Every finding on record at Magnolia Village Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain an effective call system to allow residents to call for staff assistance. During an observation of the main shower room on 04/09/2024 at 8:50 AM, revealed the emergency pull cord call light was not functioning. The findings include: Review of the facility's policy titled, Maintenance Services, revised December 2009, revealed maintenance service should be provided to all areas of the building, grounds, and equipment. Review of the facility's policy titled, Answering the Call Light, revised September 2022, revealed the procedure was to ensure timely responses to the resident's requests and needs. The policy listed the following general guidelines: staff should ensure the call light was plugged in and functioning at all times, accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor, and report all defective call lights to the nurse supervisor promptly. Observation on 04/09/2024 at 8:50 AM, revealed the emergency pull cord in the main shower room was not functioning. the Assistant Director of Nursing (ADON) became aware that the facility's call system was not properly operating in the main shower room. The ADON immediately notified the maintenance director to initiate repair of the call system. Observation on 04/09/2024 at 1:31 PM, revealed call lights were not functioning in rooms 101-A and 103-A. Further observation revealed the call light pull cords in the bathrooms 101-A, 102, 106, and 340 were not functioning. During an interview with the Assistant Director of Nursing (ADON) on 04/09/2024 at 8:50 AM, she stated she was not aware the call light pull cord in the main shower room was not functioning and no one had reported it to her. The ADON further stated she did not know if maintenance was aware of the issue. She stated resident's were never left alone in the shower room but if staff needed assistance, they would not be able to pull the cord to alert someone they needed help and would have to open the door and yell for help. During an interview with the former Maintenance Director on 04/09/2024 at 12:54 PM, he stated the majority of the call lights and pull cords in the resident's rooms did not work when he worked at the facility. He stated obtaining supplies was difficult due to the facility having outstanding invoices with local supply companies. The former Maintenance Director further stated the call light was a resident's life line and if it was not functioning, they could not notify staff they needed assistance. During an interview with the Maintenance Director on 04/09/2024 at 1:31 PM, he stated he was responsible to ensure the facility had a functioning call system. He stated the ADON notified him this morning of the pull cord in the main shower room not functioning and he replaced the switch. The Maintenance Director stated he had not been made aware of any call lights or pull cords not functioning properly prior to today. He stated he does rounds every day and inspects the rooms and would repair or replace the call lights or pull cords at that time. The Maintenance Director stated if the call system was not working, a resident could not call for help if needed. During an interview with State Registered Nursing Assistant (SRNA) #1 on 04/10/2024 at 1:49 PM, she stated some of the bathroom call lights had not been working but she could not remember which rooms. SRNA #1 also stated on Sunday a call light on the 200 hall would work but the light was not working at the end of the hall. She further stated the main shower room didn't even have a string for the pull cord. SRNA #1 stated if she needed help she would have to open the door and yell for help. During an interview with the Director of Nursing (DON) on 04/11/2024 at 3:16 PM, she stated she was unaware of any call lights not working. She stated she expected the call system to function properly or a need could go unmet. During an interview with the Administrator on 04/11/2024 at 3:29 PM, she stated call lights were very important. She stated if there was a concern with call lights not functioning, she expected maintenance to bring it up during morning stand up meetings and to fix it immediately. The administrator stated she expected the call system to work properly.

Based on observation, interview, record review, and review of facility documents and policy, the facility failed to assure that one resident, (Resident #6) out of nine (9) sampled residents received the necessary supervision and/or assistance device to prevent accidents (elopement.) On 07/23/2022, staff did not initially hear and immediately respond to the alarm which sounded when Resident #6 overrode the magnetic lock system and exited through the front door from the residential unit without first entering the required code. Resident #6, who was assessed with severe cognitive deficit and a history of exit seeking, left the building without staff supervision at approximately 2:00 AM and was ultimately found by facility staff at an unoccupied building across a major (five-lane) highway from the facility. This failure placed the resident at the likelihood of death or serious injury. On 10/12/2022, a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision and/or an effective assistance device to prevent accidents. The IJ was determined to exist on 07/23/2022, when Resident #6 eloped from the facility and staff did not initially hear the alarm designed to sound when the door was opened without first entering a code. On 10/12/2022 at 12:00 PM, the Administrator was notified of the past noncompliance IJ situation, which also constituted Substandard Quality of Care (SQC). On 10/12/2022 at 12:08 PM, the Administrator was provided a copy of the CMS-IJ Template. Based on the facility's implementation of corrective actions, the State Agency (SA) determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed, with substantial compliance achieved, prior to the initiation of the complaint investigation on 09/19/2022. The Findings include: Review of the facility's policy titled, Elopement of Patient, dated 05/01/2022 revealed an elopement occurred when a patient leaves the premises or safe area without prior authorization. Review of Resident #6's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with Late Onset, Dementia with Behavioral Disturbance, Anxiety Disorder, and Cerebral Infarction. Review of an 05/09/2022 Nursing Documentation Note under the Notes tab in the electronic medical record (EMR) revealed that the resident was admitted from an assisted living facility, and was alert to self only, confused to place and time. Per this note, the resident is currently pacing halls and going to doors, redirected and other activities offered but is refusing at this time .wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Review of an Elopement Evaluation completed on 05/09/2022 and located in the Assessment tab of the EMR, also identified that Resident #6 was at risk for elopement. The resident, who was able to ambulate, had risk factors including diagnosis (Dementia), a history of wandering, expressing the desire to leave, the inability to locate significant landmarks without assistance, and attempts to maintain a daily routine/leisure interests that were not consistent with their new environment which could lead to exit-seeking behaviors. The Elopement Evaluation noted that the resident's behaviors included hovering near exits, as well as hyperactivity, frustration, and restlessness and/or agitation. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2022 and located under the MDS tab of the EMR, revealed that the resident was severely cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of three (3). Per this MDS, the resident wandered one (1) to three (3) days of the seven-day assessment period, and required supervision for transfers, walking in the room and the corridor, and locomotion on and off the unit. Review of Resident #6's comprehensive care plan, initiated on 05/09/2022, revealed the resident was care planned to prevent elopements from the day of admission. The goal of will not attempt to leave the facility without an escort was to be met through multiple interventions, including: Observe risk factors/[NAME] for exit seeking behavior and adjust care delivery. Provide increased supervision as appropriate when resident is verbalizing or exhibiting desire to leave the facility .As appropriate, redirect resident/patient if near exits or doorways. Review of Resident #6's Progress Notes revealed that, in addition to wandering through the facility on a routine basis, the resident displayed exit seeking behaviors on 05/09/2022, 05/10/2022, 05/15/2022, 05/19/2022, 05/22/2022, 05/25/2022, 07/07/2022, 07/08/2022, 07/14/2022, and 07/22/2022. Review of the Progress Notes for these days revealed that the resident's exit-seeking behaviors occurred at least once on all three (3) shifts but were more common on the second (afternoon/evening) and third (night) shifts. Review of a facility document titled, Self-Reported Incident Form, dated 07/23/2022, revealed that Resident #6 eloped from the facility on 07/23/2022. Per this document, It was reported that Resident #6 had exited the facility unsupervised and was located off facility property. Review of an attachment to a five-day follow-up report to the SA, dated 07/27/2022, revealed that staff reported on 07/23/2022 around 2:00 AM they heard the front door alarms sounding and began to do a head count and realized Resident #6 was unable to be located. Procedures related to a missing resident were initiated and followed. During the facility search, staff were able to locate fifty-eight (58) of fifty-nine (59) residents. When the resident was identified the charge nurse sent two (2) employees on foot to search the perimeters of the facility and sent two (2) staff to search near the entrance of the facility. Two (2) Certified Nursing Assistants (CNA) quickly saw Resident #6 attempting to enter a place of business that was not in operation due to the time of hours. The CNA's quickly approached the resident and redirected him/her back into the facility. Review of Progress Notes for 07/23/22 revealed that after the elopement, Resident #6 was placed on one to one (1:1) care until further notice related to the elopement risk, was assessed for injuries with none found, and the physician was notified. Although Resident #6's Progress Notes and facility investigation revealed the resident sustained no injury from the elopement, a note on 07/23/2022 at 12:30 PM revealed the resident was transferred to the hospital for worsening dementia, including physical aggression/combativeness with an inability to redirect. Review of MDS tracking data revealed that, as of the date of the survey, Resident #6 had not returned to the facility and was unavailable for observation or interview. Per an attachment to the 07/27/2022 five-day follow-up report to the SA, as part of the investigation into the elopement, the Maintenance Director assessed all doors to ensure that all doors were working properly. The Maintenance Director would continue to audit doors as a precautionary measure. Review of written statements, interviews with staff, and observation revealed that although the doors were working properly, as noted in the attachment to the 07/27/2022 report to the SA, the alarm on the door through which Resident #6 exited the residential unit did not sound loudly enough to alert staff at the time that the resident was able to get off the secured unit: a. Review of an undated witness statement from CNA #1 revealed that, We went to do rounds around 2:00 AM in the morning. I heard the front door alarm going off. I looked around for anyone and when I didn't see Resident #6 as he/she was last seen at the nurse's station, I started to look for him/her. All CNA's started to search for her in the rooms, bathrooms, closets, and courtyard. When she couldn't find the resident in the building we went outside and walked the sidewalk. CNA #5 and I spotted her across the street at a building trying to get in the door. We got Resident #6 and walked back to Magnolia. Interview with CNA #1 on 10/12/2022 at 5:30 AM revealed she was working on the one-hundred (100) hall where Resident #6 resided on the night that the resident eloped. She stated she was doing rounds, and I came out to the hall to throw away trash and heard the alarm. CNA #1 stated, I didn't hear the alarm when I was in the room providing care to another resident, but as soon as I came out of the room, after opening the door and going into the hall to discard the resident's soiled brief, I heard it. CNA #1 confirmed that she was unable to hear the alarm while working in the resident's room, which she stated was at the end of hall. CNA #1 verified she was unaware that the alarm was sounding until she opened the door and went out into the hallway. CNA #1 stated she then came up to the nurses' station and found that the front (locked/coded) door off the unit was closed; however, both the panel at the nurses' station and the annunciator by the door were showing that the locked door from the unit (which went into the lobby and lead to three (3) unsecured exits from the building had been opened. Further interview with CNA #1 revealed that Resident #6 had been up by the doors earlier that night, but she had not attempted to push the exit bar, which set off the alarm, prior to the elopement. CNA #1 stated that several days earlier, Resident #6 had figured out that if he/she pressed the door long enough, it would unlock. CNA #1 estimated that it had been no more than five (5) minutes since she had last seen the resident, prior to going into another resident's room to provide care. She stated that while she was checking the panel, two (2) additional staff were coming down the hall to check as they could now hear the alarm sounding. b. Review of a witness statement from CNA #5, dated 07/23/2022, revealed that, Around 1:00 AM I was doing my round. We had to keep redirecting Resident #6 from the door. I needed to get my residents changed and begin my round. Around 2:00 AM I was assisting a resident and I heard the alarm go off, so I stopped what I was doing to go attend to it. I was in the first room on the right-hand side of one-hundred (100), I went out into the main lobby, and I walked all the way to end of the road and I notice the resident standing in front of the CED building. She was trying to get in the building. The resident had on a black and white dress. I proceeded to go across the road and lead the resident back to the building. There was no traffic or cars. When I approached the resident, there was a box of gloves in his/her hand. I escorted the resident back to the facility with CNA #1 and he/she came willingly. The nurse then took over to do her assessment. Interview with CNA #5 by telephone on 10/11/2022 at 12:09 PM revealed she was an agency staff who was not currently working at the facility. She stated she was familiar with Resident #6 who she described as always trying to get out. She stated that on the night of Resident #6's elopement, she was working on the one-hundred (100) Hall (where Resident #6 resided) and had been in a room providing care to another resident. CNA #5 stated that when she exited the room and went out into the hall, I could hear the alarm, but it was very faint. CNA #5 stated that I have hearing problems and confirmed that, I couldn't hear the alarm when I was in the room with door closed. She stated she was unaware of when the alarm first began to sound and did not know that a resident had managed to get out off the secured unit until she came out in the hall and heard the alarm sounding. She stated at this time, she and the other staff began a count of the residents and searched for Resident #6, whom they identified as the missing resident. CNA #5 confirmed that she and CNA #1 were the staff who located Resident #6 and returned her to the facility. Although CNA #5 stated she did not know when the alarm first sounded and the resident eloped, she estimated that the resident was gone for approximately eight minutes. c. Review of an undated witness statement from CNA #3 revealed, I last saw Resident #6 around 1:55 AM. CNA#2 and I were on the three-hundred (300) wing back in Resident #10's room, we did not hear the alarms sound over the TV, curtain was pulled, door was shut, and we were all talking. Once we came out of the room, we heard the alarm and CNA #1 informed us Resident #6 was gone. Per this statement, We did a head count, and checked all rooms, bathrooms, closets, dining room, and courtyard. After we could not find her in the building all four (4) of us CNA's went outside to search. CNA #1 and CNA #5 found Resident #6 at the building across the street. d. Review of an undated witness statement from CNA #2 revealed that at 1:55 AM, Resident #6 was last seen at the nurses' station. The resident had been exit seeking and rummaging all night, redirection was applied. CNA #3 and I went into Resident #10's room down three-hundred (300) hall to finish our round we had the door closed, TV on, curtain pulled and CNA #3 and I were talking to Resident #10. Once we left the room, we heard the front door alarm going off. Once we figured out Resident #6 was missing we done a head count and searched the building. Once we could not find the resident inside the building we went outside to search. CNA #1 told us Resident #6 was found across the street and had been missing for around 15 minutes. e. Review of an undated witness statement from Licensed Practical Nurse (LPN) #2, the nurse on duty, revealed that she was on break at the time Resident #6 eloped. She wrote the resident was last seen at the nurse's station around 1:50 AM. She stated that While I was on my fifteen (15) minute break, staff began their rounds and, When I came back to the floor, CNA #2 was looking around in the dining room and told me that they had been in Resident #10's room doing round and when they came out the front door alarm was sounding. They both stated they were not able to hear it from inside the room. LPN #2 wrote in her statement that when Resident #6 could not be found in the building, all four (4) CNAs went outside to look for the resident. Per the statement, Within a few minutes I received a call from CNA #1 that the resident was at the office building across the street. The resident was returned to the facility and LPN#2 assessed her with no injuries noted. f. Review of a statement dated 07/23/2022 and signed by the Administrator, Maintenance Director, and Admission Director, revealed that in response to the elopement, they did a simulation test based off the statements that were given. The test was done in Resident #10's room off three-hundred (300) hall. CED [Administrator] and the admission director both shut the door, ensured the tv was on, and the resident concentrator was on, and we also had a small conversation with the resident with the privacy curtain pulled. The maintenance director was at the main door to set the alarm off. He set the alarm off and the CED and AD both did not hear the alarm go off. After a period of time the MD [Maintenance Director] had to come in the room to tell us that the alarm was going off. g. Observation during a tour of the facility on 10/11/2022 at 8:41 AM revealed that the secure residential unit included three wings with resident rooms (100, 200, and 300 Halls), a day area, dining room, kitchen, and a central nursing station. The residential unit had five (5) exits accessible to residents and staff - four (4) of which led to locked courtyards. The fifth (5th) door, in front of the central nurses' station, led into the front lobby of the building, which had three (3) unlocked doors which lead the facility parking lot and drive. Each of the five exits had an alarm pad on an adjacent wall, on which a code had to be entered to release the magnetic lock to open the door. (Observation on 10/11/2022 at 9:45 AM also revealed an additional door to the outside from inside the kitchen; however, per observation and interview with the Dietary Manager who was present during the observation, this door was not accessible to residents.) Observation during an additional tour of the facility on 10/11/2022 at 9:54 AM revealed that each of the four (4) doors which led to the secured courtyards bore a sign that stated Push until alarm sounds. Door can be opened in fifteen (15) seconds. The front door by the nurses' station did not include such a sign. However, observation during a tour of the facility with the Maintenance Director on 10/11/2022 at 10:36 AM confirmed that by pushing on the exit bar on the front door near the nurses' station, as well as on the panic bar on each of the four doors which led to the secured courtyard, the magnetic lock holding the door closed would release and the door would open within approximately fifteen (15) seconds. During the tour on 10/11/2022 at 10:36 AM, observation also revealed that, when pushing on the release bar of each of the five (5) doors listed above, an alarm began to sound. Five (5) seconds later, a screeching siren noise began to sound and continued to [NAME] until the magnetic lock on the door released. The siren, as well as a strobe light near to the door, continued to operate until a code was entered to silence the alarm. During an interview with the Maintenance Director, on 09/21/2022 at 10:10 AM, he stated he assessed the facility's doors to ensure proper working conditions on 07/23/2022 after Resident #6's elopement incident. He confirmed that on 07/23/2022 he determined all the doors exiting the facility were in proper working condition. The Maintenance Director stated his conclusion was the door alarms were not loud enough for staff to hear while they were in resident's rooms. An additional interview with the Maintenance Director, on 10/11/2022 at 10:36 AM, revealed that the facility's investigation determined that Resident #6 could have only eloped off of the secure residential unit by going out the front door by the nurse's station, as each of the other doors that were accessible to residents lead into secured courtyards. Further interview with the Maintenance Director revealed that the siren that was heard during the test and the strobe light system that were observed during the tour on 10/11/2022, were not in place when Resident #6 eloped on 07/23/2022. He stated that when he tested the system on 07/23/2022, he found that the doors were operating as designed and the alarm that was in place on 07/23/2022 sounded when the resident pressed on the exit bar for 15 seconds, and thus overrode the magnetic lock to exit off the unit. However, he confirmed, during tests conducted as part of the investigation, he found that the alarm was not loud enough to be heard when staff were in resident rooms with