented. She ambulated in her room with an unsteady gait, holding to the furniture. She used supplemental oxygen by nasal cannula. When asked if she had experienced a fall Resident #6 stated, Falls at home. Many times, I fell . Resident #6 had a [DIAGNOSES REDACTED]. There were no interventions implemented to prevent or manage falls. The Comprehensive Care Plan dated 1/19/2021, showed there was not a Care Plan for oxygen therapy, risk of falling, use of a wheelchair for mobility, or smoking. Review of Resident #8's medical record and observation, showed the following: Resident #8 was admitted to the facility with a history of repeated falls. The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #8 had a score of 105, which indicated high risk of falling. Resident #8 had a fall on 10/9/2020 with no injuries. There were no Fall Risk Assessments completed quarterly or after the 10/9/2020 fall. Observation at the end of the South Hall on 2/7/2021 at 11:40 AM, showed Resident #8 was using a rolling walker, wandering down the hall toward the Southeast Hall. She was alert and did not answer questions appropriately. Observation in the resident's room on 2/7/2021 at 12:15 PM, showed Resident #8 was sitting on the side of her bed. A fall mat was on the floor to the right side of the bed. The Comprehensive Care Plan dated 4/1/2020 to present, showed the Care Plan for mobility did not address the use of a rolling walker and the Care Plan for high risk for falls did not include the intervention of a fall mat. Review of Resident #9's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk completed), showed Resident #9 score a 55, which indicated high risk of falling. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed Resident #9 scored a 17 which indicated a high risk for wandering. The Comprehensive Care Plan dated 9/25/2020 to present, showed there were no interventions to prevent falls until 11/3/2020 and there were no interventions for wandering/elopement risk until 2/3/2021. Resident #9 fell on [DATE] with redness to the eyes, a red mark to the neck, and an abrasion to the forehead. Resident #9 did not have a Fall Risk Assessment completed quarterly or after the fall on 11/2/2020. Review of Resident #11's medical record, showed the following: The physician's orders [REDACTED]. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed a score of 10 moderate risk for wandering. The Comprehensive Care Plan dated 6/13/2018 to present, showed there was not a Care Plan for the resident's elopement risk or the wanderguard. Review of Resident #12's medical record, showed the following: The Fall Risk assessment dated [DATE], showed Resident #12 had a score of 90, which indicated a high risk for falls. A Comprehensive Care Plan had not been developed for Resident #12 by 2/4/2021 (21 days after admission). Review of Resident #13's medical record, showed the following: Resident #13 was admitted with Dementia and behaviors. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed the resident had a score of 6, which indicated a moderate risk for wandering. The Physicians' Orders dated 10/19/2020, showed an order for [REDACTED]. The Comprehensive Care Plan dated 10/19/2020 to present, did not include the resident's elopement/wander risk. Review of Resident #14's medical record, showed the following: The Physicians' Orders dated 9/30/2020, showed Resident #14 had a wanderguard. Resident #14 had falls on 10/22/2020 with no injuries, on 10/27/2020 with an open area to the forehead, and on 10/31/2020 with no injuries. Resident #14 did not have a Fall Risk Assessment on admission, quarterly, or after the falls. Resident #14 did not have a Wandering Risk Assessment on admission or quarterly. Resident #14's Comprehensive Care Plan dated 11/2/2020 to present, showed the Comprehensive Care Plan did not address the resident's risk for falls or the resident's wandering/elopement risk. (Resident #14 had 3 falls in 10/2020, and wore a wanderguard). Review of Resident #15's medical record, observation, and interview, showed the following: The Comprehensive Care Plan dated 6/26/2019 to present, showed the intervention/task for fall prevention documented to be sure the resident's call light was within reach. Observation and interview in the resident's room on 2/22/2021 at 11:16 AM, showed Resident #15 was alert and oriented. There was no call light for her room. When asked where the call light was located, Resident #15 stated, I don't have one. Review of Resident #5's medical record, showed the following: The Nurses' Note dated 1/24/2021, showed, Resident #5 had an altercation with another resident. The comprehensive Care Plan dated 8/5/2020 to present, did not include the resident's physical aggression. Review of Resident #10's medical record, showed the following: A Patient Encounter note by the Acute Care Nurse Practitioner dated 11/30/2020, showed, Resident #10's chief complaint was Depression, was refusing medications, she continued to refuse medications from multiple nurses, and had periods of violent outbursts. The Comprehensive Care Plan dated 6/22/2020 to present, showed there was not a Care Plan for behaviors that included refusal of medications, violent outbursts, or Depression. Review of the medical records for Resident #1, #2, #3, #8, #10, #11, and #12 showed the residents did not have nursing admission assessments completed on admission. Review of the medical records for Resident #1, #3, #7, #8, #9, #13, and #14 showed neurological assessments were not completed after the residents experienced unwitnessed falls to determine if the residents had any neurological injury. During an interview on 2/4/2021 at 5:45 PM, RN #2 was asked if a competency check had been completed to determine her knowledge and skills. RN #2 stated, No .I know what to do. During an interview on 2/5/2021 at 12:16 PM, Certified Nursing Assistant (CNA) #8/Scheduler was asked if a knowledge and skills competency evaluation was completed on the licensed nurses prior to providing care for the residents. CNA #8/Scheduler stated, .We don't check competency that I know of .Agency staff get a thorough report about the residents at shift change . CNA#8/Scheduler was asked who was responsible to ensure the contract RNs and contract LPNs had competency checks prior to providing care for the residents and she stated, The DON is responsible I guess. We don't have competency checks that I know of . During an interview on 2/5/2021 at 3:25 PM, the DON was asked when a knowledge and skills assessment was conducted on licensed nurses and contract staff and what staff member conducted the assessment. The DON stated, Should be on hire, annual, and as needed. There are no competencies .As far as skills, there are none. No one has a competency. During an interview on 2/8/2021 at 11:02 AM, the DON was asked how the facility ensured the competency of contract staff and ensured they had the skills to provide care for the residents. The DON stated, I can't say I verified their competency. During an interview on 2/8/2021 at 11:48 AM, LPN #3 was asked when a wandering/elopement risk assessment and/or a neurological assessment should be completed. Contract LPN #3 stated, I'm Agency (contract). I don't know about that. Unit Manager would do the neuro check I guess. Somebody said they (assessments) are done on paper. I don't know. During an interview on 2/8/2021 at 11:58 AM, the Master Physical Therapist (MPT) was asked how contract staff affects their activities and tasks. The MPT stated, The (contract staff) don't know the patients well. I see it with behaviors. For example they think the patient is angry and acting out. All she (resident) really needed was a drink of water. She could be aphasic (loss of ability to express words). The agency staff didn't know. During an interview on 2/8/2021 at 12:30 PM, LPN #4 was asked how contract staff affect the activities and tasks in the facility. LPN #4 stated, They have questions about things they don't know. I have only been here (employed) 4 weeks. Most of the time I have to ask too. LPN #4 was asked if the facility completed a competency check for knowledge and skills prior to providing resident care. LPN #4 stated, No, ma'am. I had some orientation on abuse and fire safety. I had orientation with another nurse using the (Named electronic medical record software program) for a day . During an interview on 2/8/2021 at 12:35 PM, LPN #3 was asked how contract staff affect the activities and tasks, she stated, They need more direction throughout the shift. They don't know how we do things and need direction. I have to stop what I'm doing so they can know what to do . During an interview on 2/22/2021 at 3:58 PM, LPN #5 was asked if she had a skills competency check prior to providing resident care. LPN #5 stated, No, not when I was hired . LPN #5 was asked if she had a skills competency check during orientation. LPN #5 stated, No, not then. Didn't check me off on anything. Refer to F-600, F-610, F-656, and F-689. The surveyors verified the Removal Plan by: 1. On 2/17/2021, licensed nursing staff competencies were initiated by the Staff Development Coordinator (SDC). Competencies of all licensed nursing staff will be conducted by the DON or designee with 100% completion by 3/3/2021. Competencies will be required to be completed with all new hires while in orientation/training on the floor and will be reviewed by Human Resources to ensure completion. Competencies will be taught upon hire, annually, and as needed by the SDC. The surveyors reviewed the competencies completed and competency form/tool to be used and interviewed the DON and staff on all shifts. 2. On 2/22/2021, the DON or designee initiated staff education on comprehensive Care Plans and the role that all staff members play in contribution of interventions and resident care, and importance of following the plan of care. One hundred percent completion of all staff will be done by 3/3/2021. This will be ongoing and included in the orientation process. This will be included in all orientations. All staff education initiated by DON and Unit Manager included the following: a) Fall investigation process and intervention implementation. b) Comprehensive Care Plan process and following plan of care. c) Neurological status and assessments. d) Care of residents with behaviors and behavior management techniques. e) Fall risk assessment (how to; score and what to do next). f) Root cause analysis. The surveyors reviewed the sign in sheets and interviewed staff on all shifts. 3. All staff members will be required to attend mandatory in-servicing as well as education prior to start of any future shifts if on leave or Family Medical Leave Act (MLA). All staff members not attending initial in-service will be educated upon return and will not be permitted to work until education is completed. The surveyors interviewed staff on all shifts and the DON. 4. A second MDS Coordinator position is now open and facility is seeking a full time MDS Coordinator to assist with ensuring compliance with comprehensive care plans. A part-time MDS Coordinator started with the hiring process on 2/22/2021 and is to start on 2/24/2021. A full time MDS Coordinator has been offered a position and he has accepted the position and has initiated a 30 day notice at current employment. The surveyors confirmed interviewed the Administrator and the DON. 5. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will report findings of the administrative audits to the full Quality Assurance and Performance Improvement (QAPI) committee and the President of the company to determine if the issues have been resolved. The surveyors interviewed the Nurse Consultant and the Administrator. 