Every finding on record at Majestic Gardens at Memphis Rehab & SNC

Based on facility policy review, record review, observations, and interviews, the facility failed to ensure residents were free from physical restraints for 1 of 1 (Resident #14) sampled residents reviewed for physical restraints. The findings include: Review of the undated facility policy titled, Use of Restraints, revealed .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.Physical Restraints.are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.If the resident cannot remove a device in the same manner in which the staff applied it.and this restricts his/her typical ability to change position or place, that device is considered a restraint.Examples of devices that are/may be considered physical restraints include.trays that the resident cannot remove.Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).Documentation regarding the use of restraints shall include.full documentation of the episode leading to the use of the physical restraint.a description of the resident's medical symptoms.that warranted the use of restraints.how the restraint use benefits the resident by addressing the medical symptom.the type of restraint used.the length of effectiveness of the restraint time.observation, range of motion and repositioning flow sheets. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychotic Disorder with Delusions, Pseudobulbar Affect, Depression, and Insomnia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #14 was severely cognitively impaired. Resident #14 was not coded for the use of restraints. Review of the Physician's Orders revealed there was no order for a Geri chair (used to provide comfortable seating for individuals with limited mobility or who have difficulty sitting upright in a wheelchair) or tray. Review of the Care Plan dated 8/4/2025, revealed no interventions that included the use of a Geri chair or tray. Review of the medical record revealed no documentation of a restraint assessment, no documentation of resident representative consent, and no documentation of Geri chair or tray use. Observation at the Secure Unit's nurses' station on 9/8/2025 at 10:24 AM and 11:40 AM, revealed Resident #14 sitting in a Geri chair with a tray. There was no food or any type of activity on the tray. Observation in the Resident's room on 9/10/2025 at 8:04 AM, revealed Resident #14 was sitting in a Geri chair with a tray in place. There was no food or any type of activity on the tray. During an interview on 9/10/2025 at 11:34 AM, the Certified Nursing Assistant (CNA) I was asked how often the tray was connected to Resident #14's Geri chair. CNA I stated, .most of the time. During an interview on 9/10/2025 at 11:36 AM, Licensed Practical Nurse (LPN) J was asked how long Resident #14 had been using a tray on the Geri chair. LPN J stated, .the last couple of weeks.that's how long I've been working this hall. LPN J confirmed that Resident #14 could not remove the tray if asked. During an interview on 9/11/2025 at 9:12 AM, the MDS Coordinator was asked what the process for restraints was. The MDS Coordinator stated, We are a restraint free facility. The MDS coordinator confirmed that a restraint is something that restricts movement and cannot be removed by the resident, and the use of a tray on a Geri chair should be documented in the resident's care plan. During an interview on 9/11/2025 at 12:57 PM, the Director of Nursing confirmed that a Geri chair with tray would be considered a restraint if the resident is unable to remove the tray, and that use of a Geri chair with a tray should be documented in the medical record.

Based on policy review, medical record review, and interview, the facility failed to ensure staff reported an allegation of staff to resident abuse to the appropriate agencies in a timely manner for 2 of 3 (Resident #65 and #107) sampled residents for allegations of abuse. The findings included: 1. Review of the facility policy titled, Facility Responsibility for Reporting Allegations, dated September 2022, revealed .All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator and to other officials, including the State Survey Agency and adult protective services. 2. Review of medical records revealed Resident #65 was admitted on [DATE], with diagnoses including Cerebral infarction, Chronic Kidney Disease, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #65 was cognitively intact. Review of the facility investigation dated 8/29/2025, revealed Resident #65 reported an allegation of sexual abuse by CNA C on 8/29/2025. Resident #65 stated while providing care CNA C took his hand and placed it on her stomach, side of her hip and on her behind. Resident #65 stated CNA C walked out of the room and didn't say anything. CNA C was suspended pending investigation. The facility notified the Police, Long Term Care, Ombudsman, Adult Protective Services, and Resident #65's family. There was no documentation the State Survey Agency was notified of the allegation of abuse in a timely manner. During an interview on 9/10/2025 at 1:55 PM, the Administrator confirmed that the incident occurred on 7/10/2025 and the staff failed to report the allegation of abuse to the Director of Nursing or the Administrator until 8/29/2025. The Administrator confirmed that she should have been notified immediately. During an interview on 9/11/2025 at 1:05 PM, the DON confirmed that allegations of abuse should be reported within 2 hours of the allegation. 3. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated that Resident #107 was cognitively intact. Review of the facility investigation report dated 9/9/2025, revealed the Administrator spoke with Resident #107 regarding the allegation of staff to resident abuse. Resident #107 alleged that CNA F came in his room, and he asked her to shave him. Resident #107 stated that CNA F told him to say Please, and he told her that he didn't think he had to beg. The administrator contacted Resident #107's daughter and searched and found that CNA F matched the description Resident #107 provided. CNA F was terminated on 8/27/2025. During an interview on 9/11/2025 at 1:05 PM, The DON confirmed that allegations of abuse should be reported within 2 hours of the allegation. The incident was reported to the Administrator on 9/9/2025 at 12:03 PM and was not reported until 9/11/2025. The facility failed to report an allegation of abuse in a timely manner.

Based on policy review, medical record review, and interview, the facility failed to ensure staff were dispensing and accurately administering medications and treatments per Physician's Orders for 4 of 32 (Residents #3 #41, #51, and #148) residents reviewed. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 7/2023, revealed .Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications.Medications are administered in accordance with written orders of the attending physician.The resident's MAR/EHR [Medication Administration Record/Electronic Health Record] is initialed by the person administering the medication, in the space provided under the date and on the line for that specific medication dose administration time. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Diabetes, Psychotic Disorder with Delusions, Protein Calorie Malnutrition, and Dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #3 was severely cognitively impaired. Review of the Physician's Orders dated June 2025, revealed .amLoODIPine [amlodipine] Besylate [used for high blood pressure] .Hold for systolic < [less than] 120 . Review of the MAR dated June 2025, revealed Amlodipine was administered when the blood pressure was outside the parameters on the following dates: a. 6/3/2025 with a blood pressure (BP) of 113/63. b. 6/10/2025 with a BP of 109/93. c. 6/11/2025 with a BP of 112/84. d. 6/12/2025 with a BP of 104/68. e. 6/13/2025 with a BP of 118/72. f. 6/19/2025 with a BP of 107/61. g. 6/20/2025 with a BP of 110/68. h. 6/21/2025 with a BP of 114/72. i. 6/23/2025 with a BP of 116/76. j. 6/26/2025 with a BP of 119/69. k. 6/27/2025 with a BP of 106/64. l. 6/28/2025 with a BP of 104/60. Review of the Physician orders dated July 2025, revealed .amLoODIPine [amlodipine] Besylate [for high blood pressure] .Hold for systolic < [less than] 120 . Review of the MAR dated July 2025, revealed Amlodipine was administered when the blood pressure was outside the parameters on the following dates: a. 7/6/2025 with a BP of 112/81. b. 7/9/2025 with a BP of 110/60 c. 7/11/2025 with a BP of 110/60. d. 7/14/2025 with a BP of 104/65. e. 7/15/2025 with a BP of 111/68. f. 7/28/2025 with a BP of 118/60. g. 7/29/2025 with a BP of 108/51. Review of the MAR dated August 2025, revealed Amlodipine was administered when the blood pressure was outside the parameters on the following dates: a. 8/3/2025 with a BP of 112/56. b. 8/4/2025 with a BP of 118/66. c. 8/18/2025 with a BP of 116/65. d. 8/21/2025 with a BP of 117/64. During an interview on 9/11/2025 12:49 PM, the Director of Nursing (DON) confirmed that the medication was administered outside of the parameters and should have been held. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Chronic Kidney Disease, Encephalopathy, and Hypertension. Review of the Physician's Orders dated 4/21/2025, revealed .Triple Antibiotic External Ointment [(TAO) used for wound healing] .Apply to Rt [Right] eyebrow topically every day shift every other day for wound healing Cleanse skin tear with wound cleanser and apply TAO and a bandage every other day until healed. Review of the Treatment Administration Record (TAR) dated 4/2025, revealed no documentation for 4/23/2025, 4/25/2025, and 4/27/2025 for treatment to the skin tear to the right eyebrow. Review of the TAR dated 5/2025, revealed no documentation for 5/11/2025, 5/13/2025, 5/15/2025, and 5/19/2025 for treatment to the skin tear to the right eyebrow. There was no documentation of treatment to Resident #41's right eyebrow for 7 of 15 treatment dates. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was unable to be completed, which indicated Resident #41 was severely cognitively impaired. During an interview on 9/11/2025 at 12:57 PM, the Director of Nursing (DON) confirmed if a medication or treatment was not documented as completed then it was not done. 4. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Muscle Wasting and Atrophy, Arthritis, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #51 was cognitively intact. Review of the Physician's Orders dated 9/7/2025, revealed .cefTRIAXone Sodium [antibiotic] Intravenous Solution .Use 1 gram intravenously one time a day for UTI [Urinary Tract Infection] for 7 Days . Review of the care plan revised on 9/8/2025, revealed .The resident [Resident #51] is on Antibiotic Therapy r/t [related to] infection (UTI) [Urinary Tract Infection] .Administer medication as ordered . Review of the MAR dated September 2025, revealed .cefTRIAXone Sodium .one time a day for UTI for 7 Days .Start Date .9/8/2025 . There was no documentation on 9/8/2025 or 9/9/2025 that the medication was administered. Review of the progress notes dated 9/9/2025, revealed .Talked with [Named employee] at .Pharmacy in regard to medication. She states that medication will be delivered tonight. During an interview on 9/10/2025 at 10:48 AM, the DON confirmed the blanks on the MAR indicated the medication was not given.