the door closed. In response, he explained, the facility had installed the additional siren and strobe light system. The Maintenance Director stated that the volume of the alarm that was in place at the time of the 07/23/2022 elopement was the sound that was first heard (during the test of the system observed on 10/11/2022) when the bar was pushed, prior to the onset of the additional siren, five seconds later. A test of the alarm system's original volume was conducted on 10/11/2022 at 11:06 AM. Observation in a resident room at the far end of the three-hundred (300) Hall (which was further down the hall than the room where staff were working on the night of the elopement and which was used for the test conducted by the Administrator, Admission Director, and Maintenance Director), revealed that the alarm that was initially in place could not be heard in the resident's room when the door was closed. Further observation revealed that the new siren system which had been installed after the elopement was sufficiently loud to be heard when the door was closed, even with a radio playing in the room. During the tour with the Maintenance Director on 10/11/2022 at 11:10 AM, he pointed out the building where Resident #6 was found by staff. Observation revealed that to reach this building, Resident #6 had to traverse the facility property and cross US Highway 231, a five-lane road with a posted speed limit of forty-five (45 miles) per hour. Interview with the Assistant Director of Nursing (ADON), on 09/20/2022 at 2:50 PM, confirmed Resident #6 had eloped from the facility around 1:55 AM on 07/23/2022. The ADON stated the resident was found by facility staff off the facility's property, across the five-lane highway, at a place of business per the witness statements. The ADON confirmed the facility's investigation revealed the alarm system on the doors through which the resident exited were not loud enough for staff to hear. Interview with the Director of Nursing (DON), on 09/21/2022 at 9:52 AM, revealed Resident #6 eloped from the facility around 1:55 AM on 07/23/2022, and was found off the facility property across the five-lane highway, at a closed place of business by the facility's staff. She stated the facility failed to ensure the resident did not elope from the facility on 07/23/2022 as the alarm system on the doors (used to exit) was not loud enough for staff to hear. Interview with the Administrator, on 09/20/2022 at 5:40 PM, confirmed Resident #6 had eloped from the facility around 1:55 AM on 07/23/2022. The Administrator stated she conducted Resident #6's elopement investigation. She revealed the resident was found off the facility property across the five-lane highway at a closed place of business by the facility's staff. The Administrator confirmed the facility's investigation revealed the alarm system on the doors (used to exit) were not loud enough for staff to hear. Additional interviews with the Administrator on 10/11/2022 at 9:24 AM, 11:45 AM, 2:35 PM, and 5:00 PM revealed the facility reported the elopement to the State Agency in a timely manner (07/23/2022) and conducted a thorough investigation to determine the root cause of the incident. Witness statements were taken from staff, and all persons with possible knowledge of the incident were interviewed. The facility tested its alarm system. Per the Administrator, the facility took all the findings from the investigation through the QAPI system and provided a list of actions taken to correct the incident. Resident #6 was immediately placed on one-to-one (1:1) supervision after being returned to the facility and remained under constant supervision until she was sent out to the hospital later that day, due to non-elopement related behaviors. In response to the findings that the alarm system in place could not be heard by staff when they were working in resident rooms, the facility purchased a new system, with siren and strobe lights. The Administrator stated that during the time that facility was awaiting the new equipment, a dedicated staff was assigned to be at the nurses' station adjacent to the door was always visible and the alarm could be heard. In-services for all staff were conducted on 07/23/2022, and then again on 08/17/2022 when the new equipment was installed. All residents were re-evaluated for elopement risk, with 35 of 59 residents being identified at risk. Each of these resident's care plans was reviewed to assure that elopement risk was care planned, and the care plans were revised as needed. In addition to the in-services, the facility-initiated elopement drills that are still being conducted weekly. All findings were reported to the QA committee, with dated sign in sheets verifying all members attendance. Interview with the Administrator revealed that there had been no further elopements since each of the facility's actions had been implemented. The deficient practice was determined to be past noncompliance related to the facility identifying the IJ and implementing interventions to prevent recurrence of the situation. The facility's actions included the following: 1. The elopement incident and corrective action plans to prevent further incidents were reviewed through the facility's QAPI (Quality Assurance and Performance Improvement) program, with multiple meetings involving an interdisciplinary team. (Dates and attendees of this meeting were verified through record review.) 2. The facility conducted a root cause analysis. The facility investigated and determined that the elopement occurred because staff were unable to hear the alarm sound at the time the resident exited through the coded door which was used to secure the residential unit. (Verified through interview and review of the facility's investigation.) 3. In response to the root cause analysis, the facility purchased additional equipment, including a new annunciator system with a siren that can be heard through the entire facility. This system also includes a flashing strobe to alert staff when an attempt to exit through a coded door without first entering the code occurs. (The functioning of this system was verified through observation on 10/11/2022.) During the period the facility was awaiting installation of the new equipment, a dedicated staff was assigned to be the door monitor and assure that no residents left without staff knowledge (Verified through record review and interview.) 4. All staff were immediately provided in-services on the facility's elopement policy on 07/23/2022. Additional in-service was provided 08/17/2022 when the new equipment was installed. (These in-services were verified through record review and interview with staff on 10/11/2022 - 10/12/2022). 5. The facility began conducting elopement drills on a daily basis from 07/23/2022 through 08/06/2022. At this point, they are still conducted on a weekly basis. (The drills were verified through record review and interview with staff on 10/11/2022 - 10/12/2022.) 6. The facility began conducting door audits on a daily basis from 07/23/2022 through 08/05/2022. At this point they were still conducted on a weekly basis. (The audits were verified through record review and interview.) 7. On 07/23/2022, all residents were assessed for elopement risk. Thirty-five (35) of the 59 residents were identified at risk, based on ambulatory/locomotion status combined with other risk factors. (Verified through interview and a review of the assessments.) Those residents at risk for elopement had care plans for elopement reviewed and added/revised as needed. (Verified through interview and review of a sample of five residents to assure that, if identified at risk, the resident's care plan included the risk of elopement and interventions in response.) 8. Facility has conducted continuous audits of actions taken to assure ongoing compliance, with data from the audits reported back to QAPI committee. (Verified through record review and interview.) **The facility implemented the following actions to remove Immediate Jeopardy: 1. Dates and attendees of the Quality Assurance Performance Improvement were verified through record review. 2. The Root Cause Analysis was verified by interview and the review of the facility investigation. 3. In response to the root cause analysis, the facility purchased additional equipment, including a new annunciator system with a siren that could be heard through the entire facility. The system also included a flashing strobe to alert staff when an attempt to exit through a coded door without first entering the code occurs. The functioning of this system was verified through observation on 10/22/2022. While facility was awaiting the installation of the new equipment, a dedicated staff was assigned to be the door monitor and assure that no residents left without staff knowledge. This was verified through record review and interview. 4. Staff were educated on the facility's elopement policy on 07/23/2022. Additional inservice training was done on 08/17/2022 when the new equipment was installed. These in-services were verified through record review and interview with staff on 10/11/2022 - 10/12/2022. 5. The facility initiated daily elopement drills on 07/23/2022 - 08/06/2022. After 08/06/2022, the elopement drills were done on a weekly basis. The drills were verified through record review and interview with staff on 10/11/2022 - 10/12/2022. 6. The facility began conducting door audits on a daily basis from 07/23/2022 through 08/05/2022. At this point they were still conducted on a weekly basis. Audits were verified through record review and staff interview. 7. On 07/23/2022, all residents were assessed for elopement risk. Thirty-five (35) of the fifty-nine (59) residents were identified at risk, based on ambulatory/locomotion status combined with other risk factors. These were verified through interview and a review of the assessments. The residents at risk for elopement had care plans for elopement reviewed and added/revised as needed. This was verified through interview and review of a sample of five (5) residents to assure that, if identified at risk, the resident's care plan included the risk of elopement and interventions in response. 8. The facility has conducted continuous audits of actions taken to assure ongoing compliance, with data from the audits reported back to QAPI committee. This was verified through record review and interview. 40417

Based on observation, interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure freedom from abuse for five (Resident #2, #3, #4, #6 and resident #7) of nine (9) sampled residents. Resident-to-resident abuse was substantiated in four instances with residents being hit, pushed, or slapped by other residents of the facility Findings include: Review of the facility policy titled Abuse Prohibition, revised 05/01/2022, revealed the Center would ensure staff would do all that was within their control to prevent occurrences of abuse. Further review of the document revealed if suspected abuse was resident to resident, the resident who had a history of disruptive or intrusive interactions would be removed from the setting or the situation and an investigation would be completed, with options for room changes being provided based on the situation. 1. Review of a Self-Reported Incident Form, dated 09/08/2022, revealed that the facility reported to the State Agency (SA) an allegation regarding a resident-to-resident incident. Per the form, on 09/08/2022, a Certified Nursing Assistant (CNA) witnessed two residents (Resident #3 and Resident #5) having an altercation with each other in their room. Review of an attachment (Part C) to the 5 Day Follow Up/Final Report submitted to the SA on 09/12/2022 revealed that, After a comprehensive investigation that included an interview, observation, and record review, this resident-to resident will be substantiated with no harm. Although the attachment noted that This was an isolated incident, as a precautionary measure, education and post-test regarding abuse prevention and accident and incidents in regard the resident to a resident were completed and was ongoing. Record review for the two residents, who were roommates at the time of this incident, included the following: a. Review of Resident #5's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included dementia. The most recent assessment prior to the 09/08/2022 incident, a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/02/2022 in the electronic medical record (EMR), revealed the resident was severely cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15). Per this assessment, Resident #5 displayed no physical or verbal behaviors towards others in the seven-day assessment period. Review of Resident #5's current comprehensive care plan revealed that the potential for physical behaviors had been care planned since 03/14/2022 and the potential for verbal behaviors had been care planned since 03/25/2022. b. Review of Resident #3's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, and malignant neoplasm (cancer). The most recent MDS conducted prior to the 09/08/2022 incident, a quarterly MDS with an ARD of 07/01/2022, revealed the facility was severely cognitively impaired, based on a BIMS score of three (3) out of fifteen (15). Per this MDS, the resident, who was independent in walking in the room at the time, displayed no physical or verbal behaviors during the seven-day assessment period. Review of Resident #3's current comprehensive care plan revealed that the potential for physical behaviors had been care planned since 06/15/2022 and the potential for verbal behaviors had been care planned since 06/17/2022. Review of a witness statement, dated 09/08/2022, revealed that CNA #4 documented that she heard a pound and grunting from Resident #3/Resident #5's room. CNA #4 noted that the door to the resident's room was closed. When I entered the room, Resident #5 was holding on to Resident #3's arm and using the other hand to punch him/her on the left side near rib cage. I did not witness Resident #3 hitting the other resident. Resident #5 said he/she did it because Resident #5 was trying to damage the blinds. When I entered in the room they were not broken. I immediately separated them and asked them what was going on. I took Resident #5 out of the room and I flagged down the nurse to come and assist. Review of a witness statement from the former interim Director of Nursing (DON) dated 09/08/2022, revealed that when he went to talk to and assess the residents, he asked Resident #5 if he had an altercation with his roommate and Resident #5 said he didn't know. Resident #3 could not tell me what had happened either. Review of a current staff list provided by the facility revealed the former interim DON was no longer employed by the facility and unavailable for interview. Observations on 10/11/2022 - 10/12/2022 and review of Resident #5 and Resident #3's EMR revealed that Resident #5 and Resident #3 were no longer roommates. Observations and interviews with the two residents included: a. Observation of Resident #5, on 10/11/2022 at 8:45 AM, revealed the resident was walking slowly but steadily in the day room/dining area. An interview with the resident at this time revealed the resident did not recall the 09/08/2022 incident. The resident was not oriented to time, stating that /she had lived in the facility all my life. Resident #5 stated that he/she had never had problems with anyone in the facility, had never been in a fight or altercation with anyone, and no one had ever been rough with Resident #5. The resident reported feeling safe, with no fear of other residents or staff. Observation on 10/11/2022 at 11:54 AM, revealed the resident was calmly sweeping in the day room. The resident was pleasant and did not remember the previous interview. Observation on 10/11/2022 at 1:39 PM revealed the resident was walking in the dining room, throwing away trash. The resident did not recall the incident with Resident #3, saying he/she had never been involved in any issues with anyone else, adding, They don't bother me, I don't bother them. On 10/11/2022 at 4:05 PM, Resident #5 was observed laying on his bed. No issues were observed between the resident and the current roommate, who was present in the other bed in the room. Throughout the observations on 10/11/2022, as well as additional observations on 10/12/2022 at 5:15 AM, 6:54 AM, 8:04 AM, 11:20 AM, and 12:35 PM, Resident #5 displayed no behaviors, and the resident was pleasant and calm at all times. During the observations of Resident #5 on 10/11/2022 at 4:05 PM and 10/12/22 at 5:15 AM, 6:54 AM, 11:20 AM, and 12:35 PM, it was noted that Resident #5 occupied the far bed in the room, next to the window which was covered by blinds. b. Observation of Resident #3, on 10/11/2022 at 8:51 AM, revealed the resident was sitting on the side of his bed. The resident was unable to answer basic screening questions and did not respond to his/her name. During the attempted interview, the resident made low, mumbling sounds that could not be identified as words. Observation on 10/11/2022 at 9:40 AM, 1:33 PM, 3:54 PM, and 10/12/2022 at 5:15AM, 6:54 AM, 8:10 AM, 11:12 AM, and `12:20 PM revealed the resident was in bed during all observations. Multiple attempts to interview the resident during these observations revealed that the resident was not oriented to person, place, or time during basic screening questions. The resident mumbled with no discernable words when asked about the resident-to-resident altercation; however, during an attempt at an interview on 10/12/2022 at 8:10 AM, when asked if the resident felt safe, the words sure thing could be understood. Interview with CNA #4, on 09/19/2022 at 4:30 PM, revealed she witnessed the altercation between the two residents around a week or two ago. CNA #4 stated the incident occurred in the two residents' room. She revealed she was in the next room over and heard a thump and grunting. She went into their room and saw Resident #5 had Resident #3 by the arm and was punching Resident #3 in the ribs. CNA #4 stated she removed Resident #3 from the room and reported the incident to the nurse, An additional interview was conducted with CNA #4 on 10/12/2022 at 1:37 PM. She confirmed that, while working in another resident room, she heard like noises that shouldn't be. I immediately went over to Resident #3 and Resident #5's room. During this interview, CNA #4 noted that the door to the room had been closed because both residents were on isolation due to COVID-19. She confirmed that Resident #5 had Resident #3 by the arm and was punching the resident in the ribs. CNA #4 stated that she separated the residents and got a nurse who assessed the residents. Further interview with CNA #4 revealed that Resident #5 was very protective of his things and had gotten agitated because Resident #3 was touching his/her blinds. She stated that Resident #3 was not aggressive back to Resident #5, saying, the resident just stood there. CNA #4 reiterated that Resident #5 was Pretty particular about his/her things and that the incident had occurred when Resident #3 had come onto Resident #5's side of the room and was handling the window blinds. Interview with the Assistant Director of Nursing (ADON), on 09/20/2022 at 3:19 PM, confirmed Resident #5 was witnessed by the facility's staff holding Resident #3's arm and punching him in the left flank area. The ADON stated that Resident #5 physically abused Resident #3 and the facility investigated the allegation of abuse and reported to the State Office of Inspector General Office of Health Care on 09/08/2022. An additional interview with the ADON, on 10/12/2022 at 10:50 AM, confirmed that at the time of this incident, Resident #5 and Resident #3 were roommates. She said that, to her knowledge, there had never been any issues between the two residents prior to the 09/08/2022 incident. She stated that when CNA #4 told her what she saw, she went and assessed both residents and found that Resident #3 had redness that looked as if it was going to bruise, as well as a scratch to the elbow. In response, an x-ray was ordered. Review of a Radiology Results Report, dated 09/08/2022 and located in the facility's investigation file, revealed that there was no acute rib fracture notes and no significant soft tissue swelling. Further interview with the ADON revealed that Resident #5 was more cognitively aware than Resident #3, and therefore the decision was made to move Resident #3 to another room, which did not have any impact on the resident. The ADON stated that Resident #5 was provided a new roommate, who was non-ambulatory and could therefore not touch Resident #5's belongings, and no further instances had occurred. Interview with the Social Services Director (SSD), on 09/21/2022 at 2:00 PM, revealed the altercation between Resident #3 and Resident #5 was an isolated incident and no altercations between the two residents occurred prior to or after the incident. Interview with the Administrator, on 09/20/2022 at 5:40 PM, revealed facility staff witnessed the incident between Resident #5 and Resident #3. She further stated the facility investigated the incident as an abuse allegation and it was substantiated. An additional interview was conducted with the Administrator on 10/12/2022 at 10:56 AM. The Administrator stated that because both residents were on COVID precautions, they had to stay in their room with the door closed. She noted that, as had been observed on 10/11/2022 and 10/12/2022, Resident #5 was social, pleasant and did not like to stay in his room, as he was routinely out and about in the facility, particularly liking to help clean. She stated that the facility's investigation found that the incident occurred when Resident #3 went over to fiddle with and touch the blinds which were on Resident #5's side of the room. The Administrator described this as a on-off situation in which Resident #5 became agitated with the roommate. 