6. An audit will be completed by Human Resources and the Administrator to track progress of competencies on new hires, contract, and annual to ensure 100% completion. All findings will be reported to QAPI monthly. The surveyors reviewed the audit forms and interviewed the Administrator. 7. All new hire orientation and annual competencies will be reviewed and signed off on by the DON or designee upon completion. The surveyors interviewed the DON. Noncompliance of F-726 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, video camera footage review, medical record review, observation, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopements, and conduct a Quality Assurance and Performance Improvement (QAPI) Committee meeting when a resident exited the facility without facility knowledge. The facility Administration failed to ensure residents at risk for falls was assessed, adequately supervised, and had a comprehensive Care Plan with appropriate interventions that were put into place and implemented to prevent falls and wandering/exit seeking behavior. The facility Administration failed to ensure the licensed nurses had the specific knowledge and skill sets necessary to assess residents, complete fall risk assessments, complete neurological checks, implement appropriate interventions, provide care for residents with behaviors, and failed to investigate incidents. These failures resulted in Immediate Jeopardy for Resident #1, #7, #2, #3, #6, #7, #8, #9, #11, #12, #13, #14, and #15. These failures resulted in actual Harm when Resident #1 suffered a hematoma (collection of blood between the layers of tissue) to his forehead and lacerations (cuts or tears in the skin) that required repair (stitches) and actual Harm when Resident #7 fell and suffered a sacral (large triangular bone at the bottom of the spine) fracture and displaced fractures of the pelvis. Resident #1 and #2 exited the building through a window, to an unsafe area. Resident #2, a vulnerable resident with Dementia, exited the facility through a window, staff responded immediately after exit, and this incident was not investigated. Then, 2 months later, Resident #1, a confused vulnerable resident with Dementia, exited the facility through a window in an unoccupied resident room. The facility was unaware Resident #1 was missing from the facility for 9 minutes and the resident was outside unattended for an additional 8 minutes when staff left him alone. Resident #1 walked down a steep hill, across the drive, was sitting under a pavilion, next to an integrity impaired (broken) fence with an unsecured gate, near a creek with swift moving water. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-835 on 2/6/2021 at 3:45 PM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-600, F-610, F-656, F-726, F-689, F-835, and F-867. The facility was cited an Immediate Jeopardy at F-600 and F-610 at a scope and severity of J, and at F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/13/2020 through 2/9/2021. An acceptable Removal Plan, which removed the immediacy of jeopardy for F-835, was received on 2/8/2021 at 2:50 PM, and was validated onsite by the surveyors on 2/9/2021 - 2/10/2021 through observations, review of audits and meeting minutes, and staff interviews. The findings include: The facility's policy titled, Elopement Action Items, Missing Resident, dated 5/2016 showed, .Review camera footage if available .Begin interviewing ALL staff on duty to get statements include visitors if applicable .Complete an event and thorough assessment in event manager (computer program) .Begin investigation to determine root cause analysis and schedule ad hoc (as needed) QA (Quality Assurance) meeting within 24 hours to discuss findings .Audit all patient's elopement assessments to assure accurate and no other patient at risk .Elopement books to be updated with all changes .All residents to be assessed for risks of elopement on admission, condition change, quarterly and annual. Those at risk will be placed in elopement risk binders on each unit and care plans developed to address individual safety needs .An ad hoc QA meeting should be held as soon as possible with IDT (Interdisciplinary Team) members and the MD (Medical Doctor) and Medical Director to review findings of the investigation, RCA (root cause analysis) and .action plan . The facility's undated policy titled, Elopement/Wandering, showed, .An elopement/wandering assessment will be completed upon admission .and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services and kept at nurses' stations. Updates will be done at least quarterly . Review of the undated Administrator job description, showed, .Provides leadership, oversight and administration to all long-term care operations. Responsible for ensuring maximum operating efficiency .strict compliance with all applicable State and Federal rules and regulations. Develops, monitors and improves facility quality standards .Assures that the facility maintains standards at the highest possible level and is responsible for the results of survey by the Department of Health .Develops, implements and assesses facility policies and procedures to ensure compliance with applicable State and Federal rules, regulations and accreditation standards .Oversees, evaluates and ensures the ongoing delivery of care and services. Provides routine analysis of the quality of care .Plans, directs and monitors compliance with State and Federal government regulatory agencies .Provides high quality services, processes and programs while consistently seeking ways to improve outcomes and enhance the facility . Review of the undated Director of Nursing job description, showed, .Manage administrative and functional areas or programs within the Nursing Department. Assist the Administrator to overall operations of the facility in accordance with Company policies, and standards of nursing practices and government regulations, as to maintain quality care .Planning, developing, organizing, implementing, evaluating and directing the day-to-day functions of the nursing department in accordance current rules, regulations, and guidelines .Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department .Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident .Regularly inspect the facility and nursing practices for compliance with company, federal, state, and local standards and regulations .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of Resident #1's medical record and video camera footage, showed the following: There was no documentation of a Fall Risk Assessment or Wandering Risk Assessment completed and there was no documentation of a Fall Risk Assessment for the admission on 12/4/2020. Resident #1's Fall Risk Assessment completed on 1/7/2021, showed Resident #1 was at moderate risk for falls. Review of the Incident Notes and Nurses' Notes showed the following falls: Resident #1 fell on [DATE] with no injuries. Resident #1 fell on [DATE] with a hematoma to his forehead. Resident #1 fell on [DATE] with lacerations to his lip requiring stitches. There were no Fall Risk Assessments completed after the falls and no interventions for falls on the Care Plan. The facility's video camera North Hall footage on 1/24/2021, showed Resident #1 exited the facility. The Comprehensive Care Plan dated 1/28/2021, did not include Resident #1's risk for falling, impaired cognition function/dementia or impaired thought processes related to dementia, elopement/wandering risk. A Care Plan for wandering/elopement risk was not initiated until 1/28/2021. The facility's failure to ensure a resident at risk for falls was assessed and had a Comprehensive Care Plan with appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #1 suffered a hematoma to his forehead and lacerations that required stitches. Review of Resident #7's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #7 scored a 75, which indicated high risk for falls. Resident #7's Comprehensive Care Plan dated 3/3/2020 to present, showed the Care Plan for high risk for falls had no interventions for fall prevention until 1/8/2021. The Incident Report dated 1/8/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to reinforce to use call light when needing assistance and the resident was severely cognitively impaired. The Incident Report dated 2/10/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to educate on use of call light and the resident was severely cognitively impaired. The Nurse's Notes dated 2/10/2021, showed, Resident #7 fell and suffered a sacral fracture and displaced fractures to the pelvis. The facility's failure to ensure a resident at risk for falls had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #7 fell and suffered a sacral fracture and displaced fractures of the pelvis. Review of Resident #2's medical record, showed the following: The Comprehensive Care Plan dated 6/18/2020 to present, did not include the Resident #2's elopement/wander risk or any interventions to address a risk of wandering. The Nurses' Notes dated 11/3/2020 at 2:53 AM, showed, Resident #2 was pacing up and down the halls most of the night, would not get in bed, and said he wanted to go home. The Comprehensive Care Plan dated 6/18/2020 to present, showed there was not a Comprehensive Care Plan which addressed the elopement/wandering risk. The Nurses' Notes dated 11/13/2020, showed Resident #2 broke a window and exited the facility, and was located immediately by staff The Comprehensive Care Plan dated 6/18/2020 to present, did not include interventions for the elopement attempt on 11/13/2020. There was no Wandering Risk Assessment completed on admission, quarterly, or after the elopement attempt. Review of Resident #3's medical record, showed the following: There was no Fall Risk Assessment completed on admission of 12/20/2020. The Incident Note dated 12/22/2020, showed Resident #3 fell with a small skin tear to his elbow. There was no Fall Risk Assessment completed after the fall. Review of Resident #6's medical record, observation, and interview, showed the following: Observation at the exit door on the Southeast Hall on 2/7/2021 at 12:55 PM, showed Resident #6 was seated in a wheelchair with a group of other residents. Resident #6 stated, Waiting to go smoke. Observation and interview in the resident's room on 2/8/2021 at 11:58 AM, showed Resident #6 was alert and oriented. She ambulated in her room with an unsteady gait, holding to the furniture. She used supplemental oxygen by nasal cannula. When asked if she had experienced a fall Resident #6 stated, Falls at home. Many times, I fell . Resident #6 had a [DIAGNOSES REDACTED]. There were no interventions implemented to prevent or manage falls. The Comprehensive Care Plan dated 1/19/2021, showed there was not a Care Plan for oxygen therapy, risk of falling, use of a wheelchair for mobility, or smoking. Review of Resident #8's medical record and observation, showed the following: Resident #8 was admitted to the facility with a history of repeated falls. The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #8 had a score of 105, which indicated high risk of falling. Resident #8 had a fall on 10/9/2020 with no injuries. There were no Fall Risk Assessments completed quarterly or after the 10/9/2020 fall. Observation at the end of the South Hall on 2/7/2021 at 11:40 AM, showed Resident #8 was using a rolling walker, wandering down the hall toward the Southeast Hall. She was alert and did not answer questions appropriately. Observation in the resident's room on 2/7/2021 at 12:15 PM, showed Resident #8 was sitting on the side of her bed. A fall mat was on the floor to the right side of the bed. The Comprehensive Care Plan dated 4/1/2020 to present, showed the Care Plan for mobility did not address the use of a rolling walker and the Care Plan for high risk for falls did not include the intervention of a fall mat. Review of Resident #9's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk completed), showed Resident #9 score a 55, which indicated high risk of falling. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed Resident #9 scored a 17 which indicated a high risk for wandering. The Comprehensive Care Plan dated 9/25/2020 to present, showed there were no interventions to prevent falls until 11/3/2020 and there were no interventions for wandering/elopement risk until 2/3/2021. Resident #9 fell on [DATE] with redness to the eyes, a red mark to the neck, and an abrasion to the forehead. Resident #9 did not have a Fall Risk Assessment completed quarterly or after the fall on 11/2/2020. Review of Resident #11's medical record, showed the following: The physician's orders [REDACTED]. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed a score of 10 moderate risk for wandering. The Comprehensive Care Plan dated 6/13/2018 to present, showed there was not a Care Plan for the resident's elopement risk or the wanderguard. Review of Resident #12's medical record, showed the following: The Fall Risk assessment dated [DATE], showed Resident #12 had a score of 90, which indicated a high risk for falls. A Comprehensive Care Plan had not been developed for Resident #12 by 2/4/2021 (21 days after admission). Review of Resident #13's medical record, showed the following: Resident #13 was admitted with Dementia and behaviors. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed the resident had a score of 6, which indicated a moderate risk for wandering. The Physicians' Orders dated 10/19/2020, showed an order for [REDACTED]. The Comprehensive Care Plan dated 10/19/2020 to present, did not include the resident's elopement/wander risk. Review of Resident #14's medical record, showed the following: The Physicians' Orders dated 9/30/2020, showed Resident #14 had a wanderguard. Resident #14 had falls on 10/22/2020 with no injuries, on 10/27/2020 with an open area to the forehead, and on 10/31/2020 with no injuries. Resident #14 did not have a Fall Risk Assessment on admission, quarterly, or after the falls. Resident #14 did not have a Wandering Risk Assessment on admission or quarterly. Resident #14's Comprehensive Care Plan dated 11/2/2020 to present, showed the Comprehensive Care Plan did not address the resident's risk for falls or the resident's wandering/elopement risk. (Resident #14 had 3 falls in 10/2020, and wore a wanderguard). Review of Resident #15's medical record, observation, and interview, showed the following: The Comprehensive Care Plan dated 6/26/2019 to present, showed the intervention/task for fall prevention documented to be sure the resident's call light was within reach. Observation and interview in the resident's room on 2/22/2021 at 11:16 AM, showed Resident #15 was alert and oriented. There was no call light for her room. When asked where the call light was located, Resident #15 stated, I don't have one. Review of the medical records for Resident #1, #3, #7, #8, #9, #13, and #14, showed neurological assessments were not completed after the residents experienced unwitnessed falls to determine if the residents had any neurological injury. During an interview on 2/3/2021 at 3:00 PM, the Administrator was shown how many of the windows in the residents' rooms would open completely or wide enough residents could climb out of. He stated, .We need to place a large screw in the window to prevent opening enough for residents to climb out . When the Administrator was asked how would he ensure other residents would not break a window and climb through the broken window. He stated, .I can't .we need alarms on the windows . During an interview on 2/4/2021 at 11:06 AM, the Administrator confirmed the facility had no risk management policy, and no Quality Assurance Performance Improvement (QAPI) policy. He stated, .I am not going to beat around the bush, I have no QAPI policy. I need to purchase one . During a phone interview on 2/4/2021 at 12:00 PM, the Medical Director stated, .No one from the facility talked directly to me (about Resident #1's elopement) .I don't remember .I do remember discussing with (named Nurse Practitioner) later about it . The Medical Director was asked if the QAPI committee has met or had an ad hoc committee meeting to discuss the elopement incidents of Resident #1 and #2. He stated, .no, never called me with an ad hoc .never discussed an RCA (root cause analysis) or investigation . During an interview on 2/4/2021 at 5:45 PM, Registered Nurse (RN) #2 was asked if a competency check had been completed to determine her knowledge and skills. RN #2 stated, No .I know what to do. During an interview on 2/4/2021 at 12:43 PM, the Medical Records Nurse confirmed there was no documentation of an incident report or investigation of Resident #2's incident, or interventions after the incident. During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if the facility had any elopements prior to the elopement of Resident #1 on 1/24/2021. He stated, .well four months (was two months prior) prior (Named Resident #2) broke a window .our interventions were every 15 minute checks and medication review .I didn't do an investigation (for Resident #2) . The Administrator was asked if he did a thorough investigation of Resident #1's elopement. He stated, .I failed at this one .I see it .I should have known . During an interview on 2/5/2021 at 10:00 AM, the Administrator confirmed the facility had not had a QAPI meeting concerning Resident #1 or #2's elopement incidents. He stated, .No, the committee has not met .we have not discussed it . During an interview on 2/8/2021 at 11:02 AM, the DON was asked how the facility ensured the competency of contract staff and ensured they had the skills to provide care for the residents. The DON stated, I can't say I verified their competency. During an interview on 2/8/2021 at 11:48 AM, Licensed Practical Nurse (LPN) #3 was asked when a wandering/elopement risk assessment and/or a neurological assessment should be completed. Contract LPN #3 stated, I'm Agency (contract). I don't know about that. Unit Manager would do the neuro check I guess. Somebody said they (assessments) are done on paper. I don't know. During an interview on 2/22/2021 at 3:58 PM, LPN #5 was asked if she had a skills competency check prior to providing resident care. LPN #5 stated, No, not when I was hired . LPN #5 was asked if she had a skills competency check during orientation. LPN #5 stated, No, not then. Didn't check me off on anything. Refer to F-600, F-610, F-656, F-689, F-726, and F-867. 1. On 2/8/2021, a security screw was placed in all resident windows and resident areas so the windows will raise no more than 6 inches. Maintenance will be making periodic checks to ensure windows remain secured. Nursing Services will check windows every shift and document on the Medication Administration (MAR) Sheet. The surveyors observed all windows, security screws and checked the width the windows would open. The surveyors confirmed documentation on the residents' MAR indicated [REDACTED]. The surveyors confirmed per TELS (Technology Enhanced Learning System) schedule of maintenance scheduled weekly checks. 2. On 2/8/2021, a locking device was placed on the outside gate. The lock will be checked weekly to ensure it is secure by maintenance. The surveyors observed the secured lock on the gate. The surveyors confirmed per TELS schedule of maintenance scheduled weekly checks. 3. By 2/9/2021, psychiatric services to deal with the anger and feelings of loneliness and isolation was consulted, the Care Plan was updated for Resident #1 and #2, 1 on 1 care was provided, windows were repaired and secured to not raise greater than 6 inches, a window alarm was placed on window to alert staff. The surveyors observed the alarm on the windows in Resident #1 and #2's room, the window security screw in all rooms and verified they would not open greater than 6 inches. The surveyors observed 1 on 1 care provided by staff. The surveyors reviewed the documentation for Resident #1 and #2, interviewed the Psychologist and observed psychiatric services in house reevaluating all residents on 2/10/2021. 4. On 2/8/2021, licensed nursing staff performed elopement assessments on all residents and the Care Plans has been updated to reflect any recommendations or interventions. The surveyors reviewed the documentation and interviewed nursing staff. 5. By 2/9/2021, The Administrative/IDT will be educated by an outside consultant regarding appropriate QAPI/QA processes for incident investigation, to include ad hoc committees and root cause analysis. The surveyors reviewed the education and interviewed the Administrative and the IDT team. 6. By 2/9/2021, the Administrative/Interdisciplinary Teams have developed a QAPI/QA process to conduct a yearly facility assessment through the QAPI/QA process that includes a mechanism to ensure the environment is safe for confused and wandering Residents. The surveyors reviewed the QAPI process and interviewed Administration. 7. By 2/9/2021, all windows in Resident rooms have been inspected by facility maintenance staff and secured to only allow the window to open no more than 6 inches. Facility maintenance staff will conduct window inspections monthly to ensure windows will not raise more than 6 inches. Additionally, alarms have been ordered for all windows in resident areas and will be installed as soon as they are received. Nursing services will check windows every shift, the window check will be placed on the Medication Administration (MAR) Sheet for sign off. The surveyors reviewed the invoice of window alarm order, the window inspection schedule in TELS for maintenance, the MARS, and interviewed the Director of Maintenance and nursing staff on all shifts. 8. By 2/9/2021, the Staff Development Coordinator of designee will educate all staff to report any noted concerns with windows raising more than 6 inches to Administrator and maintenance staff immediately. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 9. By 2/9/2021, the Administrator will initiate a QAPI program for security of Resident windows and will audit 100% of the maintenance window checks monthly for 3 months to ensure windows are remaining secure. The Administrator will report findings of the audit to the full QAPI Committee to determine if the issue is resolved or should continue. The Director of Nursing or designee will audit Medication Administration records to ensure alarms are being checked daily for 7 days then weekly for 4 weeks and then monthly for 3 months. The Director of Nurses will then report findings to the full QAPI committee for review. The surveyors reviewed the audit tool and interviewed the Administrator. 10. The facility has an elopement drill scheduled for 02/7/2021 and 2/8/2021. The drill will be used as a return demonstration for the education that has been delivered. The surveyors reviewed the drill sign in sheets and interviewed staff on all shifts. 11. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will also deliver education to the Administrative team as needed. The Nurse Consultant 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 interviewed the Nurse Consultant. 