Based on policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured at the beside for 4 of 32 (Resident #11, # 72, #122, and #148) residents. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 4/2025, revealed .The facility is responsible for maintaining proper storage.All medication will be stored according to state and federal laws and regulations.Oral (solid) medication-stored in medication carts except those requiring refrigeration.All medication with routes other than PO (oral) must be stored in separate compartments in medication cart, medication room cabinets, or refrigerator. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Arthritis, Chronic Pancreatitis, Anemia, and Hypertension. Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #11 was cognitively intact. Observation in Resident #11's room on 9/8/2025 at 9:52 AM and 10:50 AM, revealed a 0.5 milliliter (ml) bottle of earwax removal aid was observed at bedside. During an observation and interview on 9/8/2025 at 11:47 AM, Licensed Practical Nurse (LPN) E confirmed that the bottle of earwax removal aid should not be at Resident #11's bedside. 2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anemia, Epilepsy, and Hypertension. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #72 was cognitively intact. Observation in Resident #72's room on 9/8/2025 at 9:42 AM and 11:20 AM, revealed an approximately one-half full roll of (Named) over the counter antiacid wrapped in foil observed at the bedside. During an observation and interview on 9/8/2025 at 11:42 AM, LPN E confirmed the (Named) over the counter antiacid should not be at Resident #72's bedside. 3. Review of the medical record revealed Resident #122 was admitted to the facility on [DATE], with diagnoses including Protein Calorie Malnutrition, Diabetes, Pressure Ulcer, and Encephalopathy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #122 was cognitively intact. Observation in Resident #122's room on 9/10/2025 at 7:50 AM, revealed a bottle of wound cleanser and tube of moisture barrier ointment were observed on the nightstand. During an observation and interview on 9/10/2025 at 7:52 AM, the Director of Nursing (DON) confirmed the wound cleanser and barrier ointment should not be left in Resident #122's room. 4. Review of the medical record revealed Resident #149 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarct (condition where blood flow to the brain is interrupter), Vascular Dementia, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #149 was severely cognitively impaired. Observation in Resident # 149's room on 9/8/2025 at 10:22 AM and 2:52 PM, revealed a tube of antifungal ointment at the bedside. During an interview on 9/8/2025 at 2:53 PM, LPN G confirmed antifungal ointment should not be at Resident #149's bedside. During an interview on 9/11/2025 at 12:57 PM, the DON confirmed that medications including over the counter medications and/or topical ointments should not be left at a Resident's bedside unattended.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 4 nurses (Licensed Practical Nurse (LPN) A) failed to disinfect reusable resident equipment for 1 of 5 (Resident #151) residents observed during medication administration. The findings include: Review of the undated facility policy titled, Cleaning and Disinfection of Resident -Care Items and Equipment, revealed .Resident-care equipment, including reusable items.will be cleaned and disinfected.Reusable items are cleaned and disinfected or sterilized between residents.Reusable resident care equipment is decontaminated and/or sterilized between residents. Review of medical record revealed Resident #151 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, and Schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #151 was moderately cognitively impaired. Observation in Resident #151's room on 9/9/2025 at 4:16 PM, revealed Licensed Practical Nurse (LPN) A obtained Resident #151's blood pressure with an automatic wrist blood pressure monitor and failed to clean the blood pressure monitor before or after use. During an interview on 9/11/2025 at 12:58 PM, the Director of Nursing (DON) confirmed that reusable equipment should be cleaned and disinfected between resident use.

Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering and personal hygiene care for 4 of 5 (Resident #2, #3, #89 and #148) sampled residents reviewed for ADLs. The findings include: 1. Review of the undated facility policy titled, Activities of Daily Living (ADLs), Supporting, revealed .Residents will be provided with care to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene .Appropriate care and services will be provided for the residents who are unable to carry out ADLs independently .including assistance with .hygiene (bathing, dressing, grooming and oral care) . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiparesis and Morbid Obesity. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #2 was cognitively intact. Resident #2 required maximum assistance from the staff for personal hygiene. Review of the Care Plan dated 7/2/2025, revealed Resident #2 had an ADL Self Care deficit and required staff assistance with ADLs. Review of the undated Shower Schedule revealed Resident #2 was to get a shower on Tuesday and Friday on the 7:00 AM-3:00 PM shift. During an observation and interview on 9/8/2025 at 10:57 AM, Resident #2 stated she had not had a shower for at least a week. The resident's hair appeared oily and was uncombed. During an interview on 9/10/2025 at 2:29 PM, Certified Nursing Assistant (CNA) L stated that the electronic medical record (EMR) would show whether a resident had received a shower or a bath and what days it was given. CNA L opened up the EMR to reveal there was no documentation for a shower or bath on the EMR from 8/29/2025 until 9/10/2025. During an interview on 9/11/2025 at 12:58 PM, the Director of Nursing (DON) confirmed it was not acceptable for a resident who was dependent on staff for ADL care to go 10 days without a shower. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Diabetes, Psychotic Disorder with Delusions, Protein Calorie Malnutrition, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #3 was severely cognitively impaired. Review of the care plan dated 5/10/2025, revealed Resident #3 required substantial assistance from the staff for personal hygiene. Observation in Resident #3's room on 9/9/2025 at 8:36 AM, revealed that Resident #3's toenails were tan in color and extended about 1/2 inch from the end of the toe. During an observation and interview in Resident #3's room on 9/9/2025 at 2:43 PM, revealed the DON was shown Resident #3's toenails, and she confirmed they were long and needed to be cut. 4. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Diabetes, Anxiety, and Malignant Neoplasm of the Colon. Review of the care plan dated 3/2/2025, revealed Resident #89 had an ADL Self Care Performance Deficit related to (r/t) decreased mobility/Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #89 was severely cognitively impaired. Resident #89 required moderate to maximal assistance from staff with ADLs. Review of the care plan for Resident #89 with a revision date of 9/9/2025, revealed .BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . During an observation in Resident #89's room on 9/10/2025 at 7:43 AM, Family Member N was in the room and had removed Resident #89's socks. Resident #89's toenails were thick, long, and curling upward. The family member stated .they [toenails] need to be cut . During an observation and interview in Resident #89's room on 9/10/2025 at 7:57 AM, the DON was shown the Resident's toenails. The DON confirmed the nails were extremely long and needed to be cut. 4. Review of the medical record revealed Resident #148 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Spinal Stenosis, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the care plan for Resident #148 dated 9/4/2025, revealed . has an ADL Self Care Performance Deficit .BATHING: I require substantial/maximal staff participation with bathing . Review of the undated Shower Schedule revealed Resident #148 was to get a shower on Monday and Thursday on the 3:00 PM-11:00 PM shift. The facility was unable to provide shower sheets for Resident #148. Review of the .Skilled Nursing Center Documentation Survey Report . dated September 2025, revealed no documentation Resident #148 received a shower since admission on [DATE]. During an interview on 9/9/2025 at 9:17 AM, Resident #148 stated she had not had a shower since 9/4/2025. During an interview on 9/10/2025 at 10:10 AM, Unit Manager K was asked if the shower sheet had any documentation that Resident #148 received a shower since she was admitted . Unit Manager K stated .it doesn't look like it .