2. Review of a Self-Reported Incident Form, dated 06/15/2022, revealed that the facility reported to the SA an allegation regarding a resident-to-resident incident. Per the form, on 06/15/2022, It was reported that a staff member witnessed Resident #3 make physical contact with Resident #4 in the activity room. Per the attachment to the 5-Day Follow up/Final Report submitted to the SA on 06/19/2022, the facility reported that, After a comprehensive investigation that included an interview, observation and record review this resident to resident will be substantiated with no harm. This was an isolated incident and after 15 minute checks daily for two (2) days, neither Resident #3 had any other altercations with Resident #4. There were no bruises on either resident. Resident #3 was also seen by the Geri-psych. Resident #3 has responded well to the new orders received. As a precautionary measure, education regarding abuse prevention in regard to the resident to a resident has been completed and is ongoing. Record review for the two-resident involved included the following: a. Review of Resident #3's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Malignant Neoplasm (Cancer). Per the most recent MDS prior to the 06/15/2022 incident (an admission MDS with an ARD of 03/31/2022), Resident #3 had a BIMS of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. The resident was ambulatory and wandered and displayed no physical or verbal behaviors during the seven-day assessment period. A review of Resident #3's current comprehensive care plan, initiated on 03/26/2022, revealed that the problem of behaviors was not care planned until 06/15/2022 (when this incident occurred), as there had been no previous issues. A review of all Progress Notes confirmed the resident did not display physical or verbal behaviors towards others prior to this incident. Review of Resident #3's Progress Notes revealed the resident was sent out to the hospital for evaluation after the 06/15/2022 incident, and returned the same day with no new orders, and was placed on fifteen (15) minute checks. Further review of physician orders under the Orders tab in the EMR revealed an order for hospice care and treatment effective 06/17/2022, as well as multiple orders for medication changes with concurrent medication regimen reviews. b. Review of Resident #4's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses including Dementia with Behavioral Disturbance Psychotic Disorder with Delusions, and Schizophrenia. Per the most recent MDS prior to the 06/15/2022 incident, (a quarterly MDS with an ARD of 05/06/2022), the resident was assessed by staff to have moderate cognitive impairment after the resident was not able to complete the BIMS test. Per the MDS, Resident #4 displayed physical and verbal behaviors towards orders one (1) to three (3) days of the assessment period. Review of the current comprehensive care plan revealed that the problem of potential for both physical and verbal behaviors had been care planned since 02/28/2022. Review of an undated witness statement completed by the Activities Director (AD), revealed that the 06/15/2022 incident occurred when, We were all sitting at the activity table, and we were watching virtual tour of a dairy farm. Resident #3 stood up and was looking straight at Resident #4 and pointing at the resident. I told Resident #3, Resident #4 was fine and wasn't bothering anyone. Resident #3 then voiced he/she was leaving and getting out. My back was cattycornered to Resident #4 and Resident #3 got up like he/she was leaving and instead quickly went over to Resident #4 and made physical contact with a closed fist on Resident #4's right cheek. Resident #4 grabbed his/her face and said oh. Resident #3 then took off running down the hall, I intervened and got a charge nurse to come and evaluate Resident #4. Observations on 10/11/2022 - 10/12/2022 revealed no evidence of behaviors by either Resident #3 or Resident #4. Observations and interviews with the two residents included: a. Observation of Resident #3 on 10/11/2022 at 8:51 AM, 9:40 AM, 1:33 PM, 3:54 PM, and 10/12/2022 at 5:15AM, 6:54 AM, 8:10 AM, 11:12 AM, and 12:20 PM revealed the resident was in bed during all observations. Multiple attempts to interview the resident during these observations revealed that he was not oriented to person, place, or time during basic screening questions. The resident mumbled with no discernable words when asked about the resident-to-resident incident with Resident #4; however, during an attempt at an interview on 10/12/22 at 8:10 AM, when asked if the resident felt safe, the words sure thing could be understood. b. Observation of Resident #4 on 10/11/2022 at 8:51 AM, 9:40 AM. 11:59 AM, 1:33 PM, 3:54 PM, and 10/12/2022 at 5:15 AM, 6:54 AM, 8:07 AM, 11:15 AM, 12:20 PM, revealed the resident was in bed during all observations. No evidence of bruising or other injuries were noted to the resident's face. Multiple attempts to interview the resident were made during these observations; however, the resident did not answer any basic screening questions, including his/her name. Interview with CNA #10, who was present and feeding the resident during the observation on 10/11/2022 at 11:59 AM revealed that the resident is pretty calm and currently has no behaviors. Interview with the AD on 09/20/2022 at 4:09 PM, revealed she witnessed Resident #3's closed fist physically contact Resident #4's cheek. The AD also confirmed physical assault was considered abuse. An additional interview was conducted with the AD on 10/12/2022 at 8:36 AM. The AD showed where she had been sitting in the activity room, noting that Resident #3 was sitting at the table with her. She stated that Resident #3 stood up, began mumbling, and pointed at Resident #4, who was sitting in a chair, catty-cornered behind her. She said that she asked Resident #3 to sit back down, but he/she did not, and began walking away like he/she was leaving the activity room. The AD stated, Before I could get to the resident, Resident #3 hit Resident#4 in the face. She stated that this was the first resident-to-resident behavior she had ever seen Resident #3 display, and to her knowledge, was the first time the resident had been physical to another resident. She said that although I didn't see the punch coming, she did see Resident #3 make contact with Resident #4, adding that although she was less than three feet away, I just couldn't get to Resident #3 in time. It was unprovoked. She said she immediately checked Resident #4 and hollered down the hall for the nurse. The AD stated that when Resident #3 first hit Resident #4, the resident grabbed his/her face; however, within three minutes Resident #4 had forgotten it. The AD stated that she thought the resident's face was red but there was no bruising. The AD described the incident as unexpected, stating that it could not be predicted that as Resident #3 walked by Resident #4, the resident would just reach out and punch Resident #4. Interview with the Skin Health Lead (SHL) on 10/12/2022 at 9:31 AM revealed she was previously the DON. She stated she was called in after the incident and all residents, including Resident #4, had a skin assessment and no issues were identified Interview with the ADON, on 09/20/2022 at 3:44 PM, revealed the facility confirmed Resident #3's fist made physical contact with Resident #4's face, and substantiated abuse of Resident #4 by Resident #3. Interview with the Administrator on 10/12/2022 at 9:49 AM revealed that in response to the incident, the facility dove deeper to try and determine the root cause of Resident #3's behavior on 06/15/2022, noting that this incident was the first incidence of physical abuse that the resident had displayed. In addition to reaching out to the family to understand the resident's past history and its possible impact on his/her behavior, the facility brought in hospice to assess if pain from the resident's cancer, which was spreading, was an issue in the resident's behavior. She stated that based on the resident's past history, the facility had begun looking for a different placement that would better suit the residents' needs; however, a transfer had become unnecessary as the resident had gone downhill as the cancer spread and the resident no longer displayed any behaviors. 3. Review of a Self-Reported Incident Form, dated 05/15/2022, revealed that the facility reported to the SA an allegation regarding a resident-to-resident incident. Per the form, on 05/15/2022, Resident #6 swatted at Resident #7. Per the attachment to the 05/19/2022 5 Day Follow Up/Final Report, the investigation found that Resident #6 was in Resident #7's room. When staff noticed the resident in there, they went to remove/redirect him/her. As staff removed Resident #6 from Resident#7's room, Resident #7, proceeded to tell Resident #6 to stay out of his/her room. Resident #6 then slapped Resident #7 on the inside of her forearm. Staff quickly separated and removed both residents from the area. Resident #7 was placed on a 15-minute watch, while Resident #6 was transferred to the hospital for evaluation due to the behavior. Review of the attachment for the final report revealed that the facility found that After a comprehensive investigation that included an interview, observation and record review this resident to resident will be substantiated with no harm. This was an isolated incident and after the 15-minute checks daily for 3 days neither Resident #7 nor Resident #6 had any other altercations. There were no bruises [sic] on either resident. Resident #6 did receive orders for new medication while he/she was at the hospital and will be seen by Geri-psych. In addition, the attachment noted that a stop sign was ordered and would go across Resident #7's room, upon delivery and, As a precautionary measure, education regarding abuse prevention in regard to resident to a resident has been completed and is ongoing. Record review for the two residents involved included the following: a. Review of Resident #6's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, Dementia with Behavioral Disturbance, Anxiety Disorder, and Cerebral Infarction. Review of an 05/09/2022 Nursing Documentation Note under the Notes tab in the EMR revealed that the resident was admitted from an assisted living facility, and was alert to self only, confused to place and time. Per this note, the resident is currently pacing halls and going to doors, redirected and other activities offered but is refusing at this time .wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Review of Resident #6's admission MDS, with an ARD of 05/16/2022 (one day after the 05/15/2022 resident-to-resident abuse) revealed that the resident was severely cognitively impaired, based on a BIMS score of three (3) of fifteen (15). Per this MDS, the resident wandered one (1) to three (3) days of the seven-day assessment period, and required supervision for transfers, walking in the room and the corridor, and locomotion on and off the unit. Review of Resident #6's comprehensive care plan, initiated on 05/09/2022, revealed the resident was care planned for the potential wandering behaviors and exit seeking from admission on 05/09/2022. The problem of physical behaviors was added to the care plan on 05/15/2022, the day of the resident-to-resident incident. Further review of Resident #6's closed medical record revealed the resident was no longer in the facility and had been transferred to the hospital on 07/23/2022 and never returned. b. Review of Resident #7's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, and Anxiety Disorder. Review of the resident's most recent MDS prior to the 05/15/22 incident revealed a quarterly MDS with an ARD of 04/08/2022. This assessment showed that the resident was cognitively intact, based on a BIMS of thirteen (13) out of fifteen (15), and displayed no behaviors during the seven-day assessment period. Review of Resident #7's comprehensive care plan, initiated 02/08/2022, revealed that there was no care plan for behaviors prior to 05/15/2022, as the resident did not display any and this problem area was not triggered. Further review of Resident #7's medical record revealed the resident was not currently in the facility and was being treated in the hospital. Review of an undated witness statement from CNA #6 revealed that, it was after lunch, I heard Resident #7 yelling so I went into the room to help him/her. Resident #6 was in her room beside the bed, digging through Resident #7's items. Licensed Practical Nurse (LPN) # 2, was there trying to tell Resident #6 that it wasn't her room and that we needed to leave because she was in the wrong room. And we got Resident #6] out of the room shortly after that. Can't remember what Resident #7 said to Resident #6, but I know she was upset. So Resident #6 slapped Resident #7 on the arm. Then we separated the two (2) and tried to calm them both down. Review of a witness statement dated 05/15/2022 by LPN #2 revealed the same description of Resident #6 rummaging through Resident #7's things., Per this statement, Resident #7 became upset and started screaming at Resident #6. I explained to Resident #7 that yelling will not help the situation as Resident #6 does not understand what she is doing .Resident #6 became resistant to leaving the room, CNA #6 and I were able to remove the resident after a few minutes. As we were passing Resident #7 in the hallway. She began yelling at Resident #6 again. Resident #6 was able to open hand slap Resident #7 on the inside of the forearm. Per the statement, as Resident #7 began swinging back at Resident #6, the CNA moved Resident #6 away while the LPN stood in front of Resident #7. LPN #2's statement noted that when she assessed Resident #7, the resident was not injured and there were no visible marks from the altercation on the residents arm. Review of facility staffing records revealed that LPN#2 was no longer employed by the facility. Attempts were made to contact LPN #2 by telephone on 10/11/2022 at 1:09 PM and 4:35 PM; however, she did not answer the telephone or return a call-in response and was unavailable for interview. Review of an undated statement from the Social Services Director revealed that she spoke with Resident #7 on 05/16/2022 to discuss the incident that took place over the weekend, Per this note, Resident #7 was content and friendly, and stated that she was not too upset, knowing Resident #6 does not know what she is doing. The note from the Social Services Director noted that Resident #7 was asked if any resident had ever physically abused her in the facility and she said, 'no'. As both residents were out to the hospital at the time of the investigation, no observations or interviews could be conducted. Interview with CNA #6 on 10/12/2022 at 3:21 PM revealed that Resident #6 would often wander into other resident's rooms, and she described the resident as always roaming and so quick. She stated on the day of the incident, She went into Resident #7's room. Resident #7 was mad at her and yelling at her. CNA #6 stated that Resident #6, who had severe dementia, did not intend to upset other residents, and thought he/she was helping by going into closets and drawers and arranging things. However, Resident #7 was angry that Resident #6 was in her room. CNA #6 confirmed that she saw Resident #6 hit Resident #7 on her arm after Resident #7 yelled at her. Per the CNA, Resident #6 struck out at Resident #7 before she and the nurse had a chance to do anything. CNA #6 stated that after this incident, Resident #6 was sent out to the hospital and the facility ordered a stop sign for Resident #7's door which was in place and used until Resident #7 was recently transferred to the hospital. Interview with the ADON, on 09/20/2022 at 5:25 PM, revealed Resident #7 was not free from abuse. She confirmed two facility staff -LPN #2 and CNA #6 witnessed Resident #6 open handed slap Resident #7 on the arm and therefore, the facility substantiated physical abuse of Resident #7. Interview with the Administrator, on 09/20/2022 at 5:40 PM, also confirmed that the facility substantiated resident-to-resident abuse, based on staff witnessing Resident #6 slap Resident #7 on the arm. The Administrator stated that although abuse was substantiated, Resident #7 was not injured by the physical abuse. 4. Review of a Self-Reported Incident Form, dated 06/13/2022, revealed that the facility reported to the SA an allegation regarding a resident-to-resident incident. Per the form, on 06/13/2022, staff witnessed Resident #6 being pushed up against the wall by Resident #2. As staff intervened, Resident #2 then informed the staff member that Resident #6 hit her. Per the attachment to the 5 Day Follow Up/Final Report noted that, After a comprehensive investigation that included an interview, observation and record review this resident to resident will be substantiated with no harm. This was an isolated incident and after fifteen (15) minute checks daily for two (2) days Resident #6 nor Resident #2 had any other altercations with each other .There were no bruises on either resident. Per the report, Resident #6 was sent out to the medical center on 06/13/2022 and returned the same day, with a new diagnosis of urinary tract infection (UTI) and receipt of an antibiotic injection. In addition, Resident #6 was seen by Geri-psych and has responded well to the new orders received. A stop sign was placed across the doorway to Resident #2's room. In addition, as a precautionary measure, education regarding abuse prevention in regard to the resident to resident has been completed and ongoing. Record review for the two residents involved included the following: a. Review of Resident #2's hard copy Admission Record revealed the resident was admitted on [DATE] with diagnoses including Dementia with Behavioral Disturbance and Anxiety Disorder. Review of the most recent MDS prior to the 06/13/2022 incident revealed a quarterly MDS with an ARD of 04/05/2022. Per this MDS, Resident #2 was severely cognitively impaired, based on a BIMS score of three (3) out of fifteen (15), and had no behaviors or wandering during the seven-day assessment period. Review of Resident #2's comprehensive care plan revealed that a plan for behaviors was in place since 04/03/2021, with an additional plan related to verbal behaviors initiated on 02/02/2022, Further review of Resident #2's medical records revealed that in response to Resident #2's allegation that he/she was hit, the facility obtained medical imaging. Review of the Radiology Report, dated 06/13/2022 revealed that there was no pelvic or hip fracture. b. Review of Resident #6's hard copy Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with Late Onset, Dementia with Behavioral Disturbance, Anxiety Disorder, and Cerebral Infarction. Review of Resident #6's most recent MDS prior to the 06/13/2022 incident, revealed an admission MDS with an ARD of 05/16/2022. Per this MDS, the resident was severely cognitively impaired, based on a BIMS score of three (3), wandered one (1) to three (3) days of the seven (7) day assessment period, and required supervision for transfers, walking in the room and the corridor, and locomotion on and off the unit. Review of Resident #6's comprehensive care plan, initiated on 05/09/2022, revealed the resident was care planned for the potential wandering behaviors, as well as exit seeking from admission on 05/09/2022. In addition, the problem of physical behaviors was added to the care plan on 05/15/2022, the day that Resident #6 slapped Resident #7. (See finding #3.) Further review of Resident #6's closed medical record revealed the resid [TRUNCATED]

Based on interview, record review, facility policy review, facility work order form review, review of Law Incident Print Out, and review of Emergency Medical System Note, it was determined the facility failed to revise a care plan with individual interventions, for one (1) of three (3) sampled residents (Resident #1). On the evening of 04/15/19, Resident #1 exited the facility, without staff knowledge, through a window that was propped open with a picture frame, pushed the screen from the window, and climbed a (6) six foot privacy fence. The resident was located by local law enforcement in a residential neighborhood two (2) blocks away. Review of the resident's 04/02/19 care plan meeting notes revealed the resident's behaviors were discussed, which included trying to take the windows apart. Review of Work Orders, dated 04/10/19 and 04/11/19, revealed the screen was partially out and the window was propped up with a picture in one (1) room; and, in Resident #1's room, one (1) screen was out of the window and another screen was torn. Additionally, on 04/14/19, Resident #1 lifted a window and pushed the screen from the window in the dining room, and attempted to exit through the window. However, the facility failed to revise the care plan to include interventions related to Resident #1 tampering with the windows and screens; and attempting to exit through the window. The facility's failure to revise the resident's care plan related to wandering/exit seeking behavior has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/25/19. The facility was notified of the Immediate Jeopardy on 04/25/19. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on 05/01/19 alleging the Immediate Jeopardy was removed on 04/26/19. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/26/19, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed the facility must develop and implement a baseline centered care plan within forty-eight (48) hours for each resident that includes the instruction needed to provide effective and person-centered care that meets professional standards of quality care. A comprehensive, individualized care plan will be developed within seven (7) days after completion of the comprehensive assessments that includes measurable objectives and timetables to meet patient's (resident's) medical, nursing, nutrition, mental, and psychosocial needs that are identified in the comprehensive assessments. The care plan must be customized to each individual resident's preferences and needs, and care plan meetings will be documented by use of the care plan meeting notes. Review of the facility's policy titled, Wandering, last revised 04/02/18, revealed wandering behavioral symptoms will be documented on the Behavior Monitoring and Interventions Flow Record and will be reviewed to determine triggers associated with the behavior and effectiveness of non-pharmological interventions. Behavioral symptoms will be addressed in the care plan. Review of the facility's policy titled, Elopement of Resident, last revised 05/15/14, revealed residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Further review of the policy revealed an elopement care plan will be developed with individual risk factors, and patterns will be identified and addressed within the care plan. Staff witnessing an identified elopement risk resident attempting to leave the center will intervene and prevent elopement. Record review revealed the facility admitted Resident #1 on 03/29/19, with [DIAGNOSES REDACTED]. Review of Resident #1's Initial Nursing Assessment, dated 03/29/19, revealed the facility assessed the resident to have the following behaviors: anxiety, agitation/restlessness, verbalizing/history of a desire to leave/exit seeking. In addition, review of Resident #1's Kardex, dated 03/29/19, revealed Resident #1 had a problem with short and long term memory and behavior of wandering. Review of Resident #1's Elopement Evaluation, dated 04/01/19, revealed the resident had a history of [REDACTED]. Additionally, the Elopement Evaluation revealed Resident #1 exhibited behaviors as hovered near exits, frustration, impulsiveness, restlessness and/or agitation, and boredom. Review of Care Plan Meeting Notes, dated 04/02/19 at 10:00 AM, revealed Resident #1 taking windows apart was discussed. Review of Resident#1's Comprehensive Care Plan, dated 04/03/19, revealed interventions to be alert to any conditions that may contribute to elopement behavior, including wandering, psychiatric disorder, cognitive loss/dementia,[MEDICAL CONDITION](stroke), [MEDICAL CONDITION], delusions, hallucinations, [MEDICAL CONDITION], TBI, pain or medication/alcohol withdrawal; be alert to medications for side effects that potentially contribute to elopement; personalize resident's room and shadow box with familiar items; listen to resident and try to calm, offer pen and paper for resident to write feelings down; approach resident in a calm, unhurried manner when exhibiting exit-seeking behavior; reassure as necessary; resident will wonder and worry about spouse-provide empathy, encourage and reassurance that spouse is okay. However, there were no interventions to address the resident taking windows apart. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require limited assistance with activities of daily living (ADL's) except for bathing/hygiene, which required extensive to total assistance and he/she had no wandering behaviors. Review of Work Order forms, dated 04/10/19, revealed a screen was partially pushed out, the window was propped up with a picture in a room; and on 04/11/19, one (1) screen was out and one (1) screen was torn in Resident #1's room. Review of Resident #1's (MONTH) 2019 Behavior Monitoring and Interventions Form, revealed constant exit seeking behaviors on 04/11/19, 04/13/19, and 04/14/19 that remained unchanged with redirection and familiarization with surroundings. Additionally, Progress Notes, dated 04/14/19 at 8:22 AM, revealed Resident #1 attempted elopement through the window and had removed the screen. Review of the Progress Note, dated 04/14/19 at 1:01 PM, revealed Resident #1 wandered the halls. However, review of Resident#1's Care Plan, revised 04/14-15/19, for Resident/Patient was at risk for elopement revealed no interventions for increased supervision were placed related to Resident #1 tampering with windows or screens and attempting to elope through a window. Review of the Law Incident Printout and time line notes, dated 04/15/19 at 7:25 PM revealed a call was received at 6:42 PM of a suspicious person in neighborhood and officers were on scene at 7:03 PM. Further review revealed at 7:18 PM identification was made that Resident #1 had walked away from local facility, with deputy transporting Resident #1 to facility at 7:23 PM. Review of 04/15/19 at 6:46 PM through 04/16/19 at 4:09 AM Progress Notes revealed Resident #1 had a change in condition, exit seeking, and was able to get out of the facility on 04/15/19 at night with orders to send to Emergency Department for evaluation. Review of the 04/15/19 at 7:25 PM Progress Notes revealed the facility performed a skin check with scratches noted to bilateral upper extremities (BUE) and (RLE) right lower extremities (RLE). Review of Progress Notes dated 04/15/19, at 9:34 PM revealed Resident #1 with unplanned transfer and 04/16/19 at 4:09 Progress Note revealed Resident #1 returned back to facility from ED per EMS. Review of (EMS) Emergency Medical Services Note dated 04/15/19 at 9:39 PM revealed Resident #1 had eloped from the facility and needed evaluation. Resident had opened a window earlier in the night, climbed out, and jumped three (3) separate fences and was wandering around before police department found resident and returned him/her to the facility. Nurse states that resident had to be evaluated because of wandering for about an hour, has a history of drug/alcohol issues, and multiple abrasions to arms. Interview, on 04/25/19 at 12:18 PM, with Licensed Practical Nurse (LPN) #4 revealed Resident #1 had been trying to take the windows out in his/her room before; however, she had caught the resident and put them back in (windows and screens). LPN #4 additionally stated this had happened about a week before the resident eloped. LPN #4 stated she did not think the resident could get out of the window, and the resident had told her he/she wasn't trying to escape. The LPN stated she had reported this information. LPN #4 further stated she did not think any interventions were added to the care plan to address these behaviors. Interview, on 04/25/19 at 11:45 AM, with LPN #3 revealed no interventions were placed on Resident #1's care plan the night the screens were removed in Resident #1's room. Interview, on 04/21/19 at 2:48 PM, and 04/25/19 at 11:49 AM, with Registered Nurse (RN) #4 revealed, on 04/14/19 at approximately 8:20 AM in the dining room, Resident #1 had opened the window, removed the screen in the dining room and been discovered by the Activity Aide. RN #4 stated she had to go outside to place the screen back in the window after the resident had pushed it out. Additionally, RN #4 stated the MDS Coordinator usually did the care plans. She stated the nurse would just do the admission care plans. RN #4 stated she was not aware of any interventions in place for Resident #1 related to the windows/screens. Interview, on 04/23/19 at 5:00 PM, with RN #2 revealed she was aware that Resident #1 had opened a window in the dining room on 04/14/19 and had tampered with the windows in his/her room and attempted to open the windows. RN #2 further stated she was aware of the resident's exit seeking behaviors; however, the facility was not a 1:1 supervision facility. Additionally, RN #2 stated that nurses do admission care plans, they can add to the care plans and the MDS Coordinator followed up on them. RN #2 stated if a resident didn't have a care plan, she would create a care plan and add interventions. She stated if there was already a care plan, they would review and revise it, if needed. Interview, on 04/24/19 at 2:03 PM, with the MDS Coordinator revealed she could not remember accurately what happened with Resident #1, just something about a window. She stated she completed the comprehensive care plans, and the initial care plan, and if there was an order, the nurse would add it on the care plans. Interview, on 04/24/19 at 3:02 PM, with the Director of Nursing (DON) revealed everyone updated the care plans according to their section; however, if she noted something that needed to be updated on the section, she would put it on the care plan. Further interview revealed she did not know if there were interventions addressing the resident's exit seeking behaviors, prior to the elopement. The DON stated that Resident #1 had not actually eloped from the building and it was more of a behavior issue. Additionally, the DON stated when they further discussed RN #4's Progress Note, dated 04/14/19 at 8:22 AM, in the morning clinical meeting concerning Resident #1's incident in the dining room, was when she became aware that the resident had opened the window and kicked out the screen. During further interview, the DON stated she was told the resident had taken the window apart, but he/she had not gotten out of the building. Interview, on 04/18/19 at 4:05 PM, and 04/23/19 at 10:36 AM, with the Administrator revealed she felt their systems and facility safeguards were/are in place, and the resident had constantly said he/she wanted to go home. She stated, the resident is just so tiny is the problem. Additionally, the Administrator stated they had followed their policies to a T. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Social Services Director (SSD) completed audit of Behavior Monitoring sheets on 04/16/19 to ensure no other resident had similar behaviors (exit seeking through windows) 2. On 04/16/19 all windows were checked by Maintenance Director to ensure safeguards were in place. 3. Elopement drills were initiated on 04/16/19 to be completed every shift times (x) seven (7) days, then two (2) shifts per day x seven (7) days; then one (1) shift a day x fourteen (14) days, then three (3) times a week for sixty (60) days, then one (1) time a week x thirty (30) days, then two (2) times a month for (60) sixty days by Center Executive Director (CED), Center Nursing Executive (CNE), or Assistant Director of Nursing (ADON). 4. Corporate Medical Director briefed on elopement event by CED on 04/15/19 at 9:15 PM 5. CED spoke with Resident #1's spouse on 04/16/19 regarding his/her conversation with Resident #1 prior to elopement. 6. On 04/16/19, CED, CNE, Corporate Medical Director, and Personal Care Physician (PCP) discussed Resident #1's status and elopement event with new medication ordered given. 7. On 04/16/19, Resident #1's PCP at facility to assess Resident #1 further with progress note written. 8. On 04/16/19, 04/19/19, and 04/23/19, a Brief Interview Mental Status (BIMS) of Resident #1 done by SSD with a BIMS score ranging from eleven (11) to twelve (12) signifying moderate cognitive impairment. 9. On 04/15/19, re-education of CED, CNE, and ADON by Clinical Quality Specialist (CQS) on elopement policy. A post-test to validate learning completed with each employee scoring 100%. 10. On 04/15/19-04/19/19, re-education of all staff on elopement policy and procedure by CED, CNE, and/or ADON. Any staff not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 11. On 04/15/19, re-education of CED, CNE, and ADON was completed by CQS regarding significant behaviors specifically related to exit seeking and appropriate interventions. 12. On 04/15/19-04/19/19, re-education of licensed nurses regarding significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying administration was initiated by CED, CNE, and/or ADON. Any nurse not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 13. On 04/19/19, two (2) inch window locks were installed by the Maintenance Director on all windows in resident care areas that prohibit window from opening more that (4) four inches. 14. On 04/19/19, elopement evaluations were completed by CNE on 58 of 58 residents. 15. On 04/19/19, Secure Window Check Sheet (SWCS) to be completed every shift by CED, CNE, ADON, or nurse. 16. On 04/23/19, it was identified by Maintenance Director that a work order on 04/10/19 was written for a window screen partially pushed out in room [ROOM NUMBER] and a work order on 04/11/19 was written for (1) one window screen being out and (1) one window screen being torn in room [ROOM NUMBER]. On, 04/23/19, all work orders from 01/01/19 through present (04/23/19) were reviewed for any work orders related to window screens by the Maintenance Director with no additional findings. 17. On 04/23/19, Maintenance Director was re-educated by CED regarding work orders that pertained to window screens and required notification of CED or CNE upon discovery of work order. 18. Beginning 04/23/19, CED or CNE will monitor work orders on a daily basis with recorded findings notated on a work order monitoring log audit form. 19. On 04/25/19, all residents Behavior Observation Profile (BOP) sheets (59 of 59 residents) were reviewed for exit seeking behaviors by CED or CNE with no additional exit seeking behavior findings. 20. On 04/25/19, all residents care plans were reviewed by CED or CNE for exit seeking behaviors and to ensure appropriate interventions were in place with no additional corrective action required. 21. On 04/25/19, re-education of the CED, CNE, and ADON was provided by the Clinical Quality Specialist (CQS) regarding updating residents care plans to represent behaviors and interventions. A post test was given to validate learning with a score of 100% required. 22. On 04/25/19, ADON re-educated all nurses regarding updating care plans to represent behaviors and interventions. A post test was given to validate learning with a score of 100% required. Any nurse not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 23. On 04/25/19, the BOP sheets and nurses notes will be audited for exit seeking behaviors and to determine if appropriate interventions are in place by the CNE or ADON daily for two (2) weeks, then five (5) days a week two (2) weeks, three (3) days a week for four (4) weeks, then two (2) days a week for eight (8) weeks, then one (1) day a week for eight (8) weeks. 24. On 04/25/19, any resident whose BOP sheet or Nurses Note shows exit seeking behavior will have his/her care plan audited to ensure appropriate interventions by CNE or ADON daily two (2) weeks, then five (5) days a week for two (2) weeks, then three (3) days a week for four (4) weeks, then two (2) days a week for eight (8) weeks, then (1) one day a week for (8) eight weeks. 25. On 04/25/19, Resident #1 remains on 1:1 supervision. 26. Quality Assurance Performance Improvement (QAPI) meeting was held on 04/16/19 to discuss the action plan including audits, re education, and compliance monitors. In attendance was: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Regional Medical Director (RMD), Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. 27. On 04/17/19, Safety Committee meeting was held with following members in attendance: CED, CNE, ADON, HR, FSD, HIM, Program Director, HM, BOM, CRS, AD, DoR, and Maintenance Director. The Safety Committee reviewed the process of purchasing and implementing (2) two inch window locks. 28. Audits to include elopement drills, SWCS, work order monitoring tool, Behavior Observation Profile (BOP) sheets for exit seeking behaviors, Nurses Notes for exit seeking behaviors, and Care Plan updates will be reviewed by CED, CNE, and ADON daily with corrective action upon discovery. 29. Trends from the elopement drills, SWCS, work order audits, BOP sheets and Nurses Notes audits, to include care plan audits for appropriate interventions will be identified and provided to the QAPI committee for review monthly times (6) six months and any additional follow-up and or inservicing until the issue is resolved and ongoing as determined by the QAPI committee. QAPI Committee members consist of: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. **The State Survey Agency validated the corrective actions implemented by the facility as follows: 1. Interview on 05/02/19 at 12:03 PM with SSD revealed she completed audit of the Behavior Monitoring Sheets to ensure no other resident had similar behaviors (exit seeking through window) on 04/16/19 at approximately 9:25 AM. 2. Interview on 05/02/19 at 6:04 PM with Maintenance Director revealed he had completed a walk around outside facility to ensure that no other windows had problems on 04/16/19 and all safeguards were in place. 3. Review of elopement drill documentation revealed the drills were initiated on 04/16/19 and were completed every shift through 05/02/19. 4. Interview on 05/02/19 at 16:38 PM with Resident #1's PCP/Medical Director revealed he had been notified of the elopement of Resident #1 on 04/15/19. Additionally, the PCP/Medical Director stated Medical Director for the Corporation came and met with him about the elopement and physically examined Resident #1 and discussed outcome with DON and other Administrative staff. 5. Attestation of CED discussion with Resident #1's spouse on 04/16/19 at 4:30 PM revealed a conversation with spouse was conducted about him/her being in a halfway house and the spouse had notified Resident #1 of this before the elopement. 6. Interview at 12:40 PM on 5/02/19 with CNE revealed a QAPI meeting with corporate was held on 04/16/19 with Medical Director, PCP, CNE, CED and a medication change was completed. 7. Interview on 05/02/19 at 4:38 PM with PCP/Medical Director of Resident #1 revealed he had been notified of the elopement of Resident #1 on 04/15/19. He stated the Corporation came and met with him about the elopement and he physically examined Resident #1 and discussed the findings with the DON and other Administrative staff. Review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. 8. Interview on 05/02/19 at 12:03 PM with SSD revealed she had assessed the resident's BIMS several times upon his/her return to the facility after the elopement. 9. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated on the elopement policy by CQS and had a passing score of 100%. Review of a signature sheet, dated 04/15/19, education materials and post-tests revealed the described education and post test were provided to the CNE, CED, and ADON. 10. Review of signature page dated 04/25/19 revealed nursing staff was educated on elopement policy and procedure and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on elopement policy and procedures and stated they had to take a post test and pass with a score of 100%. In addition, interviews on 05/02/19 with Certified Nursing Assistant (CNA) #1 at 2:00 PM, CNA #2, CNA #13, Certified Medication Technician (CMT) #1, Cook #2, and Activities Aide #2 at 2:19 PM revealed they were educated on elopement procedures/policy and elopement drills and completed a post test with 100% accuracy. Interview on 05/02/19 at 2:20 PM with the CED revealed no one would be allowed to work on the floor until they had been educated and that included new staff. 11. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated by the CQS about significant resident behaviors specifically related to exit seeking and appropriate interventions and had to take a post test and score 100%. 12. Review of signature page dated 04/15-19/19 revealed nursing staff was educated on significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying the administration and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying the administration and stated they had to take a post test and pass with a score of 100%. Interview on 05/02/19 at 2:20 PM with the CED revealed no one would be allowed to work on the floor until they had been educated and that included new staff. 13. Interview on 05/02/19 at 6:04 PM with Maintenance Director revealed he placed two (2) inch window/door locks to all windows in resident care areas on 04/19/19. Observations on 05/02/19 revealed window/door locks on resident care area windows. 14. Interview, on 05/02/19 at 12:34 PM and 5:35 PM with the CNE; and on 05/02/19 at 5:45 PM with the CED, revealed audits of elopement evaluations, were conducted and were kept in the elopement binder. Review of the elopement binder revealed a list of residents at risk for elopement. 15. Review of SWCS dated 04/19/19 through 05/02/19 revealed windows were checked every shift. Interviews with RN #2 on 05/02/19 at 1:45 PM revealed the nurses do the window checks every shift on the windows, fill out SWCS, and turn in to Administrative staff at end of shift. 16. Review of work orders dated 04/10/19 and 04/11/19 revealed the work orders were for windows propped with picture frame, and for windows with screens out. Interview with Maintenance Director on 05/02/19 at 6:04 PM revealed the work orders for the windows were dated 04/10/19 and 04/11/19 and they were fixed on 04/15/19 in the morning hours. He stated work orders dated 01/01/19 -04/23/19 were reviewed. He stated there had been no more work orders related to screens torn or out since the review. 17. Interview with Maintenance Director on 05/02/19 at 6:04 PM revealed he was educated on elopement, 1:1 sitting supervision, keeping the doors open during elopement drills, window audits, screen audits, work order audits, and to notify the CED or CNE when he gets work orders related to screens or windows. The Maintenance Director stated he was given a test and passed test with the required 100% passing score. 18. Review of work order monitoring log revealed work orders were reviewed daily from 04/22/19 through 05/02/19. Interviews on 05/02/19 with CED at 5:35 PM, CNE at 5:44 PM, and ADON at 6:03 PM revealed audits were completed daily. 19. Interview on 05/02/19 at 5:35 PM with CNE revealed all resident BOP sheets were reviewed for exit seeking behaviors with no additional exit seeking behaviors identified. 20. Interviews on 05/02/19 with CED at 5:45 PM and the CEN at 5:35 PM, revealed all resident care plans were audited for exit seeking behaviors to ensure appropriate interventions were in place with no concerns identified. 21. Review of a signature sheet, dated 04/25/19, education materials and post-tests revealed the CNE, CED, and ADON were educated on updating resident care plans to represent behaviors and interventions and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated on updating the care plan to represent behaviors and interventions by the CQS and had to have a passing score of 100% on the post test. 22. Review of signature page dated 04/25/19 revealed licensed nurses were educated on updating resident care plans to represent behaviors and interventions and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse (RN) #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on updating care plans related to behaviors and interventions and stated they had to take a post test and pass with a score of 100%. 23. Interview on 05/02/19 with CEN at 5:45 PM revealed she was auditing the BOP sheets and nurses notes for exit seeking behavior. 24. Interview on 05/02/19 with CEN at 5:45 PM revealed any residents identified as having exit seeking behavior will have there care plans audited to ensure appropriate interventions are in place. 25. Observation on 05/02/19 at 1:30 PM, 2:00 PM and 2:18 PM revealed Resident #1 was on 1:1 supervision. Interviews on 05/02/19 with Cook #2 at 2:19 PM, CMT #1 at 2:20 PM, RN #2 at 1:30 PM, RN #1 at 1:45 PM, and LPN #3 at 4:25 PM revealed Resident #1 was still on 1:1 supervision. 26. Review of QAPI sign in sheet dated 04/16/19 revealed the following staff attended the meeting: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Regional Medical Director (RMD), Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. Further review revealed they discussed the action plan including audits, re-education, and compliance monitors. Interview with CNE on 05/02/19 at 12:40 PM revealed a QAPI meeting was held with corporate, the Medical Director, PCP, CNE, and CED after Resident #1 eloped from the facility. 27. Review of Safety Committee attendance meeting dated 04/17/19 revealed the CED, CNE, ADON, HR, FSD, HIM, Program Director, HM, BOM, CRS, AD, DoR, and Maintenance Director met to discuss purchase and implementation of (2) two inch window locks. Interview on 05/02/19 at 6:04 PM with the Maintenance Director revealed the safety committee meets once a month and discusses the P[NAME] and audits, and looks at ways to prevent this from happening again. He stated it was how the facility came up with the 2 window locks. 28. Interviews on 05/02/19 with the CED at 5:35 PM, CNE at 5:44 PM, and ADON at 6:03 PM revealed they reviewed the elopement drills, secure window check sheets, work order monitoring tool, BOPs and Nursing Notes for exit seeking behaviors, with Care plans updated daily.