12. On 2/7/2021, the DON and nursing management team formulated an incident/accident fall investigation checklist and introduced to the nurses in an incident/accident notebook at every nurse's station with instructions on how to complete a fall investigation and intervention guidance. The checklist will assist to ensure initial investigation is completed and neuro checks are completed, as necessary. The neuro check assessment sheet is included in the fall investigation packet. The surveyors reviewed the checklist and notebook and interviewed nursing staff on all shifts. 13. On 2/6/2021, Nursing education was initiated by the DON and Staff Development Coordinator (SDC) on fall investigation process and appropriate intervention implementation with additional individual step by step training for fall investigation, root cause analysis, and implementation of appropriate interventions beginning. One hundred percent of all licensed nursing staff will be educated by 3/3/2021. The surveyors reviewed the in-service sign in sheet and interviewed staff on all shifts. 14. Neurological checks that are in progress will be reviewed daily in clinical stand up meetings by the DON or designee until completed. The surveyors reviewed the 24-hour report notebook: neurological checks tab, and interviewed staff on all shifts. 15. On 2/3/2021, Fall Assessments were completed by the nursing management team to determine risk factors and this is ongoing. The Interdisciplinary Team (IDT) began reviewing assessments and updating Care Plans for appropriate interventions to address risk factors and this will be completed by 3/3/2021. The surveyors reviewed the lists, forms, Care Plans, assessments, and interviewed staff on all shifts. 16. All new hire orientation and annual competencies will be reviewed and signed off on by the DON or designee upon completion. The surveyors interviewed the DON. 17. All staff will be educated on comprehensive Care Plans and the role that all staff members play in contribution of interventions and resident care, and importance of following the plan of care. One hundred percent completion of all staff will be done by 3/3/2021. This will be ongoing and included in the orientation process. This will be included in all orientations. All staff education included the following: a) Fall investigation process and intervention implementation. b) Comprehensive Care Plan process and following plan of care. c) Neurological status and assessments. d) Care of residents with behaviors and behavior management techniques. e) Fall risk assessment (how to; score and what to do next). f) Root cause analysis. The surveyors reviewed the sign in sheets and interviewed staff on all shifts. 18. All licensed nursing staff competencies will be conducted by the DON or designee with 100% completion by 3/3/2021. Competencies will be required to be completed with all new hires while in orientation/training on the floor and will be reviewed by Human Resources to ensure completion. Competencies will be taught upon hire, annually, and as needed by the Staff Development Coordinator (SDC). The surveyors reviewed the competencies completed and competency form/tool to be used and interviewed the DON and staff on all shifts. Noncompliance of F-835 continues at a scope and severity of E for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on the policy review, job description review, video camera footage review, medical record review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to falls and elopement/wandering behaviors. The QAPI committee failed to ensure a safe environment, a thorough investigation of resident elopement was completed, and failed to conduct a QAPI committee meeting when residents eloped from the facility without staff knowledge. The facility failed to ensure processes and systems were in place and reviewed through the QAPI committee to ensure residents at risk for falls were assessed, adequately supervised, and had a comprehensive Care Plan with appropriate interventions that were put into place and implemented to prevent falls and wandering/exit seeking behavior. The facility failed to ensure the QAPI committee reviewed and validated systemic problems and determine a system was in place to ensure licensed nurses had the specific knowledge and skill sets necessary to assess residents, complete fall risk assessments, complete neurological checks, implement appropriate interventions, and provide care for residents with behaviors. These failures resulted in Immediate Jeopardy for Resident #1, #7, #2, #3, #6, #7, #8, #9, #11, #12, #13, #14, and #15. These failures resulted in actual Harm when Resident #1 suffered a hematoma (collection of blood between the layers of tissues) to his forehead and lacerations (cuts or tears in the skin) that required repair (stitches) and actual Harm when Resident #7 fell and suffered a sacral (large triangular bone at the bottom of the spine) fracture (broken bone) and displaced fractures of the pelvis. Resident #2, a vulnerable resident with Dementia, eloped from the facility through a window, staff responded immediately, but the facility did not thoroughly investigate the incident. Then, 2 months later, Resident #1, a confused vulnerable resident with Dementia, eloped from the facility through a window in an unoccupied resident room. The facility was unaware Resident #1 was missing from the facility for 9 minutes and the resident was outside unattended for an additional 8 minutes. Resident #1 was sitting under a pavilion, next to an integrity impaired (broken) fence with an unsecured gate, near a creek with swift moving water. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-867 on 2/6/2021 at 3:45 PM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-600, F-610, F-656, F-689, F-726, F-835, and F-867. The facility was cited an Immediate Jeopardy at F-600 and F-610 at a scope and severity of J, and at F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/13/2020 through 2/9/2021. An acceptable Removal Plan, which removed the immediacy of jeopardy for F-867, was received on 2/8/2021 at 2:50 PM, and was validated onsite by the surveyors on 2/9/2021 - 2/10/2021 through observations, review of in-service sign in sheets, review of audits and meeting minutes, and staff interviews. The findings include: The facility's policy titled, Elopement Action Items, Missing Resident, dated 5/2016 showed, .Review camera footage if available .Begin interviewing ALL staff on duty to get statements include visitors if applicable .Complete an event and thorough assessment in event manager (computer program) .Begin investigation to determine root cause analysis and schedule ad hoc (as needed) QA (Quality Assurance) meeting within 24 hours to discuss findings .Audit all patient's elopement assessments to assure accurate and no other patient at risk .Elopement books to be updated with all changes .All residents to be assessed for risks of elopement on admission, condition change, quarterly and annual. Those at risk will be placed in elopement risk binders on each unit and care plans developed to address individual safety needs .An ad hoc QA meeting should be held as soon as possible with IDT (Interdisciplinary Team) members and the MD (Medical Doctor) and Medical Director to review findings of the investigation, RCA (root cause analysis) and .action plan . The facility's undated policy titled, Elopement/Wandering, showed, .An elopement/wandering assessment will be completed upon admission .and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services and kept at nurses' stations. Updates will be done at least quarterly. The facility's undated policy titled, Abuse, Neglect and Misappropriation of Property, showed, .the Facility Administrator, or his or her designee, will direct a reasonable investigation of each such alleged violation .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .Investigation guidelines: The Facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute 'allegations of abuse' .as defined in this document .The investigation should include interviews of persons who may have knowledge of the alleged incident .The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Review of the undated Administrator job description, showed, .Provides leadership, oversight and administration to all long-term care operations. Responsible for ensuring maximum operating efficiency .strict compliance with all applicable State and Federal rules and regulations. Develops, monitors and improves facility quality standards .Assures that the facility maintains standards at the highest possible level and is responsible for the results of survey by the Department of Health .Develops, implements and assesses facility policies and procedures to ensure compliance with applicable State and Federal rules, regulations and accreditation standards .Oversees, evaluates and ensures the ongoing delivery of care and services. Provides routine analysis of the quality of care .Plans, directs and monitors compliance with State and Federal government regulatory agencies .Provides high quality services, processes and programs while consistently seeking ways to improve outcomes and enhance the facility . Review of the undated Director of Nursing job description, showed, .Manage administrative and functional areas or programs within the Nursing Department. Assist the Administrator to overall operations of the facility in accordance with Company policies, and standards of nursing practices and government regulations, as to maintain quality care .Planning, developing, organizing, implementing, evaluating and directing the day-to-day functions of the nursing department in accordance current rules, regulations, and guidelines .Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department .Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident .Regularly inspect the facility and nursing practices for compliance with company, federal, state, and local standards and regulations .