Based on policy review, medical record review, observation and interview, the facility failed to provide care and services when 1 of 3 (Resident #18) discharged sample residents reviewed did not receive a personal refund within 30 days of discharge. The findings include: Review of the facility's policy titled Resident Funds Policy and Procedure, dated 2025, revealed .To ensure that.residents have access to, and are able to manage, their personal funds.Conveyance upon discharge, eviction, or death.Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days, the resident's funds, and a final accounting of those funds, to the resident, his or her legal representative. Review of the medical record revealed Resident #18 was admitted on [DATE], with diagnoses including Psychotic Disorder with Delusions, Dementia, and Hypertension. Resident #18 was discharged to another facility on 12/13/2025. Review of the facility's Patient Fund Request Form dated 1/30/2025, revealed .Refund due to discharged on 12/13/2025 [Named Resident] .Closed account due to discharged . During a telephone interview on 8/19/2025 at 10:30 AM, Resident #18's daughter (responsible party) confirmed Resident #18's personal account was not received through the mail until 2/5/2025. During an interview on 8/19/2025 at 11:25 AM, the Business Office Manager and the Administrator confirmed the account was not refunded within 30 days.

Based on policy review, Director of Maintenance job description, facility investigation, manufacturer's manual recommendations, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 2 of 5 (Resident #14 and #86) sampled residents reviewed for accidents. On 4/29/2024 and 5/7/2024, dangerous elevated hot water temperatures ranging from 121 degrees Fahrenheit (F) to 142 degrees Fahrenheit (F) were found in 32 of 169 (Resident Rooms #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #115, #116, #203, #205, #212, #213, #215, #216, #306, #309, #316, #317, #318, #320, #325, #332, #400, #401, #406, #413, and #414) resident rooms checked for water temperatures. Hot water temperatures ranging from 121 degrees to 133 degrees F were found in 3 of the 4 (Resident Shower Rooms 100 hall, 200 hall and 400 hall) resident shower rooms. Three Residents who were physically and/or cognitively impaired (Residents #46, #85, and #114) resided in a room with elevated dangerous hot water temperatures and two residents were able to access the hot water in their rooms. Five residents were assessed for wandering (Resident #28, #41, #47, #117, and #479) and at risk of serious bodily injury, harm, burns, or death. Three cognitively intact (Residents #8, #115 and #280) stated the water would get too hot. The facility's failure to prevent the dangerously hot water temperatures placed all residents with the ability to access the hot water in Immediate Jeopardy. The facility's failure to properly use a mechanical lift during the transfer of Resident #86 resulted in Actual Harm when Resident #86 fell and sustained a Lumbar 1 (L1 - a fracture of the lumbar spine that causes moderate to severe pain) compression fracture, and when the facility's failure to implement one on one care for a resident resulted in Resident #14 sustaining a fall which resulted in an emergency room visit. The failure of the facility to maintain safe hot water temperatures placed all residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or has potential to cause serious injury, harm, impairment, or death to a resident). The facility's census was 131. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy (IJ) for F689 on 4/29/2024 at 6:19 PM, in the Conference Room. An acceptable allegation of removal was received on 5/3/2024. On 5/7/2024 beginning at 10:00 AM, while attempting to validate the allegation of removal, dangerously elevated hot water temperatures ranging from 121 degrees F to 124 degrees F were observed in resident rooms #115, #203, #212, #215, #400, #406, #413 and #414 and in the 200 and 400 hall resident shower rooms. The Interim Administrator, Facility Consultant and the DON were notified of the Immediate Jeopardy (IJ) for the amended F689 on 5/7/2024, at 5:19 PM, in the facility Conference Room. An extended survey was conducted 5/1/2024 through 5/8/2024. The Immediate Jeopardy for F-689 began on 4/29/2024. The Immediate Jeopardy is ongoing. The findings include: 1. Review of the facility policy titled, WATER TEMPERATURES, SAFETY OF, revision date 12/2009, revealed .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures on no more than 100 .F or the maximum allowable temperature per state regulation .Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log .If any time water temperatures feel excessive to the touch .staff will report this finding to the immediate supervisor .exposure to warm or hot water .to certain temperatures will cause scalding or burns .Nursing staff will be educated about signs and symptoms of burns . Review of the State licensure regulations revealed at 720-18-.08, .Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105 F and 115 F . Review of the undated and unsigned Director of Maintenance job description revealed .The Maintenance Director is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .Maintaining the building in compliance with current federal, state .regulations, and guidelines .Maintaining the building in good repair and free from hazards .Export knowledge of general building maintenance duties .Knowledge of safe practices in Long Term Care environment .Knowledge of Federal and State Regulations . Review of the facility's policy Fall Prevention And Management, dated 10/2023, revealed .It is the policy . to ensure a safe environment .A Fall Prevention and Management Program is used to provide a safe environment for residents .designed to identify residents at risk for falls .define interventions for the prevention of falls and/or decrease the likelihood of injury .A fall is when a resident comes to rest unintentionally on the floor .Interventions appropriate to individual residents and their risk for falls will be implemented .All products and devices included as interventions .will be used according to manufacturer's recommendations . Review of the facility's policy titled, Accidents/Falls, dated 6/8/2022, revealed .The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents .All employees must follow these guidelines and procedures for safe resident handling . Review of the facility's policy titled, Safe & Proper Resident Handling, dated 6/5/2023, revealed .To provide guidelines that will assist with the facility to select the safest technique and/or equipment for resident handling and movement tasks .Key Points for health care staff to consider .Identify any equipment required and know how to use it . Review of the facility's policy titled, Use of a Mechanical Lift, dated 10/2022, revealed .To define the guideline for use of a Mechanical lift .must be used by two (2) nursing assistants to perform the procedure . Review of the manufacturer's manual Invacare Reliant 450 .600 .Patient Lift, revealed .Operating the Lift WARNING .recommends that two assistants be used for all lifting . Using the Sling WARNING .Be sure to check the sling attachment each time .to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode) .Transferring the Patient WARNING When elevated a few inches off the surface of the stationary object .and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object .and correct this problem . 3. The surveyor's thermometers were calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before water temperature checks were obtained. The surveyor's hot water temperature checks in resident rooms on 4/29/2024 beginning at 1:22 PM, revealed the following: room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 120 degrees F The Maintenance Team Lead and the surveyor's hot water temperature checks using a calibrated thermometer in resident rooms and showers on 4/29/2024 beginning at 2:40 PM, revealed the following: room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 134 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 134 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 141 degrees F. room [ROOM NUMBER] was 140 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 132 degrees F. room [ROOM NUMBER] was 127 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 120 degrees F. room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 136 degrees F. room [ROOM NUMBER] was 129 degrees F. room [ROOM NUMBER] was 129 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 142 degrees F. room [ROOM NUMBER] was 138 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 121 degrees F. The Residents' Shower room on the 100-hall in stall #1 was 133 degrees F and in stall #2 was 131 degrees F. The Residents' Shower room on the 200-hall in stall #1 was 122 degrees F. The Maintenance Technician and the surveyor's hot water temperature checks using a calibrated thermometer in residents rooms and showers on 5/7/2024 beginning at 10:00 AM, revealed the following: room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 124 degrees F. room [ROOM NUMBER] was 122 degrees F. The Residents'Shower room on the 200-hall in stall #1 was 120 degrees F. The Residents'Shower room on the 400-hall in stall #1 was 121 degrees F. 3. Per Minimum Data Set (MDS) review revealed Residents #46, #85 and #114 were cognitively and/or physically impaired, and the Residents had access to the hot water with the dangerously elevated hot water temperatures. The facility provided a list of ambulatory residents and a list of residents who wander. The facility lists revealed Residents #28, #41, #47, #117 and #479 were cognitively impaired and had been identified by the facility as Residents with wandering behaviors (random, repetitive, or aimless locomotion/movement throughout an area) had the potential to be affected by the dangerously hot water temperatures. 4. Medical record review revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Cognitive Communication Deficit, and Malignant Neoplasm of the Prostate. Review of the annual MDS dated [DATE], revealed a BIMS score of 9 which indicated the Resident was moderately cognitively impaired, and required moderate assistance with bed to chair transfer, required maximum assistance with toileting hygiene and was dependent on staff for bathing. Review of the Wander List dated 4/26/2024, revealed Resident #28 was moderate to high for wandering. Resident #28 resided in a room which measured the dangerously elevated hot water temperature of 137 degrees F in the resident's sink, and the Resident had the ability to access the hot water. 5. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Dementia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #46 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the Resident was severely impaired cognitively. Resident #46 required partial to moderate assistance from staff to wash and dry their face and hands and to shower/bath self. Observation and interview on 4/29/2024 at 4:18 PM, revealed Resident #46 dressed, lying in the bed and was asked about the hot water in his bathroom. Resident #46 stated, The water be too hot. I tell them they have to change the water to make it be not so hot . Resident #46 resided in a room which measured the dangerously hot water temperatures of 121 degrees F. 6. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Traumatic Subdural Hemorrhage, Diabetes, Depression, and Hypertension. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 10 which indicated the Resident was moderately cognitively impaired. Resident #85 used a wheelchair and requires assistance for bathing. Observation on 4/29/2024 at 10:39 AM, revealed 2 staff members in Resident #85's room assisting the Resident to the wheelchair. Observation on 4/30/2024 at 4:15 PM, revealed Resident #85 dressed, and sitting in a wheelchair in the friendship area at the table with other residents playing bingo. Resident #85 resided in a room which measured the dangerously elevated hot water temperatures of 122 degrees F. and had the ability to access the hot water. 7. Review of the medical record revealed Resident #114 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Chronic Obstructive Pulmonary Disease, Hypothyroidism, and Left Leg Above the Knee Amputation. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 8 which indicated the Resident was moderately cognitively impaired. Observation on 4/30/2024 at 9:29 AM, revealed Resident #114 sitting in a wheelchair outside with other residents in the smoking area, wearing an apron and smoking a cigarette. Observation on 5/01/2024 at 11:15 AM, revealed Resident #114 self-propelling in a wheelchair down the hall, and stated she was looking for someone to get her some ice. During an interview on 4/29/2024 at 4:21 PM, Resident #114 was asked if the water was hot in her bathroom. Resident #114 stated, .the hot water is too hot . Resident #114 resided in a room which measured the dangerously elevated hot water temperature of 122 degrees F. and the Resident had the ability to access the hot water. 8. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Congenital Diaphragmatic Hernia, Aphasia, Dysphagia, Sleep Disorder, and Alcohol and Cocaine Abuse. The facility identified the resident as ambulatory and had a wanderguard. Review of the quarterly MDS dated [DATE], revealed Resident #41 BIMS score was not assessed. Resident #41 required set up to moderate assistance with Activities of daily living skills, and moderate assistance with toileting hygiene, bathing and mobility. Review of the Care Plan dated 1/23/2024, revealed Resident # 41 was identified for wandering and elopement. Resident #41 resided in a room which measured the dangerously elevated hot water temperature of 137.8 degrees F, and the Resident had the ability to access the hot water. 9. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnosis including Diabetes, Kidney Failure, Psychotic Disorder with Delusions, and Heart Failure. Review of the annual MDS dated [DATE], revealed Resident #47 has a BIMS score of 7 which indicated the Resident was severely cognitively impaired. Resident #47's upper/lower extremities were with no impairment, ambulated with a walker, used a wheelchair, and required maximum assistance with bathing. Review of the Care Plan dated 1/23/24, revealed, .I [Resident #47] am a wanderer . Observation on 4/30/2024 at 7:47 AM, revealed Resident #47 dressed, and sitting in a wheelchair across from nursing station with their eyes closed. Resident #47 resided in a room which measured the dangerously hot water temperature of 121 degrees F, and the Resident had the ability to access the hot water. 