Based on interview, record review, review of the hospital Emergency Department (ED) record, Emergency Medical Services (EMS) record, and the facility's policy, it was determined the facility failed to provide adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #1). On 04/02/19, a care plan meeting was held due to Resident #1 trying to take windows apart. On 04/10/19 and 04/11/19, work orders were placed due to screens being partially pushed out in room [ROOM NUMBER]; a window propped up by a picture frame; a screen out of a window in room [ROOM NUMBER]; and, a torn screen. In addition, on 04/14/19, Resident #1 lifted a window and pushed the window screen from the window in the dining room; and, on 04/14/19 at 8:22 AM, Resident #1 attempted to elope/exit from the facility through a window, where the screen had been removed. However, the facility failed to ensure increased supervision was put in place to address the resident's tampering with the windows/screens, and attempting to exit the facility. On 04/15/19, Resident #1 propped a window open with a picture frame, pushed the screen from the window, climbed a (6) six foot privacy fence, and eloped/exited the facility, without staff knowledge. The resident was located in a residential neighborhood two (2) blocks away (approximately 0.22 miles) by local law enforcement after they had been notified of someone looking for a halfway house in the neighborhood. The facility's failure to provide adequate supervision related to wandering/exit seeking behavior has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/25/19 and the facility was notified of the Immediate Jeopardy on 04/25/19. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on 05/02/19 alleging the Immediate Jeopardy was removed on 04/26/19. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/26/19, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Accidents/Incidents, last revised 11/28/16, revealed if staff discovered a situation that posed an immediate threat to safety or security they would secure the area to prevent an incident or further incidents from occurring. A follow-up/investigation would be conducted to ascertain the cause of the accident/incident and initiate actions to prevent further accidents/incidents. Review of the facility's policy titled, Wandering, with a revision date of 04/02/18, revealed wandering behavioral symptoms would be documented on the Behavior Monitoring and Interventions Flow Record. Behavioral symptoms would be addressed in the care plan. Review of the facility's policy titled, Elopement of Resident, last revised 05/15/14 revealed residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. In addition, an elopement care plan will be developed with individual risk factors, patterns will be identified and addressed within the care plan. Record review revealed the facility admitted Resident #1 on 03/29/19, with [DIAGNOSES REDACTED]. Review of an Initial Nursing assessment dated [DATE], revealed Resident #1 had behaviors of agitation/restlessness, anxiety, and verbalizing/history of a desire to leave/exit seeking. Review of Resident #1's Admission Kardex dated 03/29/19, revealed Resident #1 exhibited behaviors of wandering. In addition, review of Resident #1's Elopement Assessment, dated 04/01/19 revealed a history of actual elopement or attempted elopement; wandering that placed the resident at significant risk of getting to a potentially dangerous place; and, wandering that significantly intruded on the privacy and/or activity of others. Further review of the assessment revealed the resident had expressed the desire to leave/attempted to pack belongings; and, had behaviors of boredom, hovering near exits, frustration, impulsiveness, restlessness, and agitation. However, review of the 04/05/19 Admission Minimum Data Set (MDS) revealed the facility assessed the resident had no behaviors of wandering during the seven (7) day look back period (03/29/19-04/05/19). Review of Care Plan Meeting Note dated 04/02/19 at 10:00 AM revealed there was a discussion of Resident #1 taking windows apart. Review of Resident#1's Comprehensive Care Plan dated 04/03/19 revealed Resident #1 was at risk for elopement related to Cognitive Loss/Dementia; and, the resident sits by the door in the entry. Further review of the care plan revealed interventions included to be alert to any conditions that may contribute to elopement behavior, including wandering; be alert to medications for side effects that potentially contribute to elopement; and, approach resident in a calm, unhurried manner when exhibiting exit-seeking behavior. Further review of the Admission MDS assessment, dated 04/05/19 revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident was interviewable. In addition, the MDS assessment revealed the facility assessed the resident required limited assistance with transferring, bed mobility, walking in and out of room, locomotion on/off the unit and activities of daily living (ADL's). Review of Work Order forms revealed a screen was partially pushed out/window propped up with a picture in a room on 04/10/19 in room [ROOM NUMBER]; and one (1) screen was out and one (1) screen was torn in Resident #1's room on 04/11/19 (room [ROOM NUMBER]). Review of Resident #1's Behavior Monitoring and Interventions Form for (MONTH) 2019 revealed the resident was having constant, continually exit seeking behaviors on 04/11/19, 04/13/19 and 04/14/19 that remained unchanged with redirection. Additionally, review of Nursing Progress Notes revealed Resident #1 attempted to elope through window/removed screen on 04/14/19 at 8:22 AM, and Resident #1 was wandering halls on 04/14/19 at 1:13 PM. However, record review revealed no documented evidence the facility provided closer monitoring or increased supervision related to this identified behavior. Interview on 04/21/19 at 2:48 PM and on 04/25/19 at 11:49 AM with Registered Nurse (RN) #4 revealed on 04/14/19 at approximately 8:20 AM in the dining room, Resident #1 had opened the window, removed the screen in the dining room and been discovered by the activity aide. RN #4 stated she had to go outside to place the screen back in the window after the resident pushed it out. RN #4 stated she was not aware of any interventions added for Resident #1 related to removing the windows/screens. Review of 04/15/19 at 6:46 PM Progress Notes revealed Resident #1 was able to get out of the facility. Review of the 04/15/19 at 7:25 PM Progress Notes revealed the facility performed a skin check with scratches noted to bilateral upper extremities (BUE) and (RLE) right lower extremities (RLE). Review of Progress Notes dated 04/15/19, at 9:34 PM revealed Resident #1 with unplanned transfer and 04/16/19 at 4:09 Progress Note revealed Resident #1 returned back to facility from ED per EMS. Review of the Law Incident Printout and time line notes, dated 04/15/19 at 7:25 PM revealed a call was received at 6:42 PM of a suspicious person in neighborhood and officers were on scene at 7:03 PM. Further review revealed at 7:18 PM identification was made that Resident #1 had walked away from local facility, with deputy transporting Resident #1 to facility at 7:23 PM. Interview on 04/20/19 at 4:58 PM with local law enforcement (deputy) revealed they had received a call at 6:42 PM that Resident #1 was about 0.50-0.75 miles from facility in a neighborhood. He stated Resident #1 was confused and unsure of his/her location and upon deputy discovering facility paperwork in pocket he/she was determined to be a missing resident from local facility. He revealed he returned Resident #1 to facility making contact with Administrator concerning the JC-3 form because resident had made it so far from facility and was on prescription medications. Deputy stated he did not know if anyone at the facility had been looking for resident but he had received a call that an older gentleman/lady had showed up at a house looking for a halfway house and the homeowner had called local law enforcement. He stated he arrived with Resident #1 at the facility at approximately 7:25 PM. Review of JC-3 Form titled, Commonwealth of Kentucky Child Abuse, Adult Abuse, and Domestic Abuse Standard Report and narrative, dated 04/15/19 at 7:04 PM revealed officer responded to facility in reference to a missing person, with Resident #1 having left location approximately 5:30 PM-6:50 PM and health complication of Dementia. Upon arrival at facility the officer was informed Resident #1 had been located in a neighborhood after local enforcement had been notified of a suspicious person in the neighborhood. Officer was notified Resident #1 had left through window and a damaged screen was inside bedroom. Officer stated in narrative that the report was made due to the time delay in notifying police of Resident #1 missing, health complications, visible injuries and Resident #1 giving law enforcement false identifying information upon contact. Interview with Officer #1 on 04/20/19 at 5:19 PM revealed he had received a call from the facility about 7:00 PM related to a report of Resident #1 missing between 5:30 PM and 6:50 PM with the resident showing up at the facility not long after his arrival at the facility. Review of EMS Note dated 04/15/19 at 9:39 PM revealed Resident #1 had eloped from the facility and needed evaluation. Resident had opened a window earlier in the night, climbed out, and jumped three (3) separate fences and was wandering around before police department found resident and returned him/her to the facility. Nurse states that resident had to be evaluated because of wandering for about an hour, has a history of drug/alcohol issues, and multiple abrasions to arms. According to AccuWeather and TimeandDate.com, the climate and temperature was: 59 high/43 low degrees Fahrenheit and clear with humidity at 65%. Wind was from the East at 1.243 mph on 04/15/19. Observation of Resident #1's picture provided by the facility taken after the resident's return revealed the resident was wearing a t-shirt, under a plaid long sleeve shirt; a pair of blue jeans, work boots, and a baseball cap when he/she eloped. Interview on 04/18/19 at 11:52 AM with Certified Nursing Assistant (CNA) #12 revealed on 04/15/19, Resident #1 had been noticed missing after supper when his/her tray was not touched and the last time she had seen the resident was before 5:15 PM when Resident #1 was leaving the dining room. She stated the resident was always wanting to go home, had pushed at the doors of the facility, and had been that way since admission. Interview with Registered Nurse (RN) #2 on 04/18/19 at 3:20 PM revealed she had last seen Resident #1 on 04/15/19 at approximately 5:15 PM. She stated they were looking for him/her to give his/her medication; and they noticed the window in the room open around 6:45 PM. Further interview on 04/23/19 at 5:00 PM with RN #2 revealed she was aware that Resident #1 had opened a window in the dining room on 04/14/19 and had tampered with the windows on the window side of his/her room and attempted to open windows before. RN #2 stated she was aware of exit seeking behaviors of Resident #1 and the facility was not a 1:1 supervision facility. Interview on 04/18/19 at 3:30 PM with RN #3 revealed she was going to give Resident #1 his/her 7:00 PM medications on 04/15/19 when she could not find the resident and had last seen the resident at approximately 5:30 PM. Interview on 04/18/19 at approximately 10:22 AM with Maintenance Director revealed on evening of 04/15/19, Resident #1 had kicked the screen out of the window and climbed over a (6) six foot privacy fence and was found approximately (2) two blocks from facility. Interviews on 04/18/19 with CNA #1 at 1:02 PM, CNA #2 at 1:10 PM, CNA #3 at 3:45 PM, LPN #1 at 1:24 PM, RN #1 at 1:20 PM, and RN #3 at 3:30 PM; and on 04/23/19 with CNA #7 at 1:48 PM, revealed Resident #1 had tried to go outdoors and talked about going home since admission. Interview on 04/23/19 at 2:47 PM with CNA #8 revealed Resident #1 had tried to go out a window in his/her room and the screen was out; an additional screen had been torn in another window in Resident #1's room and this had happened 2-3 days before the elopement of Resident #1. CNA #8 further stated they kept an eye on the resident but did not do 1:1 supervision and did not have the staff to do that. Interview on 04/23/19 at 2:57 PM and on 04/25/19 at 11:45 AM with LPN #3 revealed Resident #1 has wandering on his/her care plan but no interventions were placed on Resident #1's care plan the night the screens were removed in Resident #1's room. Interview on 04/25/19 at 12:18 PM with LPN #4 revealed about a week before resident eloped, Resident #1 had been trying to take windows out in his/her room, but she had caught the resident and put them back in (windows and screens). LPN #4 stated she did not think the resident could get out of the window and he/she had said that he/she was not trying to escape. She revealed she reported the incident and also placed it on the twenty-four (24) hour report. Interview on 04/24/19 at 11:00 AM with LPN #2 revealed she was aware of Resident #1 standing at double doors and having to redirect the resident when someone would enter, of Resident #1 pushing windows and pushing out screens and of a window in a room being open crooked and helping RN #4 shut it, but they did not inform anyone. LPN #2 stated they had pulled out work orders and reported them prior to the residents elopement, and the windows were being worked on. Interview, on 04/24/19 at 3:02 PM, with the Director of Nursing (DON) revealed she did not know if there were interventions addressing the resident's exit seeking behaviors, prior to the elopement. The DON stated that Resident #1 had not actually eloped from the building and it was more of a behavior issue. Interview on 04/18/19 at 11:12 AM and 4:05 PM and on 04/23/19 at 10:36 AM with Administrator revealed they had called the police and the local sheriff's department had found the resident. The Administrator stated she felt their systems and facility safeguards were/are in place, and the resident had constantly said he/she wanted to go home; the resident is just so tiny is the problem. Additionally, the Administrator stated they had followed their policies to a T. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Social Services Director (SSD) completed audit of Behavior Monitoring sheets on 04/16/19 to ensure no other resident had similar behaviors (exit seeking through windows) 2. On 04/16/19 all windows were checked by Maintenance Director to ensure safeguards were in place. 3. Elopement drills were initiated on 04/16/19 to be completed every shift times (x) seven (7) days, then two (2) shifts per day x seven (7) days; then one (1) shift a day x fourteen (14) days, then three (3) times a week for sixty (60) days, then one (1) time a week x thirty (30) days, then two (2) times a month for (60) sixty days by Center Executive Director (CED), Center Nursing Executive (CNE), or Assistant Director of Nursing (ADON). 4. Corporate Medical Director briefed on elopement event by CED on 04/15/19 at 9:15 PM 5. CED spoke with Resident #1's spouse on 04/16/19 regarding his/her conversation with Resident #1 prior to elopement. 6. On 04/16/19, CED, CNE, Corporate Medical Director, and Personal Care Physician (PCP) discussed Resident #1's status and elopement event with new medication ordered given. 7. On 04/16/19, Resident #1's PCP at facility to assess Resident #1 further with progress note written. 8. On 04/16/19, 04/19/19, and 04/23/19, a Brief Interview Mental Status (BIMS) of Resident #1 done by SSD with a BIMS score ranging from eleven (11) to twelve (12) signifying moderate cognitive impairment. 9. On 04/15/19, re-education of CED, CNE, and ADON by Clinical Quality Specialist (CQS) on elopement policy. A post-test to validate learning completed with each employee scoring 100%. 10. On 04/15/19-04/19/19, re-education of all staff on elopement policy and procedure by CED, CNE, and/or ADON. Any staff not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 11. On 04/15/19, re-education of CED, CNE, and ADON was completed by CQS regarding significant behaviors specifically related to exit seeking and appropriate interventions. 12. On 04/15/19-04/19/19, re-education of licensed nurses regarding significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying administration was initiated by CED, CNE, and/or ADON. Any nurse not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 13. On 04/19/19, two (2) inch window locks were installed by the Maintenance Director on all windows in resident care areas that prohibit window from opening more that (4) four inches. 14. On 04/19/19, elopement evaluations were completed by CNE on 58 of 58 residents. 15. On 04/19/19, Secure Window Check Sheet (SWCS) to be completed every shift by CED, CNE, ADON, or nurse. 16. On 04/23/19, it was identified by Maintenance Director that a work order on 04/10/19 was written for a window screen partially pushed out in room [ROOM NUMBER] and a work order on 04/11/19 was written for (1) one window screen being out and (1) one window screen being torn in room [ROOM NUMBER]. On, 04/23/19, all work orders from 01/01/19 through present (04/23/19) were reviewed for any work orders related to window screens by the Maintenance Director with no additional findings. 17. On 04/23/19, Maintenance Director was re-educated by CED regarding work orders that pertained to window screens and required notification of CED or CNE upon discovery of work order. 18. Beginning 04/23/19, CED or CNE will monitor work orders on a daily basis with recorded findings notated on a work order monitoring log audit form. 19. On 04/25/19, all residents Behavior Observation Profile (BOP) sheets (59 of 59 residents) were reviewed for exit seeking behaviors by CED or CNE with no additional exit seeking behavior findings. 20. On 04/25/19, all residents care plans were reviewed by CED or CNE for exit seeking behaviors and to ensure appropriate interventions were in place with no additional corrective action required. 21. On 04/25/19, re-education of the CED, CNE, and ADON was provided by the Clinical Quality Specialist (CQS) regarding updating residents care plans to represent behaviors and interventions. A post test was given to validate learning with a score of 100% required. 22. On 04/25/19, ADON re-educated all nurses regarding updating care plans to represent behaviors and interventions. A post test was given to validate learning with a score of 100% required. Any nurse not available for education and post test are required to complete mandatory re-education and post test upon day of return to work before providing care. New staff hired will complete education and post test during orientation. 23. On 04/25/19, the BOP sheets and nurses notes will be audited for exit seeking behaviors and to determine if appropriate interventions are in place by the CNE or ADON daily for two (2) weeks, then five (5) days a week two (2) weeks, three (3) days a week for four (4) weeks, then two (2) days a week for eight (8) weeks, then one (1) day a week for eight (8) weeks. 24. On 04/25/19, any resident whose BOP sheet or Nurses Note shows exit seeking behavior will have his/her care plan audited to ensure appropriate interventions by CNE or ADON daily two (2) weeks, then five (5) days a week for two (2) weeks, then three (3) days a week for four (4) weeks, then two (2) days a week for eight (8) weeks, then (1) one day a week for (8) eight weeks. 25. On 04/25/19, Resident #1 remains on 1:1 supervision. 26. Quality Assurance Performance Improvement (QAPI) meeting was held on 04/16/19 to discuss the action plan including audits, re education, and compliance monitors. In attendance was: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Regional Medical Director (RMD), Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. 27. On 04/17/19, Safety Committee meeting was held with following members in attendance: CED, CNE, ADON, HR, FSD, HIM, Program Director, HM, BOM, CRS, AD, DoR, and Maintenance Director. The Safety Committee reviewed the process of purchasing and implementing (2) two inch window locks. 28. Audits to include elopement drills, SWCS, work order monitoring tool, Behavior Observation Profile (BOP) sheets for exit seeking behaviors, Nurses Notes for exit seeking behaviors, and Care Plan updates will be reviewed by CED, CNE, and ADON daily with corrective action upon discovery. 29. Trends from the elopement drills, SWCS, work order audits, BOP sheets and Nurses Notes audits, to include care plan audits for appropriate interventions will be identified and provided to the QAPI committee for review monthly times (6) six months and any additional follow-up and or inservicing until the issue is resolved and ongoing as determined by the QAPI committee. QAPI Committee members consist of: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. **The State Survey Agency validated the corrective actions implemented by the facility as follows: 1. Interview on 05/02/19 at 12:03 PM with SSD revealed she completed audit of the Behavior Monitoring Sheets to ensure no other resident had similar behaviors (exit seeking through window) on 04/16/19 at approximately 9:25 AM. 2. Interview on 05/02/19 at 6:04 PM with Maintenance Director revealed he had completed a walk around outside facility to ensure that no other windows had problems on 04/16/19 and all safeguards were in place. 3. Review of elopement drill documentation revealed the drills were initiated on 04/16/19 and were completed every shift through 05/02/19. 4. Interview on 05/02/19 at 16:38 PM with Resident #1's PCP/Medical Director revealed he had been notified of the elopement of Resident #1 on 04/15/19. Additionally, the PCP/Medical Director stated Medical Director for the Corporation came and met with him about the elopement and physically examined Resident #1 and discussed outcome with DON and other Administrative staff. 5. Attestation of CED discussion with Resident #1's spouse on 04/16/19 at 4:30 PM revealed a conversation with spouse was conducted about him/her being in a halfway house and the spouse had notified Resident #1 of this before the elopement. 6. Interview at 12:40 PM on 5/02/19 with CNE revealed a QAPI meeting with corporate was held on 04/16/19 with Medical Director, PCP, CNE, CED and a medication change was completed. 7. Interview on 05/02/19 at 4:38 PM with PCP/Medical Director of Resident #1 revealed he had been notified of the elopement of Resident #1 on 04/15/19. He stated the Corporation came and met with him about the elopement and he physically examined Resident #1 and discussed the findings with the DON and other Administrative staff. Review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. 8. Interview on 05/02/19 at 12:03 PM with SSD revealed she had assessed the resident's BIMS several times upon his/her return to the facility after the elopement. 9. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated on the elopement policy by CQS and had a passing score of 100%. Review of a signature sheet, dated 04/15/19, education materials and post-tests revealed the described education and post test were provided to the CNE, CED, and ADON. 10. Review of signature page dated 04/25/19 revealed nursing staff was educated on elopement policy and procedure and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on elopement policy and procedures and stated they had to take a post test and pass with a score of 100%. In addition, interviews on 05/02/19 with Certified Nursing Assistant (CNA) #1 at 2:00 PM, CNA #2, CNA #13, Certified Medication Technician (CMT) #1, Cook #2, and Activities Aide #2 at 2:19 PM revealed they were educated on elopement procedures/policy and elopement drills and completed a post test with 100% accuracy. Interview on 05/02/19 at 2:20 PM with the CED revealed no one would be allowed to work on the floor until they had been educated and that included new staff. 11. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated by the CQS about significant resident behaviors specifically related to exit seeking and appropriate interventions and had to take a post test and score 100%. 12. Review of signature page dated 04/15-19/19 revealed nursing staff was educated on significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying the administration and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on significant resident behaviors specifically related to exit seeking and appropriate interventions such as initiating 1:1 care and notifying the administration and stated they had to take a post test and pass with a score of 100%. Interview on 05/02/19 at 2:20 PM with the CED revealed no one would be allowed to work on the floor until they had been educated and that included new staff. 13. Interview on 05/02/19 at 6:04 PM with Maintenance Director revealed he placed two (2) inch window/door locks to all windows in resident care areas on 04/19/19. Observations on 05/02/19 revealed window/door locks on resident care area windows. 