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . Review of Resident #1's medical record and video camera footage, showed the following: There was no documentation of a Fall Risk Assessment or Wandering Risk Assessment completed and there was no documentation of a Fall Risk Assessment for the admission on 12/4/2020. Resident #1's Fall Risk Assessment completed on 1/7/2021, showed Resident #1 was at moderate risk for falls. Review of the Incident Notes and Nurses' Notes showed the following falls: Resident #1 fell on [DATE] with no injuries. Resident #1 fell on [DATE] with a hematoma to his forehead. Resident #1 fell on [DATE] with lacerations to his lip requiring stitches. There were no Fall Risk Assessments completed after the falls and no interventions for falls on the Care Plan. The facility's video camera North Hall footage on 1/24/2021, showed Resident #1 exited the facility. The Comprehensive Care Plan dated 1/28/2021, did not include Resident #1's risk for falling, impaired cognition function/dementia or impaired thought processes related to dementia, elopement/wandering risk. A Care Plan for wandering/elopement risk was not initiated until 1/28/2021. The facility's failure to ensure a resident at risk for falls was assessed and had a Comprehensive Care Plan with appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #1 suffered a hematoma to his forehead and lacerations that required stitches. Review of Resident #7's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #7 scored a 75, which indicated high risk for falls. Resident #7's Comprehensive Care Plan dated 3/3/2020 to present, showed the Care Plan for high risk for falls had no interventions for fall prevention until 1/8/2021. The Incident Report dated 1/8/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to reinforce to use call light when needing assistance and the resident was severely cognitively impaired. The Incident Report dated 2/10/2021, showed, Resident #7 fell with no injuries. The immediate intervention was to educate on use of call light and the resident was severely cognitively impaired. The Nurse's Notes dated 2/10/2021, showed, Resident #7 fell and suffered a sacral fracture and displaced fractures to the pelvis. The facility's failure to ensure a resident at risk for falls had appropriate interventions in place and implemented to prevent falls resulted in actual Harm when Resident #7 fell and suffered a sacral fracture and displaced fractures of the pelvis. Review of Resident #2's medical record, showed the following: The Comprehensive Care Plan dated 6/18/2020 to present, did not include the Resident #2's elopement/wander risk or any interventions to address a risk of wandering. The Nurses' Notes dated 11/3/2020 at 2:53 AM, showed, Resident #2 was pacing up and down the halls most of the night, would not get in bed, and said he wanted to go home. The Comprehensive Care Plan dated 6/18/2020 to present, showed there was not a Comprehensive Care Plan which addressed the elopement/wandering risk. The Nurses' Notes dated 11/13/2020, showed Resident #2 broke a window and exited the facility, and was located immediately by staff The Comprehensive Care Plan dated 6/18/2020 to present, did not include interventions for the elopement attempt on 11/13/2020. There was no Wandering Risk Assessment completed on admission, quarterly, or after the elopement attempt. Review of Resident #3's medical record, showed the following: There was no Fall Risk Assessment completed on admission of 12/20/2020. The Incident Note dated 12/22/2020, showed Resident #3 fell with a small skin tear to his elbow. There was no Fall Risk Assessment completed after the fall. Review of Resident #6's medical record, observation, and interview, showed the following: Observation at the exit door on the Southeast Hall on 2/7/2021 at 12:55 PM, showed Resident #6 was seated in a wheelchair with a group of other residents. Resident #6 stated, Waiting to go smoke. Observation and interview in the resident's room on 2/8/2021 at 11:58 AM, showed Resident #6 was alert and oriented. She ambulated in her room with an unsteady gait, holding to the furniture. She used supplemental oxygen by nasal cannula. When asked if she had experienced a fall Resident #6 stated, Falls at home. Many times, I fell . Resident #6 had a [DIAGNOSES REDACTED]. There were no interventions implemented to prevent or manage falls. The Comprehensive Care Plan dated 1/19/2021, showed there was not a Care Plan for oxygen therapy, risk of falling, use of a wheelchair for mobility, or smoking. Review of Resident #8's medical record and observation, showed the following: Resident #8 was admitted to the facility with a history of repeated falls. The Fall Risk assessment dated [DATE] (the most recent Fall Risk Assessment completed), showed Resident #8 had a score of 105, which indicated high risk of falling. Resident #8 had a fall on 10/9/2020 with no injuries. There were no Fall Risk Assessments completed quarterly or after the 10/9/2020 fall. Observation at the end of the South Hall on 2/7/2021 at 11:40 AM, showed Resident #8 was using a rolling walker, wandering down the hall toward the Southeast Hall. She was alert and did not answer questions appropriately. Observation in the resident's room on 2/7/2021 at 12:15 PM, showed Resident #8 was sitting on the side of her bed. A fall mat was on the floor to the right side of the bed. The Comprehensive Care Plan dated 4/1/2020 to present, showed the Care Plan for mobility did not address the use of a rolling walker and the Care Plan for high risk for falls did not include the intervention of a fall mat. Review of Resident #9's medical record, showed the following: The Fall Risk assessment dated [DATE] (the most recent Fall Risk completed), showed Resident #9 score a 55, which indicated high risk of falling. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed Resident #9 scored a 17 which indicated a high risk for wandering. The Comprehensive Care Plan dated 9/25/2020 to present, showed there were no interventions to prevent falls until 11/3/2020 and there were no interventions for wandering/elopement risk until 2/3/2021. Resident #9 fell on [DATE] with redness to the eyes, a red mark to the neck, and an abrasion to the forehead. Resident #9 did not have a Fall Risk Assessment completed quarterly or after the fall on 11/2/2020. Review of Resident #11's medical record, showed the following: The physician's orders [REDACTED]. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed a score of 10 moderate risk for wandering. The Comprehensive Care Plan dated 6/13/2018 to present, showed there was not a Care Plan for the resident's elopement risk or the wanderguard. Review of Resident #12's medical record, showed the following: The Fall Risk assessment dated [DATE], showed Resident #12 had a score of 90, which indicated a high risk for falls. A Comprehensive Care Plan had not been developed for Resident #12 by 2/4/2021 (21 days after admission). Review of Resident #13's medical record, showed the following: Resident #13 was admitted with Dementia and behaviors. The Wandering Risk assessment dated [DATE] (the most recent Wandering Risk Assessment completed), showed the resident had a score of 6, which indicated a moderate risk for wandering. The Physicians' Orders dated 10/19/2020, showed an order for [REDACTED]. The Comprehensive Care Plan dated 10/19/2020 to present, did not include the resident's elopement/wander risk. Review of Resident #14's medical record, showed the following: The Physicians' Orders dated 9/30/2020, showed Resident #14 had a wanderguard. Resident #14 had falls on 10/22/2020 with no injuries, on 10/27/2020 with an open area to the forehead, and on 10/31/2020 with no injuries. Resident #14 did not have a Fall Risk Assessment on admission, quarterly, or after the falls. Resident #14 did not have a Wandering Risk Assessment on admission or quarterly. Resident #14's Comprehensive Care Plan dated 11/2/2020 to present, showed the Comprehensive Care Plan did not address the resident's risk for falls or the resident's wandering/elopement risk. (Resident #14 had 3 falls in 10/2020, and wore a wanderguard). Review of Resident #15's medical record, observation, and interview, showed the following: The Comprehensive Care Plan dated 6/26/2019 to present, showed the intervention/task for fall prevention documented to be sure the resident's call light was within reach. Observation and interview in the resident's room on 2/22/2021 at 11:16 AM, showed Resident #15 was alert and oriented. There was no call light for her room. When asked where the call light was located, Resident #15 stated, I don't have one. Review of the medical records for Resident #1, #3, #7, #8, #9, #13, and #14, showed neurological assessments were not completed after the residents experienced unwitnessed falls to determine if the residents had any neurological injury. During an interview on 2/4/2021 at 11:06 AM, the Administrator confirmed the facility did not have a Quality Assurance Performance Improvement (QAPI) policy. He stated, .I am not going to beat around the bush, I have no QAPI policy. I need to purchase one . The Administrator confirmed there was no evidence of actions aimed at performance improvement for falls, no implementation of actions, and no system to track performance to ensure that improvements are realized and sustained. The Administrator confirmed the performance improvement activities did not analyze the causes of adverse resident events and implement preventative actions and mechanisms that include feedback and learning throughout the facility. He stated, .This is all the documentation we have for QAPI (dated 10/21/2020) the number of falls a month if with injury, number of major or minor injury and the total number of residents that fell .no documentation of causes analyzed, actions implemented or if successful or overall . During a telephone interview on 2/4/2021 at 12:00 PM, the Medical Director stated, .No one from the facility talked directly to me .I don't remember .I do remember discussing with (named Nurse Practitioner) later about it (Resident #1's elopement) . The Medical Director was asked if the QAPI committee has met or had an ad Hoc committee meeting to discuss the elopements for Resident #1 and #2. He stated, .no, never called me with an ad Hoc .never discussed an RCA (root cause analysis) or investigation . During an interview on 2/4/2021 at 12:43 PM, the Medical Records Nurse confirmed there was no documentation of an incident report or investigation of Resident #2's incident, or interventions after the incident. During an interview on 2/4/2021 at 4:22 PM, the Nurse Practitioner was asked if she was notified of Resident #1's elopement. She stated, .I was off 1/24 (2021) and I did not find out until the afternoon of 1/25 (2021) .My company sends out a 24 hour report and that is how I found out about it .The facility did not call or text me .I had no communication with the Medical Director at all about this elopement .since they did not notify any medical professional it was an environmental type thing . During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if the facility had any elopements prior to the elopement of Resident #1 on 1/24/2021. He stated, .well four months (was 2 months) prior Mr. (Resident #2) broke a window .our interventions were every 15 minute checks and medication review .I didn't do an investigation (for Resident #2) . During an interview on 2/4/2021 at 5:45 PM, Registered Nurse (RN) #2 was asked if a competency check had been completed to determine her knowledge and skills. RN #2 stated, No .I know what to do. During an interview on 2/5/2021 at 10:00 AM, the Administrator was asked for the documentation of the interventions of the incident with Resident #2. He stated, .I have no interventions and I did not do an investigation . The Administrator confirmed the facility had not had a QAPI meeting concerning Resident #1 or #2's incidents. He stated, .No, the committee has not met .we have not discussed it . During an interview on 2/5/2021 at 12:16 PM, Certified Nursing Assistant (CNA) #8/Scheduler was asked if a knowledge and skills competency evaluation were completed on the licensed nurses prior to providing care for the residents. CNA #8/Scheduler stated, .We don't check competency that I know of .Agency staff get a thorough report about the residents at shift change . CNA#8/Scheduler was asked who was responsible to ensure the contract RNs and contract Licensed Practical Nurses (LPNs) had competency checks prior to providing care for the residents and she stated, The DON is responsible I guess. We don't have competency checks that I know of . During an interview on 2/5/2021 at 3:25 PM, the DON was asked when a knowledge and skills assessment was conducted on licensed nurses and contract staff and what staff member conducted the assessment. The DON stated, Should be on hire, annual, and as needed. There are no competencies .As far as skills, there are none. No one has a competency. During an interview on 2/8/2021 at 11:02 AM, the DON was asked how the facility ensured the competency of contract staff and ensured they had the skills to provide care for the residents. The DON stated, I can't say I verified their competency. Refer to F-600, F-610, F-656, F-689, F-726, and F-835. The surveyors verified the Removal Plan by: 1. On 2/3/2021, a security screw was placed in all resident windows and resident areas so the windows will raise no more than 6 inches. Maintenance will be making periodic checks to ensure windows remain secured. Nursing Services will check windows every shift and document on the Medication Administration (MAR) Sheet. The surveyors observed all windows, security screws and checked the width the windows would open. The surveyors confirmed documentation on the resident's MAR indicated [REDACTED]. The surveyors confirmed per TELS (Technology Enhanced Learning System) the schedule of maintenance scheduled weekly checks. 