10. Review of the medical record revealed Resident #117 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Encephalopathy, Schizophrenia and Hypertension. Review of the quarterly MDS dated [DATE], revealed Resident #117 was rarely or never understood and had impaired long and short-term memory problems. Resident #117 was independent with toilet transfer and required supervision with toilet hygiene. The MDS did not have a BIMS score. Resident #117 resided in a room with the of the dangerously elevated hot water temperature that measured 138.7 degrees F, and the Resident had the ability to access the hot water. 11. Medical record review revealed Resident #479 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Dementia, Convulsions, Dysphagia and Hypertension. Review of the Admission MDS dated [DATE], revealed a BIMS score of 1 which indicated the Resident was severely cognitively impaired. Resident #479 required maximum assistance with toileting hygiene, transfer and bathing. Review of the Wander List dated 4/26/2024, revealed Resident #479 was moderate to high risk for wandering. Resident #479 resided in a room which measured the dangerously elevated hot water temperature of 137 degrees F, and the resident had the ability to access the hot water. 12. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Repeated Falls, Legal Blindness and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #8 with a BIMS score of 13 which indicated the Resident was cognitively intact and was dependent on staff for bathing, no impairment upper and lower extremities, requires moderate assist to transfer from bed to a chair and uses a wheelchair. During an interview on 4/29/2024 at 4:20 PM, Resident #8 stated that sometimes the water was too hot. 13. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE], revealed Resident #115 with a BIMS score of 15, which indicated the Resident was intact cognitively. Resident #115 used a wheelchair for mobility. During an interview on 4/29/2024 at 4:23 PM, Resident #115 was asked if the water was hot in the bathroom. Resident #115 stated, It gets too hot . 14. Review of the medical record revealed Resident #280 was admitted on [DATE], with diagnoses including Hypertension, Diabetes, Encephalopathy, and Acute Kidney Failure. Review of the admission MDS dated [DATE], revealed Resident #115 scored a 14 on the BIMS which indicated the Resident was cognitively intact. Resident #280 had no impairment on the upper and lower extremities, required set up for bathing and required supervision for transfers from bed to chair. During an interview on 4/29/2024 at 4:03 PM, Resident #280 stated the water temperature had been too hot when bathing and the washcloths were too hot at times. 15. During an interview on 4/29/2024 at 4:33 PM, CNA R was asked about any concerns with the water being too hot or too cold. Staff R stated, .some do get too hot .if you turn it up, it gets really hot .showers not too hot .[the hot water], it don't [doesn't] last long . During an interview on 5/1/2024 at 8:37 AM, Maintenance Team Lead was asked if he had any orientation on checking water temperatures. Maintenance Team Lead stated, No, ma'am .we just started watching them [water temperatures] a year or 2 after I got here. Maintenance Team Lead was asked when they had been notified the water was too hot. Maintenance Team Lead stated, When y'all found out . The Maintenance Team Lead was asked who had trained the Maintenance Technician. The Maintenance Team Lead stated, Nobody .we all didn't have any training .I have trained him [Named Maintenance Technician] this week on taking the water temps. The Maintenance Team Lead was asked how often water temperatures were being checked. The Maintenance Team Lead stated, .every hall gets checked once a week. I was not the one doing it .it was supposed to been done correctly .problems with water pipes in the winter .we had to turn the water up, and we never turned it back down .the water was cold .the hot water tank [heater] was turned up. The Maintenance Team Lead was asked was if the hot water heater was turned up to bring the water temperature up. The Maintenance Team Lead stated, Yes. The Maintenance Team Lead was asked when the hot water heaters were turned back down. The Maintenance Team Lead stated, We never got to it .until now .both water tanks [hot water heaters] were turned up . During an interview on 5/1/2024 at 9:21 AM, the Maintenance Technician was asked about the orientation when hired. The Maintenance Technician stated, .we went over few things I would be doing .I got hands on training .had to learn on my own . The Maintenance Technician was asked who the supervisor was. The Maintenance Technician stated, .[Named Maintenance Team Lead] because we cannot keep a maintenance supervisor . The Maintenance Technician was asked to explain how he took the water temperatures before yesterday 4/30/2024. Maintenance Technician stated, .run the water for 1 to 2 minutes, let the water get hot, place the thermometer tip in between the water. I would have half of the tip out of the water, learned now I should have the tip in the water and before .once I saw the number I would record. The Maintenance Technician was asked how the water temperatures are checked, now that he is trained. Maintenance Technician stated, Now trained to check .turn water on let it run for a few minutes .5 minutes, make sure numbers are not jumping .it will take 2 to 3 minutes of running and tip of thermometer in center to make sure . The Maintenance Technician was presented documentation of the facilities previously documented water temps and asked if he thought the documented water temps were accurate. The Maintenance Technician stated, I would say not . I was doing the tip in the water the wrong way .they are not right, if I was doing them the wrong way . The Maintenance Technician was asked how often the water temps were checked. The Maintenance Technician stated, I used to do them every day but now since . 2 months ago .changed to every Wednesday, do a hall a week . The Maintenance Technician stated he was told yesterday (4/30/2024) that the water temps were too high. The Maintenance Technician was asked had he ever been shown the federal guidelines for water temperatures. Maintenance Technician stated, No. The Maintenance Technician was asked did he know anything about the water being cold. The Maintenance Technician stated, . CNAs complained about the water being cold .I did not think the water was cold, it was warm .the people who put it in came out here and turned it up [referring to the hot water heater] .October . The Maintenance Technician was asked if the water temperatures could be visualized on the hot water heater. The Maintenance Technician stated, Yes. The Maintenance Technician was asked who monitored the water temperatures on the hot water heaters. The Maintenance Technician stated, Nobody. The Maintenance Technician was asked what the temperatures were on the hot water heaters today. The Maintenance Technician stated, .it was at 175 degrees on the oldest hot water heater and [Named Regional Director of Maintenance (RDOM)] changed it this week .[now set at] 115 . The Maintenance Technician confirmed he was not checking the shower room water temperatures. The Maintenance Technician was asked should he check the shower room temps. The Maintenance Technician stated, I think so, now. During an interview on 5/1/2024 at 4:08 PM, the RDOM, who prior to this interview was employed at a sister facility as part of their Maintenance Staff, was asked who was responsible for the maintenance of the facility. The RDOM stated, .I guess right now that would be me. The RDOM was asked about the hot water temperatures at the facility. The RDOM stated, It was brought to my attention you all had seen a temperature reading of 140 or 143. I thought that's impossible and thought that it had to be a bad mixing valve .I went downstairs and lowered temperatures on the boilers [hot water heaters]. The RDOM was asked what the temperatures were at that time. The RDOM stated, I want to say 130, 131 and I reduced it to 115 degrees and opened up the hot water valve in the janitors closet to expel the additional hot water .to bring the temperatures down .brought down to below standards .I lowered it to get the danger to the residents gone, so that it wasn't going to cause harm . This is purely assumption on my part, but makes the most sense, the [previous] Maintenance .turned up the temp and didn't follow up on it .I think when he [Previous Maintenance Director] left nobody looked or checked. If they had been doing temps the correct way, they would have caught it. The RDOM was asked were the two current maintenance staff reeducated about water temperatures and how to take temperatures properly. The RDOM stated, Honestly no, but I will. The RDOM was asked with the seriousness of the situation and the possibility of residents being seriously burned, should they have reeducated staff when this was found. The RDOM stated, .temp reading is something definitely going to be addressed .plan to address tomorrow .been working on Life Safety issues . The RDOM was asked since the problem with the water temperatures has been discovered as being too hot have the maintenance staff checked the water temperatures been taken. The RDOM stated, [Named Maintenance Team Lead] and I have .came in yesterday [4/30/2024] and took temps . did not write them down. The RDOM was asked with the seriousness of harm or death should the water temperatures be written down, kept, and reported back to the Administrator. The RDOM stated, That would fall under the Maintenance Director, and I am currently in that position, that is why I got the temp confirmed, he did not write them down. The RDOM was asked if he knew the federal regulations for water temperatures. The RDOM stated, No, what are they? The RDOM was asked what education was going to be provided to the maintenance staff if he didn't know the federal guidelines for water temperatures. The RDOM stated, . I will know them today. During an interview on 5/01/2024 at 4:49 PM, the Director of Nursing (DON) was asked about the water temperatures. The DON stated, .my understanding 104-110 in resident rooms .I don ' t know shower rooms . The DON was asked has anyone educated them on the correct water temperature ranges this week. The DON stated, I wouldn't say they educated me about it .that was the range we agreed on. The DON confirmed the Maintenance staff should have been able to tell them what the correct temperature ranges should be and stated, .I have not been keeping up with the water . During an interview on 5/02/2024 10:20 AM, the DON stated to the RDOM, . going to have to get tight on the water .the water is too low . The RDOM stated, .I talked to [named Life Safety surveyor] .he told me what the range is . During an interview on 5/02/2024 at 2:09 PM, the Administrator was asked if she had been notified of the hot water temps. The Administrator stated, .Monday night . got a text from my housekeeping supervisor .said we got an IJ [immediate jeopardy] for the water temperature . The Administrator confirmed no one else had let her know about the IJ and stated, The one that should have notified me was the DON who was second in command . The Administrator was asked how the communication was within the facility. The Administrator stated, .it's been poor . The Administrator was asked if she felt the response to the IJ had been immediate. The Administrator stated, .there was a call to a vender .and the boilers [hot water heaters] were turned down immediately .showers were halted and bed baths .until we could determine the proper temperature. The Administrator confirmed everyone should have been aware of the water temperature and stated, .100 degrees for baths .120 degrees for 5 minutes burn . The Administrator confirmed it would be too cold to receive baths/shower under 100 degrees and stated, It would be too cold . The Administrator confirmed she had no idea what the water temperature acceptable ranges should be and was asked who was responsible for the hot water temperatures. The Administrator stated Maintenance .they are supposed to do water checks daily. The Administrator confirmed she was not aware that the maintenance didn't know how to correctly take the water temps. The Administrator was asked where the communication breakdown was. The Administrator stated, .I don't know .it's definitely .a good question .maybe failure to carry out assigned duties [referring to the hot water heater being to high and not being turned down] . The Administrator was asked who was responsible for the building. The Administrator stated, I am. During an interview on 5/08/2024 at 10:51 AM, the Medical Director confirmed he was notified about the IJ related to hot water temperatures and stated, I told them the water should be fixed quickly .I think when it comes to spending money the owners drag their feet .it should be the right temperature .shouldn't be too hot or too cold .the building is [AGE] years old .it's going to cost some money but it is worth it for the residents . During an interview on 5/08/2024 at 11:20 AM, the Superintendent of the Service Department of an outside vendor was asked why they were called out to facility. The Superintendent stated, .they [the facility] are having hot water in faucets .it was hotter than it was supposed to be .when we got here .originally it was a boiler and 2 water tanks .some time ago, in the 80's .90s boiler went out and replaced .with 2 water heaters .we replaced one [referring to the water heater] in the last couple years .it had flooded down there [in the facility basement], it's been years ago when they took the boiler out, they piped it up differently, cold water feeds with them having to circulate through builder boilers, they require a holding tank . when boilers were replaced . they had a boiler with a holding tank, boiler doesn't have a tank and can't circulate .they left the cold tied into the tank instead of the water heaters, they are mixing .the problem was going into the holding tank . we have already rerouted that, to maintain that, they [the facility] kicked the hot water up . the hot and cold was mixing .they have circulating pumps and aren't working . The Superintendent was asked was the water issued fixed at this time. The Superintendent stated, .not that I ' m aware of it shows 74 degrees .to get it right, they would have to re-pipe the whole building .they are so old, they don't have a system monitoring the valves . The Superintendent was asked if the water issues can recur. The Superintendent stated the only way to properly correct the problem was, tearing out walls and ceiling are going to be the only way .yes . 16. Review of the medical record revealed Resident #14 was admitted on [DATE], and readmitted on [DATE], with diagnoses including Right Femur Fracture, Muscle Weakness, Dementia, Repeat Falls, Pain, and Psychosis. Review of a significant change MDS dated [DATE], revealed Resident #14 scored a 12 on the BIMS, indicating the Resident was moderately impaired cognitively, and required supervision or touching assistance from staff for bed mobility and transfers, had one fall with no injury and had one fall with major injury since admission/entry or reentry or prior assess [TRUNCATED]