14. Interview, on 05/02/19 at 12:34 PM and 5:35 PM with the CNE; and on 05/02/19 at 5:45 PM with the CED, revealed audits of elopement evaluations, were conducted and were kept in the elopement binder. Review of the elopement binder revealed a list of residents at risk for elopement. 15. Review of SWCS dated 04/19/19 through 05/02/19 revealed windows were checked every shift. Interviews with RN #2 on 05/02/19 at 1:45 PM revealed the nurses do the window checks every shift on the windows, fill out SWCS, and turn in to Administrative staff at end of shift. 16. Review of work orders dated 04/10/19 and 04/11/19 revealed the work orders were for windows propped with picture frame, and for windows with screens out. Interview with Maintenance Director on 05/02/19 at 6:04 PM revealed the work orders for the windows were dated 04/10/19 and 04/11/19 and they were fixed on 04/15/19 in the morning hours. He stated work orders dated 01/01/19 -04/23/19 were reviewed. He stated there had been no more work orders related to screens torn or out since the review. 17. Interview with Maintenance Director on 05/02/19 at 6:04 PM revealed he was educated on elopement, 1:1 sitting supervision, keeping the doors open during elopement drills, window audits, screen audits, work order audits, and to notify the CED or CNE when he gets work orders related to screens or windows. The Maintenance Director stated he was given a test and passed test with the required 100% passing score. 18. Review of work order monitoring log revealed work orders were reviewed daily from 04/22/19 through 05/02/19. Interviews on 05/02/19 with CED at 5:35 PM, CNE at 5:44 PM, and ADON at 6:03 PM revealed audits were completed daily. 19. Interview on 05/02/19 at 5:35 PM with CNE revealed all resident BOP sheets were reviewed for exit seeking behaviors with no additional exit seeking behaviors identified. 20. Interviews on 05/02/19 with CED at 5:45 PM and the CEN at 5:35 PM, revealed all resident care plans were audited for exit seeking behaviors to ensure appropriate interventions were in place with no concerns identified. 21. Review of a signature sheet, dated 04/25/19, education materials and post-tests revealed the CNE, CED, and ADON were educated on updating resident care plans to represent behaviors and interventions and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with CNE at 12:56 PM, CED at 5:50 PM, and the ADON at 5:26 PM revealed they were educated on updating the care plan to represent behaviors and interventions by the CQS and had to have a passing score of 100% on the post test. 22. Review of signature page dated 04/25/19 revealed licensed nurses were educated on updating resident care plans to represent behaviors and interventions and post-tests were administered with passing scores of 100%. Interviews on 05/02/19 with Registered Nurse (RN) #2 at 1:45 PM, RN #3 at 1:30 PM, Licensed Practical Nurse (LPN) #3 at 1:59 PM, and LPN #6 at 1:59 PM revealed they had been educated on updating care plans related to behaviors and interventions and stated they had to take a post test and pass with a score of 100%. 23. Interview on 05/02/19 with CEN at 5:45 PM revealed she was auditing the BOP sheets and nurses notes for exit seeking behavior. 24. Interview on 05/02/19 with CEN at 5:45 PM revealed any residents identified as having exit seeking behavior will have there care plans audited to ensure appropriate interventions are in place. 25. Observation on 05/02/19 at 1:30 PM, 2:00 PM and 2:18 PM revealed Resident #1 was on 1:1 supervision. Interviews on 05/02/19 with Cook #2 at 2:19 PM, CMT #1 at 2:20 PM, RN #2 at 1:30 PM, RN #1 at 1:45 PM, and LPN #3 at 4:25 PM revealed Resident #1 was still on 1:1 supervision. 26. Review of QAPI sign in sheet dated 04/16/19 revealed the following staff attended the meeting: CED, CNE, Program Director, Human Resources (HR), Food Service Director (FSD), Health Information Manager (HIM), ADON, Regional Medical Director (RMD), Facility Medical Director (FMD), Housekeeping Manager (HM), Business Office Manager (BOM), Clinical Reimbursement Specialist (CRS), Admissions Director (AD), Director of Rehabilitations (DoR), and Maintenance Director. Further review revealed they discussed

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure that a resident who is incontinent of bladder and/or bowel receives appropriate treatment and services to prevent urinary tract infection and to restore as much continence as possible for six (6) of seventeen (17) sampled residents (Residents #16, #26, #42, #47, #51, and #157). Record review revealed the facility failed to complete a three-day continence management diary on admission and/or when a decline in bladder and bowel continence occurred for Residents #42, #47, and #51. Additionally, a bladder and bowel program was not implemented to restore as much bladder and bowel function as possible for Residents #42, #47, and #51 per facility policy. The findings include: Review of the facility policy titled, Continence Management, last revised [DATE], revealed a urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. Purpose: to provide appropriate treatment and services for patients with urinary incontinence to minimize urinary tract infections and restore as much normal elimination function as possible; and to provide appropriate treatment and services for patients incontinent of bowel to restore as much bowel function as possible. 1. Record review revealed the facility readmitted Resident #42 on [DATE] with [DIAGNOSES REDACTED]. Review of a Three-Day Continence Management Diary dated [DATE] revealed the diary section of the evaluation was completed and revealed the resident was incontinent only one (1) time over a three (3)-day period. All other hourly checks were coded CD, indicating the resident was clean and dry. Further review of the diary revealed the sections of the form indicating the type of incontinence, type of program, licensed staff signature, or date of the assessment was not filled in or completed per facility policy. Review of the Admission Nursing Assessment, dated [DATE], revealed Resident #42 had bowel and bladder incontinence with no toileting program. Review of the 14-Day Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and bowel and was not on a toileting program. Review of the Comprehensive Care Plan revealed Resident #42 required assistance/was dependent for Activities of Daily Living (ADL) care in . toileting, dated [DATE]. Further review of the care plan revealed there were only two (2) interventions to meet the resident's care needs: provide resident/patient with extensive assist of two for bed mobility, and provide resident/patient with extensive assist of two (2) for transfers using pivot transfers. There was no documented intervention for toileting assistance or to address incontinent status. 2. Record review revealed the facility admitted Resident #47 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE], revealed Resident #47 had bladder and bowel incontinence with no toileting program. Review of a Three-Day Continence Management Diary revealed it had the three (3)-day assessment dates filled in ([DATE], [DATE], and [DATE]), however, the hourly diary was not completed as on admission per facility policy, as the form was blank. Review of the Admission MDS assessment, dated [DATE], revealed the resident was frequently incontinent of bladder and bowel. Review of the Perspective Pay System (PPS) 60-day MDS Assessment, dated [DATE], revealed the facility assessed Resident #47's cognition as severely impaired with a BIMS score of five (5), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel and was not on a toileting program, which was a decline in continence status from the previous MDS assessment. However, further review of Resident #47's medical record revealed there was no documented evidence that a Three-Day Continence Management Diary was completed for the 60-day assessment when a decline in continence status was evident, per facility policy. Review of the Quarterly Nursing Assessment, dated [DATE], revealed Resident #47 is always incontinent of bladder and bowel with no toileting program. Review of the Comprehensive Care Plan for Resident #47 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was no documented interventions to meet the resident's toileting needs. 3. Record review revealed the facility admitted Resident #51 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE], revealed Resident #51 had bladder incontinence with no toileting program. The resident's bowel continence status was not indicated on the assessment. Review of a Three-Day Continence Management Diary revealed the three (3)-day assessment dates were filled in ([DATE], [DATE], and [DATE]), however, the hourly diary was not completed on admission per facility policy, as the form was blank. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #51's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and always continent of bowel, and there was not a toileting program initiated. Review of the Comprehensive Care Plan for Resident #51 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was no documented interventions to meet the resident's toileting needs. 4. Record review revealed the facility admitted Resident #157 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE], revealed Resident #157 had bladder and bowel incontinence with no toileting program. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #157's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and bowel and was not on a toileting program. Review of a Three-Day Continence Management Diary revealed the three (3)-day assessment dates were ([DATE], [DATE], and [DATE]). However, on [DATE], Resident #157's continence status was assessed hourly from 1:00 PM to 6:00 AM and indicated the resident was incontinent only one (1) time during that time frame, and was coded as C/D (Clean and Dry) the remainder of the times. Additionally, the hourly checks from 7:00 AM to 12:00 AM on [DATE] were not completed. Further review revealed the resident was assessed to be clean and dry only three (3) times on [DATE], at 7:00 AM, 8:00 AM, and 9:00 AM. Assessment was not completed for [DATE] and the other sections of the evaluation was not completed. Review of the Comprehensive Care Plan for Resident #157 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was only two (2) interventions listed on the care plan: provide resident with limited assist of one (1) for bed mobility, and provide resident with limited assist of one (1) for transfers using a roll walker. There was no documented interventions to meet the resident's toileting needs. 5. Record review revealed the facility admitted Resident #16 on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #16's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel and was not on a toileting program. Review of the Initial (Admission) Nursing assessment dated [DATE], revealed Resident #16 had bladder and bowel incontinence with no toileting program. Review of Resident #16's Bowel and Bladder Continence Evaluation revealed it had the three (3)-day assessment dates filled in ([DATE], [DATE], and [DATE]) for ,[DATE] shift, however, the hourly diary for ,[DATE] PM and ,[DATE] PM shifts were blank on all three days. Review of Resident #16's Bowel Retraining Evaluation, dated [DATE], revealed the reason for the incontinence was due to disease process. Review of the Comprehensive Care Plan for Resident #16 revealed the resident required assistance/was dependent for ADL care for toileting, dated [DATE]. Further review of the care plan revealed staff to provide incontinent care. 6. Record review revealed the facility admitted Resident #26 on [DATE], with [DIAGNOSES REDACTED]. Review of the Initial (Admission) Nursing assessment dated [DATE], revealed Resident #26 had bladder and bowel incontinence with no toileting program. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #26's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and occasionally of bowel and was not on a toileting program. Review of Resident #26's record revealed there was no documented evidence a Bowel and Bladder Continence Evaluation had been initiated on admission per facility policy. Review of the Comprehensive Care Plan for Resident #26 revealed the resident required staff assistance/was dependent for ADL care in for toileting, dated [DATE]. Further review of the care plan revealed staff assistance of one (1) with toileting and provide incontinent care. Interview with Certified Nurse Aide (CNA) #3 on [DATE] at 11:08 AM, revealed when residents are admitted there will be a bowel/bladder form in the ADL book for the aides to complete for three days on whether the resident is incontinent. She stated when the form is complete she usually leaves it in the book because the Assistant Director of Nursing (ADON) will take it out when done. Interview with CNA #4 on [DATE] at 5:07 PM, revealed the bowel and bladder forms are kept in the CNA's ADL book when new admits come in and are documented on every hour for the resident as to whether they are wet or staff toileted them. CNA #4 stated once the form is completed it's given to the nurse working or the ADON. She further revealed if she noticed that a new admit did not have a form in the ADL book she would let the nurse know so one could be completed. Interview with Registered Nurse (RN) #2 on [DATE] at 8:06 AM revealed she worked sporadically and on whatever shift she was needed, but on occasion she admitted a new resident. RN #2 stated she initiated the 3-day bladder evaluation sheet and placed it in the ADL books then reminded the Certified Nurse Assistants (CNA's) that the evaluations needed to be completed for the resident. RN #2 revealed when she was working when the three (3) days have expired, the sheets were pulled from the ADL books and either placed in the to-be-filed basket or she gave them to the ADON or the Director of Nursing (DON). RN #2 stated she has never seen one that has not been filled out completely, but if she did, she would ask the ADON if the thee (3) days should be started over because there would not be enough data to make a decision on the continent status of the resident. RN #2 further stated, in her professional opinion, she would expect the CNA's to complete the Three-Day Continence Management Evaluations per policy. Interview with RN #1 on [DATE] at 9:29 AM revealed the three-day bowel and bladder sheets are placed in the ADL book on admission for the CNA's to complete after the name and date is written in. RN #1 stated she does tell the CNA's, but assumes the CNA's know the sheet is in the ADL book. RN #1 stated she periodically checks the CNA book but has not found a sheet that was not completed and needed to be pulled. Interviews with the ADON on [DATE] at 9:33 AM and at 4:23 PM revealed she and the DON are responsible for assuring the Three-Day Continence Management Evaluations are completed and the MDS Coordinator is responsible for assuring the bowel and bladder care plans are initiated. The ADON stated the Evaluations should have been initiated on the date of admission based on the Nursing Assessment indicating incontinence. She stated the interdisciplinary team audits the ADL books after admission to assure all areas are covered, but obviously these were missed. She stated the evaluation sheets are placed in the ADL books for the CNA's to complete daily, and she does not have any idea why the CNA's are not completing the evaluations. Interview with the DON on [DATE] at 9:57 AM revealed the ADON was responsible for over seeing the bowel and bladder program. She stated residents who are admitted or readmitted with incontinence will have a three day continence diary completed. She stated it helps identify patterns of incontinence and will be addressed on the resident's care plan. The DON stated the evaluation form is placed in the CNA's ADL book by the admitting nurse and the CNA's complete the form and it is given to the ADON or herself.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life for two (2) of seventeen (17) sampled residents (Residents #23 and #44). Observation on 04/02/19, revealed Resident #23 and #44 were not being assisted with their lunch meal, while other residents at the table were being assisted and eating. The findings include: Review of the facility policy titled, Meal Service in Dining Room, last revised 01/02/14, revealed staff should serve all patients at a table at the same time. If a patient requires assistance with eating, do not serve trays to the table until assistance is available. 1. Record review revealed the facility admitted Resident #23 on with diagnoses, which included. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/18/19 , revealed the facility assessed Resident #23's cognition as severely impaired as he/she was unable to complete the Brief Interview of Mental Status (BIMS), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident required total assistance of one (1) or two (2) staff to eat. Observation on 04/02/19 at 11:49 AM, in the Main Dining area, revealed Resident #23 was sitting in a broda chair with his/her meal tray in front of him/her. Further observation revealed Licensed Practical Nurse (LPN) #2 was feeding one (1) resident, and a another resident was feeding him/herself. Continued observation revealed LPN #2 did not attempt to assist Resident #23 until 12:21 PM and surveyor brought the lapsed time to her attention. LPN #2 retrieved a new tray from the kitchen for Resident #23. Interview with LPN #2 on 04/02/19 at 12:33 AM, revealed she feeds only one (1) resident at a time and she had planned on assisting Resident #23 when the other resident was done with his/her meal. She stated the resident was nodding off and she had not realized over thirty (30) minutes had gone by. 2. Record review revealed the facility admitted Resident #44 on 09/08/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 03/13/19, revealed the facility assessed the Resident #44's cognition as severely impaired with a BIMS score of zero (0) as he/she was unable to complete the assessment which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total assistance of one (1) staff to eat. Observation on 04/02/19 at 11:55 AM revealed Resident #44 in a broda chair sitting at a dining room table with a covered plate on the table in front of him/her. There were three (3) additional residents at the same table, two (2) were receiving feeding assistance from Certified Nurse Aide (CNA) #1 and the other resident was feeding him/herself with assistance from a family member. No one was assisting Resident #44. Additional observation revealed CNA #1 was having a personal conversation with a family member, also seated at the table, and not engaging the residents in conversation. Further observation on 04/02/19 at 12:20 PM revealed Resident #44's covered plate remained on the table in front of her. LPN #1 removed the resident's plate and took it to the kitchen. At 12:27 PM, LPN #1 returned to Resident #44's table with a plate, retrieved a chair, and sat down beside the resident and began feeding him/her lunch, thirty-two (32) minutes after the original plate was served and the other residents at the table had began eating. Interview with CNA #1 on 04/02/19 at 12:03 PM revealed no one is feeding Resident #44 because there are not enough staff to help. CNA #1 stated this is not an every day occurrence, but today has been a crazy day and there was a call in today. Interview with CNA #3, on 04/05/19 at 11:08 AM, revealed she can feed two (2) residents at a time as long as she does not cross contaminate anything. She stated Resident #23 can be lethargic during meals and was a total feed. CNA #3 further revealed all residents should be served and assisted with meals at the same time. She stated staff completed training's online about resident rights and dignity upon hire and quarterly. Interview with the Director of Nursing (DON), on 04/05/19 at 10:22 AM, revealed there was no specific policy regarding the amount of residents staff can feed a the same time, but she would expect staff to assist the residents in a timely manner at the same table. She stated staff can sit between two (2) residents and assist both at the same time, as long as they ensure there is no cross contamination. The DON further revealed all staff was checked off on certain skills and received training on resident rights and dignity.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 Users Manual Version 1.16, October, (YEAR), it was determined the facility failed to ensure three (3) of seventeen (17) sampled residents received an accurate assessment, reflective of the resident's status (Residents #37, #47, and #51). Residents #47 and Resident #51 were taking anti-coagulant medications, however, the residents' Minimum Data Set (MDS) assessments indicated the residents were not on anti-coagulants. In addition, Resident #37 fell on [DATE], however, the fall was not reflected on the resident's 03/25/29 Quarterly MDS Assessment. The findings include: Interview with the MDS Coordinator on 04/05/19 at 8:52 AM revealed the RAI Users Manual is used for reference when completing MDS Assessments. Review of the RAI 3.0 Users Manual, Version 1.16, October, (YEAR), Section N0401, Medications Received, revealed the intent of the items in this section is to record the number of days, during the last seven (7) days that any type of injection, insulin, and/or select medications were received by the resident. Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting or slowing a disease's progress, reducing or eliminating symptoms, or preventing a disease or symptom. Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life. Review the resident's medical record for documentation that any of these medications were received by the resident during the seven (7)-day look-back period. Section N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the seven (7)-day look-back period. Include any of these medications given to the resident by any route (e.g., PO, IM, or IV) in any setting (e.g., at the nursing home, in a hospital emergency room ) while a resident of the nursing home. Code a medication even if it was given only once during the look-back period. 1. Record review revealed the facility admitted Resident #47 on 01/14/19 with [DIAGNOSES REDACTED]. Review of Resident #47's physician's orders [REDACTED]. However, review of Resident #47's PPS Sixty (60)-day MDS Assessment, dated 03/15/19, Section N0410E was coded with zero (0) indicating Resident #47 had not taken anti-coagulant medication during the seven (7)-day look-back period. Interview with with MDS Coordinator on 04/05/19 at 8:52 AM, revealed Resident #47 was taking the anti-coagulant, Apixaban, during the seven (7)-day look-back period for the PPS Sixty (60)-day MDS Assessment and the medication should have been coded on the MDS. She stated the medication was overlooked when completing the MDS Assessment. 2. Record review revealed the facility admitted Resident #51 on 12/10/18 with [DIAGNOSES REDACTED]. Review of Resident #51's (MONTH) 2019 physician's orders [REDACTED]. However, review of Resident #51's PPS Quarterly MDS Assessment, dated 03/19/19, Section N0410E was coded with zero (0) indicating Resident #47 had not taken anti-coagulant medication during the seven (7)-day look-back period. Interview with the MDS Coordinator on 04/04/19 at 10:44 AM revealed Resident #51 was taking the anti-coagulant, Apixaban, during the seven (7)-day look-back period for the Quarterly MDS assessment and the medication should have been coded on the MDS. She stated the medication was an oversight/coding error when completing the MDS Assessment. Interview with the Director of Nursing (DON) on 04/04/19 at 10:32 AM revealed she expected the MDS to be coded accurately and to reflect the care the residents received. 3. Review of the RAI Manual, Version 3.0 User Manual, Section J, Health Conditions, states: Code 0, no: if the resident has not had any fall since the last assessment; and Code 1, yes: if the resident has fallen since the last assessment. Record review revealed the facility admitted Resident #37 on 10/17/16 with [DIAGNOSES REDACTED]. Review of an Event Summary Report revealed Resident #37 fell on [DATE]; however, review of the Quarterly MDS assessment, Section J-Health Conditions, dated 03/25/19, revealed the resident had not fallen since prior assessment. Interview with MDS Coordinator on 04/04/19 at 4:17 PM, revealed she reviewed nurses notes to see if the resident has had any falls. She stated she coded the assessment in error. The MDS Coordinator stated she was expected to ensure the accuracy of the MDS assessments that she codes. Interview with the Director of Nursing (DON) on 04/05/19 at 10:22 AM, revealed she expected the MDS assessments to be coded correctly to reflect the resident's status.