2. On 2/5/2021, the outside gate was secured with a locking device. The lock will be checked weekly to ensure it is secure by maintenance. The surveyors observed the locking device on the gate and reviewed the audit tools. 3. On 2/9/2021, psychiatric services to deal with the anger and feelings of loneliness and isolation was consulted for Resident #1 and #2, Care Plans were updated, 1 on 1 care is being provided, windows were repaired and secured to not raise greater than 6 inches, and window alarms were placed on the windows to alert staff. All facility Residents will be screened by psychiatric services for feelings of isolation and loneliness. The Comprehensive Plan of Care will be updated to reflect any recommendations or interventions. The surveyors observed the alarm on the windows in Resident #1 and #2's rooms, the window security screws and verified they would not open greater than 6 inches. The surveyors observed 1 on 1 care provided by staff. The surveyors reviewed the documentation of Resident #1 and #2, interviewed the Psychologist and observed psychiatric services in house reevaluating all residents on 2/10/2021. 4. By 2/9/2021, the Administrative/IDT will be educated by an outside consultant regarding appropriate QAPI/QA processes for incident investigation, to include ad hoc committees and root cause analysis. The surveyors reviewed the education and interviewed the IDT. 5. By 2/9/2021, the Administrative/Interdisciplinary Teams have developed a QAPI/QA plan to conduct a yearly facility assessment through the QAPI/QA process that includes a mechanism to ensure the environment is safe for confused and wandering Residents that are also at risk for elopement. The surveyors reviewed the QAPI plan and process. 6. On 2/8/2021, the licensed nursing staff performed elopement assessments on all residents. The Interdisciplinary Team has reviewed all the residents who scored high risk and the Care Plans were updated to reflect any recommendations or interventions. The surveyors reviewed the documentation and interviewed nursing staff on all shifts. 7. The daily morning meeting will serve as the QAPI ad hoc meeting to investigate and review incidents. The Interdisciplinary Team will serve as the committee with the Director of Nursing leading the meeting. The Interdisciplinary Team will review all incidents from the past 24 hours daily Monday through Friday at the morning stand up meeting, weekend incidents will be reviewed on Mondays and incidents on Holidays will be reviewed on the next business day. The team will ensure immediate interventions were placed at the time of the incident and the intervention is appropriate and adequate. The IDT will update the Care Plan to reflect any new interventions or recommendations. The surveyors interviewed the DON and IDT members. 8. On 2/8/2021, the Interdisciplinary Team was be educated regarding the investigation of incidents by an outside Consultant. The surveyors reviewed the education and interviewed members of the IDT. 9. The Administrator will review the minutes of the daily ad-hoc committee daily for 7 days, then a random sample of 3 meetings weekly for four weeks and 3 meetings monthly for 3 months. The Administrator will report the findings of the review to the full QAPI Committee at the completion of the review to determine if the issue is resolved or should be continued. The surveyors interviewed the Administrator. 10. The facility has an elopement drill scheduled for 2/07/2021 and 2/8/2021. The drill will be used as a return demonstration for the education that has been delivered. The surveyors reviewed the drill documentation and interviewed staff on all shifts. 11. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will also deliver education to the Administrative team as needed. The Nurse Consultant 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 interviewed the Nurse Consultant. 12. On 2/7/2021, the DON and nursing management team formulated an incident/accident fall investigation checklist and introduced to the nurses in an incident/accident notebook at every nurse's station with instructions on how to complete a fall investigation and intervention guidance. The checklist will assist to ensure initial investigation is completed and neuro checks are completed, as necessary. The neuro check assessment sheet is included in the fall investigation packet. The surveyors reviewed the checklist and notebook and interviewed nursing staff on all shifts. 13. On 2/6/2021, Nursing education was initiated by the DON and Staff Development Coordinator (SDC) on fall investigation process and appropriate intervention implementation with additional individual step by step training for fall investigation, root cause analysis, and implementation of appropriate interventions beginning. One hundred percent of all licensed nursing staff will be educated by 3/3/2021. The surveyors reviewed the in-service sign in sheet and interviewed staff on all shifts. 14. Neurological checks that are in progress will be reviewed daily in clinical stand up meetings by the DON or designee until completed. The surveyors reviewed the 24-hour report notebook: neurological checks tab, and interviewed staff on all shifts. 15. On 2/3/2021, Fall Assessments were completed by the nursing management team to determine risk factors and this is ongoing. The Interdisciplinary Team (IDT) began reviewing assessments and updating Care Plans for appropriate interventions to address risk factors and this will be completed by 3/3/2021. The surveyors reviewed the lists, forms, Care Plans, assessments, and interviewed staff on all shifts. 16. All new hire orientation and annual competencies will be reviewed and signed off on by the DON or designee upon completion. The surveyors interviewed the DON. 17. All staff will be educated on comprehensive Care Plans and the role that all staff members play in contribution of interventions and resident care, and importance of following the plan of care. One hundred percent completion of all staff will be done by 3/3/2021. This will be ongoing and included in the orientation process. This will be included in all orientations. All staff education included the following: a) Fall investigation process and intervention implementation. b) Comprehensive Care Plan process and following plan of care. c) Neurological status and assessments. d) Care of residents with behaviors and behavior management techniques. e) Fall risk assessment (how to; score and what to do next). f) Root cause analysis. The surveyors reviewed the sign in sheets and interviewed staff on all shifts. 18. All licensed nursing staff competencies will be conducted by the DON or designee with 100% completion by 3/3/2021. Competencies will be required to be completed with all new hires while in orientation/training on the floor and will be reviewed by Human Resources to ensure completion. Competencies will be taught upon hire, annually, and as needed by the Staff Development Coordinator (SDC). The surveyors reviewed the competencies completed and competency form/tool to be used and interviewed the DON and staff on all shifts. Noncompliance of F-867 continues at a scope and severity of E for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, video camera footage review, medical record review, and interview, the facility failed to provide adequate supervision to prevent neglect for 1 of 10 sampled residents (Resident #1) reviewed with wandering behaviors, when staff members left a resident that had eloped unattended and alone outside for 8 minutes after staff members had found the resident which resulted in Immediate Jeopardy for Resident #1. Resident #1, a confused vulnerable resident with Dementia, left the facility through a window in an unoccupied resident room. The facility was unaware Resident #1 was missing from the facility for 9 minutes. Resident #1 was left outside unattended for an additional 8 minutes when 2 staff members (Dietary Cook #1 and Dietary Aide #1) that found him left the premises and another staff member returned inside the facility without the resident. Resident #1 was outside alone, had walked down a steep hill, across the driveway, was sitting under a pavilion, next to an integrity impaired (broken) fence with an unsecured gate, near a creek with swift moving water. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 2/6/2021 at 3:45 PM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/13/2020 through 2/9/2021. An acceptable Removal Plan for F-600, which removed the immediacy of jeopardy, was received on 2/8/2021 at 2:50 PM, and was validated onsite by the surveyors on 2/9/2021- 2/10/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: The facility's undated policy titled, Abuse, Neglect and Misappropriation of Property, showed, .the Facility Administrator, or his or her designee, will direct a reasonable investigation of each such alleged violation .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress . Review of the facility's undated policy titled, Elopement/Wandering, showed, .An elopement/wandering assessment will be completed upon admission .and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services and kept at nurses' stations. Updates will be done at least quarterly . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 10, which indicated Resident #1 was moderately impaired for daily decision making. Review of Nursing Admission assessment dated [DATE], showed, .Motor control unsteady gait, history of falling/recent fall . Medical record review showed there was no documentation of a Wandering Risk Assessment completed. Review of the facility's video camera footage of the Gazebo dated 1/24/2021 showed the following: a. At 1:46 PM, Resident #1 walked down a steep hill, grabbed onto a tree trunk to steady himself, then walked across the driveway to an integrity impaired chain link fence (the fence was bent at the top of the fence and the bottom was bent with a crawl space underneath the fence) that had an unsecured gate, near a creek with swift moving water. He propped against the fence then walked down the fence line frequently stopping and pushing on the fence. b. At 1:50 PM, Resident #1 pushed on the fence and faced the creek, c. At 1:52 PM, he reached over the fence toward the creek, attempted to pull a tree branch, and raised his left leg and propped it on the fence. d. At 1:54 PM, he walked to the pavilion and sat on the picnic table bench under the pavilion. e. At 1:55 PM, a car came in view of the camera from the side of the building toward the pavilion and three staff members (Dietary Aide #1, Dietary Cook #1, and the Receptionist) got out of the car and walked to Resident #1. After the three staff members interacted with Resident #1, two of the staff members (Dietary Aide #1 and Dietary Cook #1) got back in the car without Resident #1 and drove away (off the premises). The third staff member (Receptionist) walked away without Resident #1 and returned into the building. f. At 1:56 PM, the car with the employees drove out of the camera view. g. At 2:03 PM, Resident #1 and two staff members (Certified Nursing Assistant (CNA) #1 and CNA #7) returned and entered the building in the basement area. Resident #1 was outside under the pavilion alone and unattended for 8 minutes. During an interview on 2/3/2021 at 4:07 PM, Dietary Cook #1 stated, .I was in my car and driving around to the back of the building on the way to the grocery (store) and I saw a man beside the fence looking at the creek. I said to (named Dietary Aide #1), 'that is one of our patients'. I drove back around to the front of the building, went into the front door looking for a nurse. I couldn't find one, so I told the Receptionist a patient is down by the river. The Receptionist got in the car with us and we drove back around to the back of the building. The Receptionist confronted him (Resident #1) and he (Resident #1) grabbed him (Receptionist) .He (Receptionist) left and went back into the building through the basement door to get somebody. I and (named Dietary Aide #1) left and went to the store .No, I didn't stay with the resident (either time when first found or after Receptionist left) .He (Resident #1) was left out there at the picnic table .We didn't stay with him, left him alone . During an interview on 2/3/2021 at 4:20 PM, Dietary Aide #1 confirmed Dietary Cook #1's statement. She stated, .After the Receptionist went into the building me and (named Dietary Cook #1) left to go to the store (grocery) .Yes, we left him (Resident #1) alone .It was cold outside . During a telephone interview on 2/4/2021 at 10:00 AM, the Receptionist stated, .A lady (Dietary Cook #1) came in the front door and said a resident was outside in the back. I jumped in her car and we drove around. He (Resident #1) was sitting under the pavilion .I walked up and asked him to come back inside and he grabbed me by the shirt. I finally got loose and went back in the building .I paged overhead nurse to lobby ASAP (as soon as possible) .people (CNA #1 and CNA #7) came to the lobby and went out the front door .I saw him (Resident #1) walking, looking like going for the fence toward the creek . Refer to F-689. The surveyors verified the Removal Plan by: 1. By 2/9/2021, Residents # 1's incident had been thoroughly investigated by the Interdisciplinary team (IDT) and recommendations and interventions had been started. The surveyors reviewed the investigations and interviewed the IDT. 2. On 2/9/2021, psychiatric services to deal with the anger and feelings of loneliness and isolation was consulted, the Care Plans were updated, 1 on 1 care was being provided, windows were repaired and secured to not raise greater than 6 inches, window alarms were placed on Resident #1's window to alert staff. All Residents will be screened by psychiatric services for feelings of isolation and loneliness, and the Care Plans will be updated with any recommendations or interventions. The surveyors observed the alarm on the windows in the resident's room, window security screw on all windows and verified they would not open greater than 6 inches. The surveyors observed one on one care provided by staff for Resident #1. The surveyors reviewed the Care Plans of the residents at risk for wandering, interviewed the Psychologist, and observed psychiatric services in house reevaluating all residents on 2/10/2021. 3. On 2/8/2021, the licensed nursing staff performed Elopement Assessments on all residents. The IDT has reviewed all the residents who scored high risk and the comprehensive Care Plans were updated to reflect any recommendations or interventions. The surveyors reviewed the assessments and Care Plans, and interviewed the licensed nursing staff on all shifts. 4. On 2/3/2021, all resident windows were assessed by maintenance and have been secured so that there are no windows in resident areas that will raise more than 6 inches. Maintenance will be making periodic checks to ensure windows remain secured. Alarms have been ordered for all windows in resident areas and will be installed as soon as they are received. Nursing services will check windows every shift and the window check will be placed on the Medication Administration Sheet (MAR) for sign off. The surveyors reviewed the invoice of the window alarm order, the window inspection schedule in TELS (Technology Enhanced Learning System) for maintenance, the MARS, and interviewed the Director of Maintenance and nursing staff on all shifts. 5. On 2/8/2021, all residents have been assessed for elopement risks and a comprehensive Care Plan was formulated to mitigate the risks for elopement. The assessments were completed by facility Management Nurses. Moving forward, residents will have an elopement risk assessment completed on admission, quarterly and with significant changes in status. Residents who scored moderate to high risk have been evaluated by the Interdisciplinary Team and a Care Plan has been initiated. Moving forward, all residents who score high risk will be evaluated by the Interdisciplinary Team (IDT) and a plan of care will be initiated. The surveyors reviewed the assessments, Care Plans, and interviewed members of the IDT. 6. On 2/5/2021, the outside gate was secured with a locking device. The lock will be checked weekly to ensure it is secure by maintenance. The surveyors observed the locking device, the audit tools, and interviewed the Director of Maintenance. 7. By 2/9/2021, all staff were educated on facility Elopement policy, remaining with vulnerable resident until help arrives, Abuse and Neglect policy and documentation of 1 on 1 care and every 15 minute checks. The surveyors reviewed the in-service sign in sheets and interviewed staff on all shifts. 8. Elopement policy and Abuse/Neglect policy will be taught upon hire, annually and periodically by the Staff Development Coordinator or Designee. Contract staff must show proof of facility policy education prior to working in the facility. A copy of all education has been sent to the contract agency for delivery to contract nurses and nursing assistants. The surveyors reviewed the documentation and interviewed facility staff and contract staff. 9. By 2/9/2021, the Director of Nurses or Designee will initiate a Quality Assurance Performance Improvement (QAPI) program related to elopement that will include at a minimum: a) 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 Quality Committee to determine if the issue has been resolved or if the initiative should continue. b) One hundred percent 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 Care Plan was initiated for those at risk. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. c) One hundred percent 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 Quality Committee to determine if the issue has been resolved or if the initiative should continue. d) A one hundred percent audit of contract nursing staff assigned to the facility to determine if contract staff produced proof of education prior to the start of their shift. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. e) A one hundred percent audit of residents receiving 1 on 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 Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors reviewed the audit tools and interviewed the DON. 10. The facility had an Elopement drill on 2/7/2021 and 2/8/2021. The drill will be used as a return demonstration for the education that has been delivered. The surveyors reviewed the drill sign in sheet and interviewed staff. 11. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will also deliver education to the Administrative team as needed. The Nurse Consultant 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 reviewed the audit tools and interviewed the Nurse Consultant. Noncompliance of F-600 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, video camera footage review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a thorough investigation was completed for 2 of 10 sampled residents (Resident #1 and #2) reviewed with wandering behaviors and accidents, which resulted in Immediate Jeopardy for Resident #1 and #2. Resident #2, a vulnerable resident with Dementia, exited the facility through a window, staff responded immediately after Resident #2 exited, but the facility failed to investigate this incident. Then, 2 months later, Resident #1, a confused vulnerable resident, exited the facility through a window in an unoccupied resident room. The facility was unaware Resident #1 was outside the facility for 9 minutes. Resident #1 was left outside alone unattended and unsupervised for 8 minutes, after he was discovered by the facility staff. Resident #1 was outside a total of 17 minutes. Resident #1 walked down a steep hill, across the driveway, was sitting under a pavilion, next to an integrity impaired (broken) fence with an unsecured gate, near a creek with swift moving water. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-610 on 2/6/2021 at 3:45 PM, in the Revolution Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/13/2020 through 2/9/2021. An acceptable Removal Plan for F-610, which removed the immediacy of the jeopardy, was received on 2/8/2021 at 2:50 PM, and was validated onsite by the surveyors on 2/9/2021-2/10/2021 through observation, review of audits and meeting minutes, and staff interviews. The findings include: The facility's policy titled, Elopement Action Items, Missing Resident, dated 5/2016 showed, .Review camera footage if available .Begin interviewing ALL staff on duty to get statements include visitors if applicable .Complete an event and thorough assessment in event manager (computer program) .Begin investigation to determine root cause analysis and schedule ad hoc (as needed) QA (Quality Assurance) meeting within 24 hours to discuss findings .Audit all patient's elopement assessments to assure accurate (accuracy) and no other patient at risk .Elopement books to be updated with all changes .All residents to be assessed for risks of elopement on admission, condition change, quarterly and annual. Those at risk will be placed in elopement risk binders on each unit and care plans developed to address individual safety needs .An ad hoc QA meeting should be held as soon as possible with IDT (Interdisciplinary Team) members and the MD (Medical Doctor) and Medical Director to review findings of the investigation, RCA (root cause analysis) and .action plan . The facility's undated policy titled, Abuse, Neglect and Misappropriation of Property, showed, .the Facility Administrator, or his or her designee, will direct a reasonable investigation of each such alleged violation .