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 21 of 32 sampled residents (Resident #1, #3, #14, #21, #26, #31, #33, #41, #47, #55, #65, #66, #70, #71, #75, #87, #88, #102, #106, #112, and #115) reviewed for Advanced Directives. The findings include: 1. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 12/2023, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive and will provide Advance Directive information if requested . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Abnormal Weight Loss, Cerebral Palsy, Major Depressive Disorder, and Diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Osteoporosis with Current Pathological Fracture, Contracture, Traumatic Brain Injury, and Diabetes. Review of the quarterly MDS dated [DATE], revealed Resident #3 had a BIMS score of 05, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of Weight Loss, Epileptic Seizures, Fracture, and Falls. Review of the significant change MDS dated [DATE], revealed Resident #14 had a BIMS score of 09, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 5. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Fracture, Anxiety, Multiple Sclerosis, and Kidney Failure. Review of the quarterly MDS dated [DATE], revealed Resident #21 had a BIMS score of 04, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 6. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Left Leg, Cerebral Infarction, Diabetes, and Schizophrenia. Review of the quarterly MDS dated [DATE], revealed Resident #26 had a BIMS score of 09, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 7. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses of Lymphadenitis, Hypertension, Psychotic Disorder with Delusions and Tachycardia. Review of the quarterly MDS dated [DATE], revealed Resident #31 had a BIMS score of 12, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 8. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses of Absence of Right Leg Below Knee, Anxiety, Cardiomegaly and Sepsis. Review of the quarterly MDS dated [DATE], revealed Resident #33 had a BIMS score of 10, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 9. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses of Acute Kidney Failure, Angina Pectoris, Chronic Kidney Disease, and Gastrostomy Status. Review of the quarterly MDS dated [DATE], revealed Resident #41 is rarely/never understood. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 10. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses of Embolism and Thrombosis of Deep Veins, Cerebral Infarction, Metabolic Encephalopathy, and Psychotic Disorder. Review of the annual MDS dated [DATE], revealed Resident #47 had a BIMS score of 07, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 11. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses of Acidosis, Pancytopenia, and Polyneuropathy. Review of the quarterly MDS dated [DATE], revealed Resident #55 had a BIMS score of 03, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 12. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Left Leg, Necrotizing Fasciitis, Schizophrenia and Anxiety. Review of a 5 day MDS dated [DATE], revealed Resident #65 had a BIMS score of 06, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 13. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses of Congestive Heart Failure, Hemiplegia, Metabolic Encephalopathy, and Convulsions. Review of the quarterly MDS dated [DATE], revealed Resident #66 had a BIMS score of 07, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 14. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses of Adult Failure to Thrive, Anorexia, Psychotic Disorder and Dementia. Review of the significant change of status MDS dated [DATE], revealed Resident #70 had a BIMS score of 03, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 15. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Schizophrenia, Obesity, and Diabetes. Review of a 5 day MDS dated [DATE], revealed Resident #71 had a BIMS score of 13, which indicated resident is cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 16. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses of Aphasia, Encephalopathy, Intracerebral Hemorrhage and Hypertension. Review of the quarterly MDS dated [DATE], revealed Resident #75 had a BIMS score of 03, which indicated resident has severe cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 17. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Left Leg, Hypertension, and Vascular Dementia with Mood Disturbance. Review of the quarterly MDS dated [DATE], revealed Resident #87 had a BIMS score of 12, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 18. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Kidney, End Stage Renal Disease, Asthma and Renal Dialysis. Review of the quarterly MDS dated [DATE], revealed Resident #88 had a BIMS score of 12, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 19. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE], with diagnoses of Acute Kidney Failure, Renal Dialysis, End Stage Renal Disease and Diabetes. Review of the annual MDS dated [DATE], revealed Resident #102 had a BIMS score of 08, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 20. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE], with diagnoses of Acute Respiratory Failure with Hypoxia, Diabetes, Heart Failure and Schizophrenia. Review of the annual MDS dated [DATE], revealed Resident #106 had a BIMS score of 11, which indicated resident has moderate cognitive impairment. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 21. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE], with diagnoses of Acute Kidney Failure, Urinary Tract Infection, Hemiplegia, Pneumonia, and Heart Disease. Review of the quarterly MDS dated [DATE], revealed Resident #112 had a BIMS score of 15, which indicated resident is cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 22. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE], with diagnoses of Alcohol Abuse, Chronic Kidney Disease, Drug Induced Subacute Dyskinesia and Schizophrenia. Review of the quarterly MDS dated [DATE], revealed Resident #115 had a BIMS score of 15, which indicated resident is cognitively intact. Review of the medical record revealed there was no documentation to indicate that the resident and/or their legal representative was informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. 23. During an interview on 4/30/2024 at 2:16 PM, the Director of Nursing (DON) was asked if she was able to provide any further Advance Directives for the residents. The DON stated, No I am not. The DON was asked should all residents have been offered an advance directive or educated about Advanced Directives on their admission. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment as evidenced by the odor of urine in Resident's rooms, the 200 and 300 hallways, dirty privacy curtains, standing water in resident's bathroom sinks and in basins, and a loose handrail observed in the 100 Hall. The findings include: 1. Review of the facility's policy, titled, Preventive Maintenance Program, with a revision date of 9/2023, revealed, . A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environmental for residents, staff, and the public .The Maintenance Director is responsible is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a sage and operable manner . Review of the facility's procedure titled, Resident Room Cleaning and Bathroom Cleaning revealed .This routine procedure will clean and disinfect resident rooms and bathrooms .providing a clean, safe, decontaminated environment .Resident rooms and bathrooms that are clean, sanitary, odor free and safe will result from proper cleaning .Use the following procedure when cleaning the residents' rooms .Check privacy curtains, drapes, and vents. Clean as scheduled and as needed .Check walls and spot wash as needed .When a sink is in the resident's room, spray the fixtures with a spray bottle of diluted disinfected cleaner .Damp dust all areas around the basin including the exposed pipes under the sink. Wipe off the fixtures with a damp cloth using the brush and general cleaner purpose cleaner as needed, to remove any residue .General purpose cleaner should be used on any stains in the basin not previously removed by wiping with the disinfectant solution .Use the following procedure when cleaning the residents' bathrooms .Spray the ceramic tub/tile cleaner inside of the toilet bowl and any plumbing fixtures. Allow disinfectant to stand 3-5 minutes. While the disinfectant is standing, clean the sink .Using the cloth and spray bottle of disinfectant solution clean the outside of the toilet bowl .Report any needed maintenance repairs to the housekeeping supervisor .If odor is still present after cleaning thoroughly cleaning the room or bathroom, contact your supervisor . 2. Observations in room [ROOM NUMBER] revealed the following: On 4/29/2024 at 10:40 AM, revealed a strong urine odor in resident's room and bathroom. Yellow stains noted on fitted sheet on resident's bed. On 4/29/2024 at 12:25 PM, revealed a strong urine odor in resident's room. On 4/30/2024 at 8:16 AM and 2:03 PM, revealed a strong odor of urine, and yellow stains noted on the fitted sheet on Resident's bed. On 5/1/2024 at 2:23 PM, revealed an odor of urine, and yellow stains on the resident's fitted sheet. 3. Observations in room [ROOM NUMBER] revealed the following: On 4/30/2024 at 2:06 PM, revealed a large brown stain on the privacy curtain between residents A and B. On 5/2/2024 at 11:17 AM, revealed a brown stain on the privacy curtain. On 5/6/2024 at 10:22 AM, revealed a brown stain on the privacy curtain. On 5/6/2024 at 10:24 AM, revealed a strong urine odor. During an interview on 5/2/2024 at 11:09 AM, Staff I confirmed that resident rooms are cleaned every day with the process of cleaning and wiping down everything in resident's room and bathroom and mopping last. Staff I confirmed that privacy curtains are changed when torn or stained. Staff I stated that there should be two privacy curtains per resident room, and they should be assessed and changed weekly. Staff I was asked if privacy curtains should be in working condition. Staff I stated, Yes. 4. Observations in room [ROOM NUMBER] revealed the following: On 4/29/2024 at 10:46 AM and 3:59 PM, revealed a gray wash basin underneath the sink with brownish water with black particles floating in the water in the shared bathroom. On 4/30/2024 at 9:21 AM, revealed a gray wash basin underneath the sink in the bathroom with yellowish/brown water and black particles in the shared bathroom. On 5/01/2024 at 1:58 PM, revealed a gray wash basin on the floor in the bathroom underneath the sink with yellowish brown water with black particles in the shared bathroom. 5. Observations in room [ROOM NUMBER] revealed the following: On 4/29/2024 at 10:50 AM, 11:35 AM, and 3:00 PM, revealed a strong odor of urine in resident's room and bathroom, and out into the 300 hallway. On 4/30/2024 at 8:00 AM and 4:05 PM, revealed a strong odor of urine in the room, the bathroom, and outside the doorway into the hallway. 6. Observations in room [ROOM NUMBER] revealed the following: On 4/29/2024 at 9:30 AM, 11:00 AM, and 1:15 PM, revealed a strong odor of a urine in the resident's room and bathroom, and an offensive odor from the green-yellowish substance noted in the resident's commode. 7. Observations in room [ROOM NUMBER] revealed the following: On 4/29/2024 at 11:06 AM and 3:27 PM, revealed the adjoining bathroom toilet was dirty with shredded paper and brown water, a dirty towel was on the bathroom floor. Resident's bathroom sink was clogged with water in the sink. On 4/30/2024 at 7:39 AM, revealed resident's toilet was full of toilet paper and dirty brown water. 8. Observations in Room # 414 A revealed the following: On 4/30/2024 at 4:35 PM, revealed standing water in resident's bathroom sink. On 5/1/2024 at 11:18 AM and 2:46 PM, revealed resident's bathroom sink had standing clear water in sink. During an interview on 5/1/2024 at 2:54 PM, CNA H confirmed that resident's sink was stopped up yesterday and that the facility staff were aware. CNA H was asked if maintenance was notified regarding the resident's sink. CNA H stated, No, but I will put in tales today. During an interview on 5/01/24 at 3:25 PM, Staff C confirmed that room [ROOM NUMBER]'s sink had not been entered into tales (a computer reporting program) for a work order request. Staff C was asked if staff should have reported the sink issue to maintenance to be fixed. Staff C stated, Yes ma'am. During an interview on 5/1/2024 at 3:55 PM, Staff C confirmed that he drained Room # 414's bathroom sink and poured Drano down it. He stated he would check it prior to leaving for the day, and if it doesn't work, they will call a plumber. During an observation and interview on 5/2/2024 at 2:58 PM, Staff C checked the water temperature of Room # 414's bathroom sink, when the sink started to fill due to not draining. Staff C stated I need to drain the sink from the pipe under the sink. The Drano did not fix the problem and we are going to have to call someone out to look at it. Staff C started to loosen the pipe from under the sink and the bathroom and water started to run out onto the bathroom floor. 9. Observations in the 100 Hall revealed the following: On 5/1/2024 at 8:27 AM and 3:47 PM, revealed a very loose handrail with one side coming out of the wall on the 100 Hall. On 5/6/2024 9:49 AM, revealed the handrail was still loose and very wobbly. During an interview on 5/8/2024 at 6:39 PM, the Director of Nursing (DON) confirmed that the handrail was not properly secured and that it needed to be fixed. 10. During an interview on 5/1/2024 11:49 AM, Staff J confirmed that she checks the cleanliness of rooms and bathrooms and notifies housekeeping and maintenance when needed. Staff J was asked regarding the odor of urine in room [ROOM NUMBER], and if she was aware. Staff J stated that [named resident] is incontinent and resident's sheets are removed daily to make sure bed is clean when she is out of the room. Staff J was asked if the odor had been reported to administration. Staff J stated, Yes, and with housekeeping and yesterday and last week before I went out of town.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by staff using bare hands to prepare food, unlabeled, undated food items, and dirty equipment. The facility had a census of 131 with 124 of those residents receiving a tray from the Kitchen. The findings include: 1. Review of the facility's policy Food Preparation and Service, dated 10/2017, revealed .Food and nutrition services employees shall prepare and serve food in a manner that complies with safe handling practices .Bare hand contact with food is prohibited. Gloves must be worn when handling food directly . Review of the facility's policy Food Receiving and Storage, dated 10/2017, revealed .Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated ['use by date] . opened containers must be dated Review of the facility's policy Food Safety Requirements, dated 12/2023, revealed .Food will be stored, prepared, distributed and served in accordance with professional standards for food safety . Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects .Facility staff shall inspect all food .and ensure timely and proper storage .Practices to maintain safe refrigerated storage include .labeling, dating, and monitoring .so it is used by its use-by-date .Use of gloves when touching and assisting with ready-to eat-foods .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination .Staff shall not touch food with bare hands . Review of the facility's policy Sanitization, dated 10/2008, revealed .The food service area shall be maintained in a clean and sanitary manner .All utensils, counters, shelves, and equipment shall be kept clean . Review of the facility's policy, Storage of Refrigerated and Dry Foods,' dated 1/2023, revealed .All containers must be labeled with the contents and date food item was placed in storage .Previously cooked foods can be held in refrigeration .for up to 7 days and then must be discarded . 2. Observation in the Kitchen on 4/29/2024 at 9:40 AM, revealed the following: a. an opened, and undated package of coconut flakes in the dry storage area. b. an opened, and undated package of pancake waffles in the freezer. c. an undated package of corn nuggets in the freezer. d. an undated bag of mangos in the freezer. e. an opened, undated, and unlabeled meat wrapped in aluminum foil in the freezer. f. 3 sleeves (elongated, packaged meat in a clear plastic wrapping) of undated, an unlabeled meat in the freezer 3. Observation in the Kitchen on 4/30/2024 at 10:23 AM, revealed the following a. a deep fryer with dark brown (almost black/could not see through) colored grease and dark brown crumbs. b. 2 undated, and unlabeled sandwiches in a metal pan. c. a plastic container labeled black eye peas dated 4/22/2024, in the refrigerator. 4. Observation in the Kitchen on 5/1/2024 at 11:19 AM, revealed the following: a. Cook/Dietary Aide O used her bare hands to take bread rolls out of its package and placed them on a serving tray. b. a dark brown (almost black/could not see through) colored grease and dark brown crumbs in the deep fryer. 5. Observation in the Kitchen on 5/1/2024 at 3:02 PM, revealed uncovered noodles in a Styrofoam container sitting on the top of a metal shelf. 6. Observation in the Kitchen on 5/8/2024 at 9:35 AM, revealed Cook/Dietary Aide O used her bare hands to pick up slices of cheese and place them on slices of bread. Staff O walked away and left the cheese slices and bread uncovered. 7. During an interview on 5/8/2024 at 5:09 PM, the Certified Dietary Manager (CDM) confirmed items stored in the freezer and other shelf areas should be labeled with a name, opened date, and have a use by date on them. The CDM confirmed dark grease is unaccepted for the deep fryer, the deep fryer should be cleaned, and the grease changed as scheduled and as needed. The CDM confirmed sandwiches should be refrigerated and labeled with name and date it was prepared. The CDM confirmed the black eye peas in the refrigerator dated 4/22/2024 should have been discarded on 4/29/2024. The CDM confirmed staff should not use their bare hands to pick up food, staff should be wearing gloves when picking up food.