Based on interview, record review, and review of facility policy, it was determined the facility failed to develop a comprehensive person-centered care plan for four (4) of seventeen (17) sampled residents (Residents #42, #47, #51 and #157). Residents #42, #47, and #157 were assessed to be incontinent of bowel and bladder and Resident #51 was assessed to be incontinent of bladder; however, the facility failed to develop a Comprehensive Care Plan to address the residents' incontinent status. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed a comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. 1. Record review revealed the facility readmitted Resident #42 on 03/05/19 with [DIAGNOSES REDACTED]. Review of the 14-Day Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and bowel and was not on a toileting program. Review of the Admission Nursing Assessment, dated 03/05/19, revealed Resident #42 had bowel and bladder incontinence. However, review of the Comprehensive Care Plan revealed Resident #42 required assistance/was dependent for Activities of Daily Living (ADL) care in toileting, dated 08/28/18., with no interventions to address toileting assistance of incontinent status. Additionally, there was no documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 2. Record review revealed the facility admitted Resident #157 on 03/29/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/05/19, revealed the facility assessed Resident #157's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and bowel. Review of the Admission Nursing assessment dated [DATE], revealed Resident #157 had bladder and bowel incontinence. However, review of the Comprehensive Care Plan for Resident #157 revealed the resident required assistance/was dependent for ADL care in . toileting, dated 03/29/19. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 3. Record review revealed the facility admitted Resident #47 on 01/14/19 with [DIAGNOSES REDACTED]. Review of the Perspective Pay System (PPS) 60-day MDS Assessment, dated 03/15/19, revealed the facility assessed Resident #47's cognition as severely impaired with a BIMS score of five (5), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel. Review of the Admission Nursing assessment dated [DATE], revealed Resident #47 had bladder and bowel incontinence. However, review of the Comprehensive Care Plan for Resident #47 revealed the resident required assistance/was dependent for ADL care in toileting, dated 01/14/19. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the Resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 4. Record review revealed the facility admitted Resident #51 on 12/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 03/19/19, revealed the facility assessed Resident #51's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and always continent of bowel. Review of the Admission Nursing assessment dated [DATE], revealed Resident #51 had bladder incontinence. However, review of the Comprehensive Care Plan for Resident #51 revealed the resident required assistance/was dependent for ADL care in . toileting, dated 12/10/18. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. Interview with the MDS Coordinator on 04/04/19 at 10:47 AM revealed she was responsible for initiating the comprehensive and quarterly care plans and the residents' continence status should have been added to the comprehensive care plans on admission. She stated it was probably an oversight because normally incontinence was addressed with the ADL's. Interview with the Director of Nursing (DON) on 04/05/19 at 10:31 AM revealed she expected a care plan to be developed to address residents who are incontinent.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of seventeen (17) sampled residents (Resident #47). Resident #47 was care planned to float heels while in bed; however, observations on 04/02/19 and 04/03/19 revealed his/he heels were not floated while in bed. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed a comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review revealed the facility admitted Resident #47 on 01/14/19 with [DIAGNOSES REDACTED]. Review of the Perspective Pay System (PPS) 60-day Minimum Data Set (MDS) Assessment, dated 03/15/19, revealed the facility assessed Resident #47's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5), which indicated the resident was not interviewable. Review of the Comprehensive Care Plans for Resident #47, last revised 03/20/19. revealed the resident had actual skin breakdown on admission and a healed unstageable to left heel,with an intervention to float heels while in bed. However, observation on 04/02/19 at 2:24 PM revealed Resident #47 was in bed, sleeping on his/her back, and his/her feet/heels were not elevated. A sign was noted over the resident's bed stating heels up while resting in bed. Further observation on 04/03/19 at 10:12 AM revealed the resident's heels were not elevated, but flat on the mattress. Interview with Certified Nurse Assistant (CNA) #1 on 04/03/19 at 10:25 AM revealed Resident #47's feet should be elevated when in bed, as the sign over the resident's bed states. Interview with Registered Nurse #2 on 04/03/19 at 10:12 AM revealed Resident #47's feet should be elevated when he/she is in bed, and acknowledged they were not at that time. Interview with the Director of Nursing (DON) on 04/05/19 at 10:31 AM revealed she expected for the resident's heels to be elevated per the care plan, and she expected staff to follow the care plan as it was written.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure residents who display or are diagnosed with [REDACTED].#43). Record review revealed no documented evidence the facility developed and implemented a person-centered care plan that included and supported the dementia care needs of Resident #43 which included communication and mood concerns. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed the center must develop and implement a baseline person-centered care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Person-centered care means to focus on the resident as the lotus of control and support the resident in making his/her own choices and having control over his/her daily life. A comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review revealed the facility admitted Resident #43 on 12/06/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/19, revealed the facility assessed Resident #43's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan dated 12/14/18, revealed the resident has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]: Dementia (other than [MEDICAL CONDITION]) with a goal that the resident will be able to make simple decisions by responding yes or no on most days throughout the next review period. Further review revealed interventions to use short phrases that request yes or no answers; allow extra time after speaking for resident to process thoughts and respond; and provide opportunities to the resident to reminisce, i.e. using photos of family/friends/pet. However, the care plan did not guide staff on how to address the noted mood issues this resident exhibited as part of the Dementia diagnosis. Interview with the Dementia Program Director (DPD) on 04/05/19 at 9:20 AM revealed she believed that the dementia care plan was person-centered. However, on first review, on 04/04/19 the cognition care plan were not individualized or person-centered. When reviewing the care plan again on 04/05/19 revealed the dementia care plan had been revised on 04/04/19. The care plan was revised to reflect the following interventions: use short phrases with resident that require yes or no answers or that resident can answer by non-verbal communication such as nodding her head or shaking her head as indicated for yes or no; give the resident two options such as picking out clothing, or asking the resident if she wants to participate in her favorite activities, and when doing so allow extra time for the resident to respond; and provide opportunity to the resident/patient to reminisce about photos by asking if she can recall family and loved one's names or is she can point to family or loved one's face in picture. Additionally, a new care plan was initiated that identified the resident exhibits or is at risk for signs and symptoms of depression related to [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed care planning was new to the DPD and she was learning. She stated it was the responsibility of the MDS Coordinator and the DON to oversee the care plan process until the DPD was proficient at care planning. The DON stated the dementia care plan, prior to the 04/04/19 update, was not person-centered or individualized for Resident #43. The DON stated she expected going forward, the care plans to be more person-centered and individualized for the specific resident and for us (DON and the MDS Coordinator) to oversee the process more closely.

Based on interview, record review, and review of the Nursing Drug Handbook by Lipponcott, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents was administered a [MEDICAL CONDITION] medication without an appropriate diagnosis (Resident #43). Record review revealed Resident #43 was administered [MEDICATION NAME] ([MEDICATION NAME]-an antipsychotic) with a [DIAGNOSES REDACTED]. The findings include: Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed the facility was unable to provide a policy for [MEDICAL CONDITION] medication use. Review of a Nursing Drug Handbook by Lipponcott, dated 2014, revealed [MEDICATION NAME] was used for the following: [MEDICAL CONDITION], Aggression, Irritability, Temper Tantrums, and Self-Injury associated with Autism, and [MEDICAL CONDITION]. Review of the Black Box Warning revealed fatal Cardiovascular or Infectious adverse events may occur in elderly patients with dementia and is not safe or effective in these patients. Record review revealed the facility admitted Resident #43 on 12/06/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/19, revealed the facility assessed Resident #43's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident did not have hallucinations, delusions, rejection of care, wandering, no other behaviors were exhibited, and there were no mood indicators coded on the MDS. Additionally, review of Section N0450B, Antipsychotic Medication Review, revealed the physician documented gradual dose reduction as clinically contraindicated. Review of Resident #43's physician's orders [REDACTED]. Review of Behavior Monitoring and Intervention Sheets for Resident #43 for December, (YEAR); January, 2019; February, 2019, and March, 2019, revealed the resident had zero (0) behaviors since admission. Review of the Comprehensive Care Plans for Resident #43 revealed the resident is at risk for complications related to the use of [MEDICAL CONDITION] drugs Medication: [MEDICATION NAME], dated 12/20/18. Listed interventions included complete behavior monitoring flow sheet; and monitor for continued need of medication as related to behavior and mood. Review of the Pharmacy review sheet revealed Resident #43's medications were reviewed on 1/29/19, 02/16/19, and 03/26/19 with no irregularities noted. Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed Resident #43 was prescribed [MEDICATION NAME] on admission and had only been in the facility three (3) months. She stated the physician will not order a gradual dose reduction or discontinue a [MEDICAL CONDITION] medication without first monitoring the resident's behavior. The DON further stated she was not aware of the reason [MEDICATION NAME] was ordered to begin with. Additionally, the DON stated she was aware that Dementia with Behavioral Disturbance was not an appropriate [DIAGNOSES REDACTED]. Interview with Resident #43's attending Physician/ Medical Director on 04/05/19 at 10:48 AM revealed the resident was admitted with Risperidal ordered and with the [DIAGNOSES REDACTED]. He stated the resident had only been in the facility for approximately three (3) months and protocol was to monitor the resident for a period of time then begin to gradually reduce the medication. He revealed [MEDICATION NAME] was typically prescribed for [MEDICAL CONDITION] and Bi-polar Disorder. He further stated he understood that Dementia with Behavior Disturbance was not an appropriate [DIAGNOSES REDACTED].

Based on observation, interview and facility policy review, it was determined the facility failed to serve food in accordance with professional standards for food service safety for seven (7) residents not in the selected sampled. Observation on 02/27/18, revealed Certified Nurse Aide (CNA) #1 served cornbread to seven unsampled residents with his/her bare hands and did not use gloves or properly sanitize hands. The findings include: Review of the facility policy titled, Food Handling, dated 11/28/17, revealed foods are stored, prepared, and served in a safe and sanitary manner to prevent bacterial contamination and the possible spread of infection. The policy further revealed food is prepared with a minimum of handling and no bare hand contact with ready to eat food is allowed. Observation of lunch meal pass in the Front Dining Room, on 02/27/18 at 11:45 AM, revealed CNA #1 touching and serving corn bread muffins with bare hands as she placed the bread on seven (7) unsampled residents' plates. Further observation revealed she failed to sanitize in between serving the plates of food. Interview with CNA #1 on 02/27/18 at 1:49 PM, revealed she does not consider it sanitary to touch the residents' food with bare hands. She stated she should have used tongs to serve the corn bread muffins and sanitized her hands more to prevent cross contamination. Interview with CNA #2 on 03/01/18 at 10:40 AM, revealed food items should not be touched with bare hands because it is unsanitary. Interview with the Director of Nursing (DON) on 02/28/18 at 3:47 PM, revealed she expected staff to use tongs or gloves to serve bread and not to use bare hands. She stated she expected staff to wash or sanitize their hands during meal pass.

Based on observation, interview, record review and review of the facility's Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to provide services according to the residents' written plan of care for one (1) of thirteen (13) sampled residents (Resident #7). Resident #7 was care planned to have barrier cream applied after each cleansing; however, observation on 02/08/17, revealed the Certified Nurse Aide (CNA) failed to apply the barrier cream after incontinent care. The findings include: Review of the RAI Manual (chapter 2) titled, Assessments for the RAI, dated October 2016, revealed the care plan process should identify problems, causes, contributing factors, and risk factors related to the resident's care problems which were identified during the assessment process. Further review revealed the information gained to develop a care plan should be followed in the context of resident's strengths, problems and needs. Record review revealed the facility admitted Resident #7 on 07/27/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/03/16, revealed the facility assessed Resident #7's cognition as moderately impaired with a Brief Interview for Mental Status (BIM's) score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment, revealed Resident #7 was totally dependent on one (1) person for toilet use and always continent of urine and incontinent of bowel. Review of the Comprehensive Care Plan for incontinent bowel dated 08/09/16, revealed to apply moisture barrier to perianal and perineal area, as indicated. Review of the February 2017 CNA Care Record for Resident #7 revealed to apply barrier cream with each cleansing. Further review of the care record, revealed CNA #1's signature on 02/08/17 for the day shift (7:00 AM-3:00 PM shift) which indicated the CNA was responsible for providing Resident #7's care according to care plan that shift. Observation of CNA #1 providing incontinent care for Resident #7, on 02/08/17 at 10:10 A, revealed CNA #1 failed to apply barrier cream to Resident #7 per written plan of care, after providing incontinent care. Interview with CNA #1, on 02/09/17 at 9:05 AM, revealed he was in such a rush providing incontinent care for Resident #7 and trying to get him/her to lunch he failed to apply the barrier cream to the resident's coccyx area. He stated the cream was available in Resident #7's bathroom in a locked cabinet accessible with a key and was on the CNA care plan to be applied after each incontinent episode. Interview with the Director of Nursing (DON), on 02/09/17 at 9:30 AM, revealed she would have expected CNA #1 to have followed the resident's care plan and to have applied the barrier cream after the incontinent care had been provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an infection control program was maintained to prevent the development and transmission of disease and infection. Staff failed to change gloves after providing peri-care and incontinent care for one (1) of thirteen (13) sampled residents (Resident #7). On 02/08/17, Certified Nurse Aide (CNA) #1 failed to change his soiled gloves after providing peri-care and incontinent care for Resident #7, then proceeded to touch Resident #7, his/her personal items, and bed with the soiled gloves. The findings include: Review of the facility's policy titled, SH601Personal Protective Equipment, not dated, revealed Latex-free gloves will be worn when it is reasonably anticipated that the employee handles or touches contaminated items or surfaces. Change gloves after contact with each individual resident or after contact with contaminated articles. Disposable single use gloves are to be replaced as soon as possible when contaminated or immediately when torn, punctured, or when ability to function as a barrier is compromised. Record review revealed the facility admitted Resident #7 on 07/27/16 with [DIAGNOSES REDACTED]. Observation of CNA #1 providing incontinent/peri-care for Resident #7, on 02/08/17 at 10:10 AM, revealed CNA #1 failed to change his/her soiled gloves and wash hands after providing peri-care and incontinent care for Resident #7. CNA #1 proceeded to touch Resident #7, his/her personal items, and bedding; then repositioned the resident, before changing soiled gloves and washing hands. Interview with CNA #1, on 02/08/17 at 11:00 AM, revealed he should have changed his gloves after they had become soiled with bowel, before touching and repositioning Resident #7. He stated not changing his gloves after providing peri-care/incontinent care and continuing to touch the resident and his/her personal belongs and bedding would likely spread infection and germs wherever his soiled gloves touched. Interview with Unit Manager #1, on 02/08/17 at 1:55 PM, revealed she expected all staff to change gloves several times when providing peri-care and incontinent care, in order to help prevent the spread of infection and germs throughout the resident's room and personal belongings, especially when the gloves become soiled. Interview with the Director on Nursing (DON) on 02/09/17 at 9:30 AM, revealed she would have expected CNA #1 to have changed his gloves after providing peri-care and incontinent care, especially once the gloves became soiled, and to not touch the resident or any of their personal belonging in order to prevent the spread of infection.