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .Investigation guidelines: The Facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute 'allegations of abuse' .as defined in this document .The investigation should include interviews of persons who may have knowledge of the alleged incident .The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated Resident #1 was moderately cognitively impaired. Review of the facility's video camera footage with a timestamp of 1/24/2021 at 1:44 PM, showed Resident #1 standing at the North Hall exit door looking out the window. At 1:44 PM, Resident #1 walked from the exit door into an unoccupied resident room. At 1:46 PM, Resident #1 walked down a steep hill, grabbed onto a tree trunk to steady himself, then walked across the driveway to an integrity impaired (the fence was bent at the top of the fence and the bottom was bent with a crawling space underneath the fence) chain linked fence with an unsecured gait, near a creek with swift moving water. He propped against the fence then walked down the fence line frequently stopping and pushing on the fence. At 1:50 PM, he pushed on the fence and faced the creek. At 1:52 PM, he reached over the fence toward the creek and attempted to pull a tree branch and raised his left leg and propped his leg on the fence. At 1:54 PM, Resident #1 walked to the pavilion and sat on the picnic table bench under the pavilion. At 1:55 PM, a car came in view of the camera from the side of the building toward the pavilion and three staff members (Dietary Aide #1, Dietary Cook #1, and the Receptionist) got out of the car and walked to Resident #1. After these three staff interacted with Resident #1, at 1:55 PM, two employees (Dietary Aide #1 and Dietary Cook #1) got back in the car and drove away. The third employee (Receptionist) walked away and into the building. Resident #1 was left alone and unsupervised outside under the pavilion. At 1:56 PM, the car drove out of the camera view. At the North Entrance at 2:03 PM, Resident #1 and two staff members (Certified Nursing Assistant (CNA) #1 and CNA #7) returned and entered the building in the basement area. Review of the facility's investigation of the elopement (on 1/24/2021) of Resident #1, showed the facility failed to interview all staff that were involved when the elopement occurred. There were no interviews of other staff on duty, Dietary Cook #1, Dietary Aide #1, Receptionist, or staff working previous shifts. The facility did not review the video camera footage. Review of Resident #1's medical record, showed no vital signs or assessment were documented after his elopement and there were no interventions documented on the 7:00 PM shift after Resident #1 eloped on 1/24/2021. During an interview on 2/3/2021 at 4:20 PM, Dietary Aide #1 confirmed Dietary Cook #1's statement. She stated, .After the Receptionist went into the building me and (named Dietary Cook #1) left to go to the store (grocery) .Yes, we left him (Resident #1) alone .It was cold outside . During a telephone interview on 2/4/2021 at 10:00 AM, the Receptionist stated, .A lady (Dietary Cook #1) came in the front door and said a resident was outside in the back. I jumped in her car and we drove around. He (Resident #1) was sitting under the pavilion .I walked up and asked him to come back inside and he grabbed me by the shirt. I finally got loose and went back in the building .I paged overhead nurse to lobby ASAP (as soon as possible) .people (CNA #1 and CNA #7) came to the lobby and went out the front door .I saw him (Resident #1) walking, looking like going for the fence toward the creek . During a telephone interview on 2/4/2021 at 11:46 AM, Licensed Practical Nurse (LPN) #2 stated, .I worked 1/24 (2021) 7:00 PM shift after his (Resident #1) elopement .they gave me report at shift change but no instructions of any interventions, like it was not a serious thing .no, we did not do one on one .it was the next night (1/25/2021) when he (Resident #1) got one on one, I thought that was odd because the night (1/24/2021) after it happened earlier that afternoon (1/24/2021) they didn't do any interventions . During an interview on 2/4/2021 at 1:18 PM, the DON and Medical Records Nurse confirmed the facility had not completed an incident report for the elopement of Resident #1 on 1/24/2021, and had no documentation or evidence of interventions for the resident during the 7:00 PM-7:00 AM shift on 1/24/2021. Observation in the North Hall on 2/4/2021 at 1:37 PM, showed Resident #1 ambulating down the hall with an unsteady gait, holding onto the wall and/or chair rail for balance. He walked toward the exit door, looking in every room. If the door was closed, he would attempt to push the resident's room door open as he walked by. He pushed room [ROOM NUMBER]'s door but the door did not open, he then proceeded to room [ROOM NUMBER], pushed the door open, and he walked into the room. The Certified Nursing Assistants (CNAs) were alerted and as they opened the door, Resident #1 was standing at the window. Resident #1 was redirected out into the hallway and down the hall. During an interview on 2/4/2021 at 5:21 PM, the MDS Coordinator stated, .I was interim DON on 1/24 (2021) .No, I did not come in nor did the Administrator come in after the elopement (1/24/2021) .No one from Administration came into the facility after the incident . During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if a thorough investigation was conducted on the elopement. He stated, .I failed at this one .I see it .I should have known . During an interview on 2/5/2021 at 2:00 PM, the Administrator confirmed the facility's video camera footage was never reviewed. Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], showed Resident #2 was assessed to have a BIMS score of 6, which indicated Resident #2 was severely cognitively impaired. Resident #2's activities of daily living needs showed the resident required supervision, oversight, encouragement or cueing. Review of the Nurse's Note dated 11/13/2020 at 9:00 PM showed, CN (Charge Nurse) was notified via (by) CNA (Certified Nursing Assistant) from South Hall, patient had been seen busting out glass from window and climbing out. Upon assessing situation, room [ROOM NUMBER]'s window glass was busted out and patient (Resident #2) was not in the room. Patient (Resident #2) was located sitting on the bench in front of entrance door .had no visible injuries .Administrator was contacted and did return to center to discuss situation with patient. Patient did agree to return to room [ROOM NUMBER] and would not attempt to escape building again. NP (Nurse Practitioner) notified by CN of incident . During an interview on 2/4/2021 at 12:43 PM, the Medical Records Nurse confirmed Resident #2's medical record contained no documentation of an incident report or investigation, and no documentation of interventions after the elopement attempt. During an interview on 2/4/2021 at 5:30 PM, the Administrator was asked if the facility had any elopements prior to the elopements of Resident #1 on 1/24/2021. He stated, .well four (was two months prior) months prior (named Resident #2) broke a window .our interventions were every 15 minute checks and medication review .I didn't do an investigation . During an interview on 2/5/2021 at 10:00 AM, the Administrator was asked for the documentation of the interventions of the incident with Resident #2. He stated, .I have no interventions and I did not do an investigation . Review of the medical record, showed Resident #2 had no documentation of interventions implemented after the elopement, no incident report completed, and no investigation completed. Refer to F-689 The surveyors verified the Removal Plan by: 1. On 2/3/2021, all resident windows were assessed by maintenance and have been secured so that there are no windows in resident areas that will raise more than 6 inches. Maintenance will be making periodic checks to ensure windows remain secured. Alarms have been ordered for all windows in resident areas and will be installed as soon as they are received. Nursing services will check windows every shift and will be placed on the Medication Administration Record [REDACTED]. The surveyors reviewed the invoices for the alarms. The surveyors confirmed per Technology Enhanced Learning System (TELS) the schedule of the maintenance weekly checks. The surveyors reviewed the MARS and interviewed nursing staff on all shifts. 2. On 2/5/2021, the outside gate has been secured with a locking device. The lock will be checked weekly to ensure it is secure by maintenance. The surveyors observed the secured lock on the gate. The surveyors confirmed per TELS the schedule of the maintenance scheduled weekly checks, and observed the locked gate. 3. The Interdisciplinary Team (IDT) will review all incidents from the past 24 hours daily Monday through Friday at the morning stand-up meeting; weekend incidents will be reviewed on Mondays and incidents on the holidays will be reviewed on the next business day. The team will ensure immediate interventions were placed at the time of the incident and the interventions are appropriate and adequate. The IDT will update the Care Plan to reflect any new interventions or recommendations. The surveyors reviewed the stand up meeting process and interviewed members of the IDT team. 4. By 2/9/2021, Resident # 1 and #2's incidents were thoroughly investigated by the Interdisciplinary Team and recommendations have been started. The surveyors reviewed the investigations and interviewed members of the IDT. 5. On 2/9/2021, psychiatric services to deal with the anger and feelings of loneliness and isolation were consulted, the Care Plans were updated, 1 on 1 care is being provided, windows were repaired and secured to not raise greater than 6 inches, and window alarms were placed on Resident #1 and #2's window to alert staff. All Residents will be screened by psychiatric services for feelings of isolation and loneliness. The surveyors observed the alarm on the windows in the residents' room, the window security screw on all windows and verified the windows would not open greater than 6 inches. The surveyors observed one on one care provided by staff. The surveyors reviewed the Care Plans, interviewed the Psychologist and observed psychiatric services in house reevaluating all residents on 2/10/2021. 6. On 2/8/2021, the licensed nursing staff performed elopement assessments on all residents. The Interdisciplinary Team has reviewed all the residents who scored a high risk and the comprehensive Care Plan was updated to reflect any recommendations or interventions. The surveyors reviewed the documentation and interviewed nursing staff on all shifts. 7. On 2/8/2021, the Administrative team was educated related to incident investigation by an outside Consultant. The surveyors reviewed the education and interviewed the Administrative team members. 8. The Quality Assurance Performance Improvement (QAPI) Coordinator or designee will audit one hundred percent of all incidents daily for 7 days for 2 weeks, then 25 percent weekly for 4 weeks, and then 10 percent monthly for 3 months to determine if the incident was thoroughly investigated by the IDT. The results of the review will be presented to the full QAPI committee to determine if the issue is resolved or should be an on-going Quality Initiative. The surveyors reviewed the audit tools and interviewed the QAPI Coordinator. 9. The facility performed elopement drills on 2/7/2021 and 2/8/2021. The drill was used as a return demonstration for the education that has been delivered. The surveyors reviewed the drill sign in sheet and interviewed staff on all shifts. 10. An outside Nurse Consultant will audit the provisions and documentation of the Removal Plan/Plan of Correction weekly for 4 weeks and then monthly for 3 months to ensure compliance. The Nurse Consultant will also deliver education to the Administrative team as needed. The Nurse Consultant 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 interviewed the Nurse Consultant. Noncompliance of F-610 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.