Based on observation, and interview, the facility failed to maintain equipment in safe operating condition for 4 of 4 (Hall 100 shower room stall #2, Hall 200 shower room stall #2, Hall 300 shower room stall #2 and Hall 400 shower room stall #2) shower rooms and for 1 of 2 elevators (200 hall elevator) reviewed for safe operating equipment. The findings included: 1. The Maintenance Director and Maintenance Team Lead and the surveyor's checked showers rooms stalls on 5/14/2024 beginning at 11:05 AM, and revealed the following: 100 hall shower room stall #2 was capped off. 200 hall shower room stall #2 was capped off. 300 hall shower room stall #2 was capped off. 400 hall shower room stall #2 was capped off. During an interview on 5/14/2024 at 9:43 AM, the Maintenance Director confirmed that they had capped off one shower stall in each residents' shower room and stated, .water coming out of the sprayer and the shower head at the same time [referring to hall 100 shower room] .water wasn't getting hot enough due to coming out at both places . During an interview on 5/14/2024 at 11:30 AM, the Maintenance Lead was asked when the stalls that were capped off in the resident's showers would be fixed. The Maintenance Lead confirmed they would have to go in behind the wall to make the repairs. 2. Observation of the 200 hall on 5/14/2024 at 3:55 PM, revealed an elevator with caution tape and an out of order sign taped to the elevator door. During an interview on 5/14/2024 at 3:15 PM, the Healthcare Consultant confirmed the 200 hall elevator has not been in working order for nearly a year.