Based on observation, interview, record review and review of the Health Care Supply Company electronic mail (e-mail), it was determined the facility failed to provide cords for five (5) bathroom call lights and the failed to provide call light cords that would be accessible to a resident if on the floor for twenty-four (24) our of twenty-six (26) resident bathrooms. The findings include: Observation on 11/04/14 from 10:00 AM through 10:30 AM, during the initial facility tour, revealed short call light cords in the bathrooms of eight (8) out of nine (9) rooms. Call light cords were of inconsistent lengths and greater than 4 (four) to 6 (six) inches from the bathroom floor. Observation, on 11/06/14 at 1:40 PM with Housekeeping Supervisor, revealed every bathroom has two (2) call light panels, one (1) near the shower area and one (1) near the commode. The Housekeeping Supervisor stated she was unsure if there was a specific length for the bathroom call light cords. Further observation revealed commode call light cords were missing in rooms: #332, #336, #337, #338, and 339 and call light cords were greater than 4 (four) to 6 (six) inches from the bathroom floor in rooms: #101, #102, #103, #104, #106, #107, #108, #109, #111, #222, #223, #224, #225, #226, #227, #228, #229, #330, #333, #334, #335, and #340. Interview, on 11/06/14 at 1:43 PM with Certified Nurses Aide (CNA) #1, revealed an unsampled resident who resided in 336-B, ambulated to the bathroom alone. She stated she was not sure if the resident would be able to push the call light panel button if he/she were not seated on the commode. Interview, on 11/06/14 at 1:45 PM with Certified Nurses Aide (CNA) #2, revealed an unsampled resident who resided in 338-A, occasionally ambulated to the bathroom alone. She stated the resident would push the button on the call light panel when he/she needed assistance. CNA #2 stated she was not sure if the resident in 338-A would be able to push the call light panel button if she/he were not seated on the commode. Interview, on 11/06/14 at 2:30 PM with unsampled resident who resided in 338-A, revealed he/she occasionally ambulated to the bathroom alone. He/she stated the call light panel near the commode did not have a call light cord attached. Further review revealed he/she could press the call light panel button if he/she needed assistance while seated on the commode but he/she would not be able to reach the button if he/she fell in the bathroom. Interview, on 11/06/14 at 1:48 PM with Housekeeping Supervisor, revealed the unsampled resident who resided in 339-B, ambulated to the bathroom alone. She stated the resident probably would not be able to reach the call light panel button if she fell or was not seated on the commode. Further interview revealed the Housekeeping Supervisor was unsure if bathroom call light cords should always be replaced. Interview, on 11/06/14 at 2:15 PM with Maintenance Director, revealed bathroom call light cords are "about six (6) feet long" when received from the Healthcare Supply Company. He stated maintenance checked one (1) hallway on Friday each week and replaced missing cords. The Maintenance Director said there were two (2) residents who wander and pull cords out of the call cord plates. He stated maintenance shortened call light cords, when replaced, to hang below the bathroom handrail to prevent a choking hazard. Review of an electronic mail (e-mail), dated 11/06/14 at 8:15 AM from the Healthcare Supply Company, revealed they "normally recommended bathroom call light cords hang four (4) to six (6) inches from the floor but it depended on the State Inspector. They may recommend a different length."

Based on interview, record review and facility policy review, the facility failed to conduct pre- admission screening to evaluate the level of services required for fifteen (15) unsampled residents(Residents A-O), upon admission. The facility also failed to complete the pre-admission screening (PASRR) according to policy guideline time frame for one (1) of fifteen (15) sampled residents(Resident #10). The findings include: Review of the facility's Pre-Admission Screening Mental Health/Mental [MEDICAL CONDITION] policy, last revised 03/01/14, revealed facility staff will assure that all Mentally Ill (MI) and/or Intellectual/Developmental Disability(ID/DD) residents receive appropriate pre-admission screenings according to federal and/or state regulations. Record review revealed the facility admitted Resident #10 on 08/05/14 with [DIAGNOSES REDACTED]. Further record review revealed there was no evidence the facility had conducted the required Level One (1) Pre-admission Screening to determine if placement in the facility was appropriate. The PASRR was completed (as signed) on 08/22/14. Interview with Admissions Director, on 11/06/14 at 1:57 PM, revealed all Medicaid residents have to have PASRR done and it can be done after the resident was admitted to facility. She stated the PASRR was not required on all admissions as it depends on their diagnosis. She revealed that a Level One PASRR was completed after a resident was admitted to the facility but she was not sure of the time frame for when Level One PASRR was to be completed after admission. She stated she can complete the PASR or the transferring facility can complete PASRR. She revealed all the facility's beds were Certified. Interview with Director of Nursing (DON), on 11/07/14 at 9:10 AM, revealed the facility did a 100% Chart Audit for the completion of PASRR'S. She stated the chart audit revealed Level One PASRR'S had not been completed on fifteen(15) residents (Residents A-O).

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for nine (9) rooms. Eight (8) resident room doors had rough and chipped edges with missing wood (rooms 107, 111, 226, 228, 330, 333, 335 and 336) and one (1) resident room with a hole in the wall by the floor board (room 340). The findings include: Review of the facility's policy titled Preventative Maintenance, not dated, revealed touch up painting and facility specific items are to be preformed monthly. Observations conducted during the environmental tour, on 09/18/13 at 4:04 PM, revealed entry doors for resident rooms 107, 111, 226, 228, 330, 333, 335 and 336 had edges that were rough and chipped with missing wood. Further observations revealed in resident room 340 a hole in the wall close to the baseboard. Interview, on 09/19/13 at 4:45 PM, with the Maintenance Supervisor revealed the Maintenance Supervisor made a monthly round of each area of the facility and addressed any issues in that area at that time as follows: the first week of the month is Hall One (1), the second week of the month is Hall Two (2), the third week of the month is Hall Three (3) and the fourth week is the general areas of the facility. The interview further revealed this was the third week of the month so the Hall Three would have been observed and worked on, but the Maintenance Supervisor had to be off that week. The Maintenance Supervisor denied being aware of the hole in the wall in room 340, but did reveal the issues with the doors was an ongoing problem due to wheelchairs. Interview, on 09/19/13 at 1:55 PM, with the Administrator revealed the facility was not aware of the hole in room 340; however, the issue with the resident entry doors was on-going due to wheelchairs. The interview further revealed the Maintenance Supervisor made monthly rounds in the facility and addressed any issues that were identified at that time. The interview further revealed if staff noticed a problem it was added to the maintenance book which was monitored daily by the maintenance supervisor.

Based on observation, interview, record review, review of the facility's policies, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interest, and the physical, mental, and psychosocial well being for five (5) of the sixteen (16) sampled residents and six (6) Unsampled Residents. Residents #1,#2,#4,#10, and #12. The findings include: Review of the facility's policy regarding Activity Assessment and Documentation, dated 04/2010, revealed the Activity Director was responsible for coordinating, obtaining, charting, and/or filing documentation including: program participation record; one-to-one activity log; progress notes denoting the resident's engagement in programming as it relates to their physical, emotional, spiritual, and functional well being; activity care plan therapeutic goals updated quarterly, and upon readmission or significant change; and care area assessments (CAA) and care plans as indicated by the Minimum Data Set (MDS) process. The policy statement revealed it was the center's policy to assess each resident's physical, mental, spiritual, psychosocial, and leisure interests for engagement in activities based on past and present patterns and interest. Review of the facility's policy regarding Care Plan-Interdisciplinary, dated 01/2008, revealed the Interdisciplinary Team (IDT) develops care plans addressing the resident's most acute problems. The care plan is comprehensive for each resident including measurable objectives and timetables to meet resident's medical, nursing, and mental and psychosocial needs. The IDT reviews each care plan at least quarterly with updates as necessary. 1) Review of Resident #2's clinical record revealed the facility admitted the resident on 01/23/09 with [DIAGNOSES REDACTED]. The resident was assessed by the facility as requiring one (1) to two (2) person assist transferring, dressing, eating, hygiene, and locomotion. On 11/29/12, the resident became active with Hospice for Failure to Thrive. Review of the resident's comprehensive plan of care revealed the facility did not have a care plan for the resident's activities. Observation of Resident #2, on 12/11/12 at 12:33 PM, revealed the resident was sitting in the dining room being fed lunch with the assistance of a certified nursing assistant (CNA). The resident frequently nods head back and forth, but made no attempt to move upper extremities, take utensils, or touch the staff. Observation of Resident #2, on 12/12/12 at 9:50 AM, revealed the resident was sitting in a wheelchair in the dining room in the back of the group during the Shake Awake Memory activity. No response was noted during activity. Interview with the Activities Director (AD), on 12/13/12 at 2:20 PM, revealed she did remember developing a care plan for activities and did not know what had happened to the plan of care. The AD revealed Resident #2 was low functioning and would be appropriate for sensory stimulation and not appropriate to initiate their own activity. She was given a list from the MDS Coordinator when assessments were completed and did not remember developing a care plan for resident #2 and did not know why it was missed. The facility Program Director provided a care plan for resident #2, on 12/13/12 at 4:30 PM, review of the care plan revealed a focus for the resident to self initiate activities which was scratched out and revised with hand written items and several hand written interventions. The Program Director revealed the care plan was just printed and hand written items were just added to update the care plan to reflect the residents current ability and function. The Program Director revealed she did not know why a care plan was not in the medical record or why it had not been revised. 2) Review of Resident #4's clinical record revealed the facility admitted the resident on 04/07/09 with [DIAGNOSES REDACTED]. The resident triggered a CAA for activities based on the facility's MDS assessment dated [DATE]. Review of the comprehensive plan of care revealed a care plan for activities had not been developed. Interview with the Activities Director, on 12/13/12 at 2:20 PM, revealed she was given a list from the MDS Coordinator when assessments were completed and did not remember developing a care plan for resident #2 and did not know why it was missed. 3) Review of Resident #12's clinical record revealed the facility admitted the resident on 12/03/04, with [DIAGNOSES REDACTED]. The resident received Hospice care and triggered a CAA in activities based on the facility's MDS assessment for 08/30/12. The Activity/Recreation assessment, dated 08/30/12, revealed the resident's interests includes massage and multi-sensory stimulation. Review of the residents comprehensive plan of care revealed the facility's goal was to participate in low stimulation activities and receive sensory stimulation. The facility's only care plan intervention was to transport to resident activities. Review of the activities calendar for November and December revealed there were no sensory activities scheduled. Observation of Resident #12, on 12/13/12 at 10:15 AM, revealed the resident was in their room, lying in bed covered with a blanket while a group activity consisting of story telling discussing unusual or strange laws was taking place in the TV area. Observation, on 12/13/12 at 10:40 AM, revealed the resident was still in bed while a nail care and hand massage group was taking place in the dining room. Interview with Registered Nurse (RN) #1, on 12/13/12 at 1:55 PM, revealed resident #12 was not very responsive and occasionally would make eye contact and acknowledge staff. The RN revealed sometimes the resident was out in a group activity but most of the time the resident was in the bed. The RN revealed he was not sure if the facility offered sensory stimulation. Interview with the Activities Director (AD), on 12/13/12 at 2:20 PM, revealed sensory stimulation consisted of massage with scented lotions, or letting the residents smell flowers. The AD revealed the calendar consisted of more active recreation and the department fills in with other things. The AD revealed a sensory session was done during nail care on 12/13/12 in the dining room. The AD revealed lotion was used with the nail care, therefore, sensory was provided to the residents who were already in the room. However, when asked who was in attendance, the AD revealed the participants in sensory were not appropriate for a sensory activity, as they were higher functioning. The AD revealed sensory was more appropriate for residents that were lower functioning and were not able to participate in the active types of recreation. The AD revealed she determined who were the lower functioning residents and also looked at documentation to see who had not participated in activities. The AD revealed the sensory activity was not done appropriately, or on the appropriate residents. The AD revealed Resident #12 did require special care and sensory stimulation and would have been appropriate for the sensory session. The AD revealed activities provided residents with meaningful activity to make them feel needed, and care plans were to let everyone know what residents like to do now as well as in the past. The AD revealed she was responsible to develop and revise resident activity care plans and ensure appropriate activities were being provided. Interview with the Program Director, on 12/13/12 at 2:50 PM, revealed she was responsible to ensure activities were being done and that care plans were developed, updated and appropriate to resident. The Program Director revealed she did audits and should have noticed that the care plans were not being done. Interview with the Director of Nursing, on 12/13/12 at 3:37 PM, revealed she was a member of the IDT but did not monitor the activity care plans. 4) Record review of the clinical record for Resident #1 revealed the facility admitted the resident on 10/28/10 with [DIAGNOSES REDACTED]. Resident #1 was assessed as non-interviewable by the facility on 09/11/12 using the Resident Assessment Instrument (RAI). In addition, Resident #1 was assessed to have inattention and disorganized thinking. Observation, on 12/11/12 at 2:55 PM, in the Activity Room, revealed Resident #1 sitting in a wheelchair. An activity was taking place where the activity person was engaging residents in a group conversation activity. Resident #1 was observed not participating. Observation, on 12/12/12 at 7:50 AM, in the dining room, revealed staff encouraged Resident #1 to eat his/her breakfast meal. Resident #1 was sitting in a wheelchair with a lap buddy placed on the wheelchair. Interview, on 12/12/12 at 8:00 AM, with Resident #1 while he/she was sitting in a wheelchair in the television room revealed Resident #1 was not looking at the television. Resident #1 was asked if he/she was watching television. Resident #1 responded "If that is what's on." Resident #1 then attempted to enter the therapy room, located next to the television room. Resident #1 was redirected out of the therapy room. Resident #1 required direction where to go. The resident could propel his/her own wheelchair. Record review of the care plan for Resident #1 revealed Resident #1 would self-initiate his/her own activities. The Focus stated Resident #1 enjoyed sewing, conversing with others and playing word and active games. The date this Focus area was initiated on 03/11/11. The revision date was 09/26/12. During one (1) year and nine (9) months, the Focus did not update with the condition of Resident #1. The activity program for Resident #1 did not match the current skills and abilities of the resident. Interview, on 12/12/12 at 2:30 PM, with Registered Nurse (RN) #1 revealed to self-initiate means to start doing an activity by yourself. He stated Resident #1 required guidance for activities. Interview, on 12/12/12 at 2:42 PM, with the Director of Nursing (DON) revealed Resident #1 could not say he/she wanted to do something. Interview, on 12/12/12 at 3:40 PM, with the Activities Director revealed to self-initiate means someone who could vocalize what they would like to do or do an activity by themselves. She revealed she was a part of the Interdisciplinary Team (IDT). She revealed the care plan was updated annually, or with a change in the condition of the resident. She stated Resident #1 could not self-initiate activities. 5) Record review of Resident #10's clinical record revealed the facility admitted the resident on 12/02/12, with [DIAGNOSES REDACTED]. Observation of Resident #10,on 12/13/12 7:54 AM, revealed Resident #10 sitting in a wheelchair and unable to talk and make his/her needs known. Record review of Resident #10's activities of daily living care plan revealed a self care deficit of weakness, unstable health condition, cognitive impairment, decreased balance, impaired coordination related to Alzheimer dementia. Record review of Resident #10's activities care plan, revealed the resident would self initiate activities and enjoyed playing cards and checkers. The goal was for the resident to continue to participate in self initiated acts 2 x per week. Interview with the Activities Director, on 12/13/12 at 2:28 PM, revealed Resident #10 enjoyed visits with his/her wife daily, loved the hand care and massage and the music program. Resident #10 was more lower functioning. The Activities Director stated, she was confused by the statement initiation on an activity. The Activities Director stated she would set a coloring book in front of the resident and the resident would start to color on his/her own. She further stated she forgot to update the care plan. Interview with the Activities Supervisor, on 12/13/12 2:40 PM, revealed Resident #10 would not be able to initiate an activity by him/her self.

Based on observation and interview, it was determined the facility failed to provide a homelike environment, one that de-emphasized the institutional character of the facility, for eighteen (18) of sixty (60) resident rooms. Rooms 1A, 3A and B, 4A, 6B, 7A, 8A and B, 9A and B, 10B, 11A, 23A, 29B, 30A, 32B and 35A and B. The findings include: The facility did not provide a policy for environmental rounds. Observation, on 12/11/12 during the tour of the facility which began at 7:00 AM, revealed resident rooms on the 100 Hall lacked personal items and pictures to support a homelike environment and encouraged links with the past. Those rooms were 1A, 3A and B, 6B, 7A, 8A and B, 10B and 11A. Observation, on 12/11/12 at 9:25 AM, revealed Resident F in his/her room, Room 6B, questioning where he/she was and was a family member coming to pick him/her up. The room contained one small wedding picture of Resident F in the window area. There were no other items visible in the room to link Unsampled Resident F to the past or make the room his/her own. The room of Unsampled Resident F presented as institutional with the lack of personal items or pictures. Observation, on 12/12/12 during an environmental tour of the facility which began at 3:00 PM, revealed additional resident rooms, Rooms 4A, 9A and B, 23A, 29B, 30A, 32B 35A and B, presented as institutional in character based on the lack of personal items and/or pictures in the resident rooms. The facility was a Dementia/Alzheimer's facility and these rooms lacked a connection with the past. Interview, on 12/12/12 at 8:00 AM, with the Therapy Program Director revealed a homelike room would be cozy and warm. She revealed the room would have the personal things of the resident, that way it would be a familiar environment to the resident. She stated it was important for residents with Dementia and Alzheimer's to have their familiar things around them as it calms their behavior. As the Therapy Program Director toured the 100 Hall, with this surveyor, she revealed she thought the residents had more of their personal things in their rooms than were present. Interview, on 12/12/12 at 8:10 AM, with the Director of Nursing revealed a homelike environment would have pictures of family and ones favorite items present. The reason for this, she revealed, was so the resident would be more comfortable and have something to connect to. She revealed the facility was responsible for creating a homelike environment if the family did not provide items for the resident. Interview, on 12/12/12 at 8:22 AM, with the Administrator revealed a homelike environment was based on the personal preference of the resident or their family. However, the facility had no residents that were interviewable, based on the MDS assessment conducted by the facility, to say what would constitute a homelike environment to them. The lack of personal items in the resident's rooms indicated that some families were not providing for a homelike environment. She revealed the facility would promote the environment. Interview, on 12/12/12 at 4:10 PM, with Certified Nursing Assistant (CNA) #5 revealed the residents who were without personal items and pictures in their room was because the family did not provide those items.