Based on observation, and interview, the facility failed to maintain equipment in safe operating condition for 4 of 4 (Hall 100 shower room stall #2, Hall 200 shower room stall #2, Hall 300 shower room stall #2 and Hall 400 shower room stall #2) shower rooms and for 1 of 2 elevators (200 hall elevator) reviewed for safe operating equipment. The findings included: 1. The Maintenance Director and Maintenance Team Lead and the surveyor's checked showers rooms stalls on 5/14/2024 beginning at 11:05 AM, and revealed the following: 100 hall shower room stall #2 was capped off. 200 hall shower room stall #2 was capped off. 300 hall shower room stall #2 was capped off. 400 hall shower room stall #2 was capped off. During an interview on 5/14/2024 at 9:43 AM, the Maintenance Director confirmed that they had capped off one shower stall in each residents' shower room and stated, .water coming out of the sprayer and the shower head at the same time [referring to hall 100 shower room] .water wasn't getting hot enough due to coming out at both places . During an interview on 5/14/2024 at 11:30 AM, the Maintenance Lead was asked when the stalls that were capped off in the resident's showers would be fixed. The Maintenance Lead confirmed they would have to go in behind the wall to make the repairs. 2. Observation of the 200 hall on 5/14/2024 at 3:55 PM, revealed an elevator with caution tape and an out of order sign taped to the elevator door. During an interview on 5/14/2024 at 3:15 PM, the Healthcare Consultant confirmed the 200 hall elevator has not been in working order for nearly a year.

Based on policy review, observation, and interview, the facility failed to treat all residents with dignity and respect when 3 of 19 staff members (Certified Nursing Assistant (CNA) - CNA S, and CNA T), and Licensed Practical Nurse (LPN) LPN U) failed to knock and announce themselves before entering a resident's room during dining The findings include: 1. Review of the facility's Resident Rights, undated policy revealed, .These rights include the resident's right to . dignified existence, be treated with respect, kindness, and dignity . 2. Observation during the Hall 300 dining on 4/29/2027 at 11:35 AM, revealed CNA S entered Resident #2's room and failed to knock or announce themself before entering resident's room. 3. Observation during the Hall 300 dining on 4/29/2024 at 11:49 AM, revealed CNA T entered Resident #15's room and failed to knock or announce themself before entering the resident's room. 4. Observation during the Hall 300 dining on 4/29/2024 at 11:55 AM, revealed LPN U entered Resident #26's room and failed to knock or announce themself before entering the resident's room. 5. Observation during the Hall 400 dining on 4/29/2024 at 12:02 AM, revealed LPN U entered Resident #29's room and failed to knock or announce themself before entering the resident's room. 6. During an interview on 5/7/2024 at 2:46 PM, the Director of Nursing (DON) confirmed that staff should knock before entering the resident's room.

Based on facility policy, facility document review, medical record review, and interview revealed the facility failed to maintain an accurate and complete medical record for 1 of 32 (Resident #66) sampled residents reviewed. Resident #66 ' s medical record contained an inaccurate Neurological check (an evaluation of brain and nervous system function). The findings include: 1. Review of the facility policy titled, Charting Errors and/or Omissions, revised 2006 revealed .Accurate medical records shall be maintained by this facility . Review of the facility policy titled, NEUROLOGICAL ASSESSMENT & FLOW SHEET, dated 12/2023, revealed .Any time an individual has an injury to the head .a Neuro Assessment needs to be done .Put the exact time that the [neurological] check was done and not when it was supposed to be done .exact time is important . 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Cognitive Communication Deficit, Dementia, Congestive Heart Failure, Hypertension, History of Falling, and Contracture of Left Hand. Review of the 5-day Medicare Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of a Progress Note dated 2/21/2024 at 5:40 PM revealed .Called to resident room per CNA [Certified Nursing Assistant], [resident] noted lying on left side on floor .open area noted over left brow . Review of Resident #66 ' s Neuro check sheet dated 2/21/2024 revealed neuro checks were documented at 12:45 PM. Review of the [Named] Fire Department Prehospital Patient Record dated 2/21/2024 revealed Resident #66 left the facility at 6:25 AM, being transported to the emergency room (ER). Resident #66 left the hospital ER at 12:55 PM and transported back to the facility. Staff documented the neuro check for Resident #66 at 12:45 PM, when Resident #66 was not present in the facility. During an interview on 05/08/24 at 10:35 AM, the Director of Nursing (DON) was asked about the neuro check documented on 2/21/2024 at 12:45 PM. The DON stated, .he would have been on his way to the hospital at that time [6:35 AM] and [12:45 PM] would be when he returned from the hospital . The facility failed to maintain accurate records and documentation related to neuro checks for Resident #66.

Based on medical record review, observation, and interview the facility failed to ensure medication was stored securely when medications were left unattended in resident rooms for 1 of 61 sampled (Resident #31) and when 2 of 7 medication carts (Back up medication cart and the 100 hall medication cart) were left unlocked, unattended and out of staff's line of sight. The findings include: 1. Observation in Resident #31's room on 5/1/2024 at 11:01 AM, revealed Resident #31 lying in bed, 2 white pills in a cup on her overbed table. Resident #31 asked for some water so she could take her medicine. LPN B was not present in the room. During an interview on 5/01/2024 at 11:13 AM, LPN B was asked what medication was left at Resident #31's bedside. LPN B stated, .potassium tablet and Vitamin D . LPN B confirmed she left the medications at the bedside because she got busy and didn't make it back to administer the medication. 2. Observation of the 100 hall Nurse's station on 5/06/2024 beginning at 4:21 PM, revealed the Back up medication cart was unlocked, unattended, and out of line of sight of staff. The Director of Nursing (DON) walked up to the Nurses station and observed the unlocked medication cart. LPN F stated, That cart [Back up medication cart] is empty . LPN F opened the top drawer of the Back up medication cart and confirmed they contain the following over the counter medications stored in the top drawer: 1. 1 bottle of ASA 81 mg 2. 3 bottles of Docusate Sodium 100 mg 3. 1 bottle of Gas Relief 80 mg 4. 1 bottle of Vitamin D 25 mcg 5. 1 bottle of Iron 25 mg 6. 1 bottle of Geri Kot 8.6 mg 7. 1 bottle of Sodium Chloride 1 Gram (15.4 gr) 8. 1 bottle of Vitamin B 12 1000 mcg 9. 1 bottle of Loratadine 10 mg 10. 1 bottle of Meclizine 12 mg 11. 1 bottle of Vitamin D 125 mcg 12. 2 bottles of Multivitamin 13. 1 bottle of Vitamin B Complex 14. 1 bottle of Cetirizine 10 mg 15. 1 bottle of Zinc Sulfate 220 mg 16. 1 bottle of Bisacodyl 5mg 17. 1 bottle of Probiotic 500 mg 18. 1 bottle of Acetaminophen 325 mg 19. 1 bottle of Magnesium Oxide 400 mg 3. Observation on the 200 hall on 5/7/2024 at 8:08 AM, revealed the 100 hall medication cart sitting in the 200 hall. The 100 hall medication cart was unlocked, unattended, and out of line of sight of staff. 4. During an interview on 5/7/2023 at 8:20 AM, DON confirmed medication carts should not be unlocked and unattended. The DON was asked why the Back up medication cart was at the 100 hall Nurse's station. The DON confirmed that 1 nurse has residents on 100 and 200 halls and has to share a cart, the nurses decided to separate the medications and make two carts. During an interview on 5/06/24 at 12:23 PM, LPN E confirmed she should not have left the medications on the over bed table when she went to wash her hands. During an interview on 5/7/2024 at 3:18 PM, the DON was asked if a nurse should leave medications unattended at bedside. The DON stated, No ma'am, they shouldn't leave them

Based on policy review, medical record review, observation and interview the facility failed to provide care and services for an indwelling catheter (a tube in the bladder that drains urine) for 1 of 1 (Resident #44) sampled resident reviewed for indwelling catheters. The findings include: 1. Review of the facility policy titled Foley Catheter Care, revised 6/2023, revealed .The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the urinary tract . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Osteomyelitis, Obstructive Uropathy, Hemiplegia, Cerebral Infarction, Hypertension, and Arteriosclerotic Heart Disease. Review of the Care Plan dated 3/13/2024, revealed .has an indwelling Catheter: Obstructive uropathy .Assess/record/report to MD for s/sx [signs and symptoms] UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns .Change foley catheter every month and [abbreviation for as needed] .Check tubing for kinks each shift .Provide foley catheter care every shift and as needed . Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #44 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact, Further review revealed Resident #44 had an indwelling catheter. Review of the Order Summary Report dated 5/6/2024, revealed .Change foley catheter on the 14th of each month and as needed for blockage/leakage or accidental dislodgement .Active 3/13/2024 . Review of the April 2024 Medication Administration Record revealed the catheter was not signed as being changed on 4/14/2024. Observation in the resident's room on 5/01/2024 at 2:22 PM, revealed Resident #44 resting in bed with an indwelling catheter hanging on the Left side of bed, a privacy bag covering the drainage bag and golden yellow urine in tubing. During an interview on 5/6/2024 at 11:08 AM, the Director of Nursing confirmed Resident #44's catheter was not changed on 4/14/2024 as ordered.

Based on policy review, medical record review, review of Skin Check sheets, and interview the facility failed to ensure Activities of Daily Living (ADL) assistance related to bathing was provided for 2 of 3 sampled residents (Resident #1 and #80) reviewed for ADL care. The findings include: 1. Review of the facility policy titled, Resident Showers, revised 3/2023, revealed, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice .Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety . 2. Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses including Spastic Quadriplegic Cerebral Palsy, Chronic Kidney Disease, Diabetes, Hypertension and Depression. Review of the Quarterly Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact, had impairments of range of motion in upper and lower extremities on both sides, received set up assist with meals, and was dependent with other ADLs including bathing. Review of the Care Plan dated 2/20/2024, revealed, .has an ADL Self Care Performance Deficit r/t Limited ROM, Limited Mobility, muscle weakness, cerebral palsy, bilateral ue [upper extremity] contractures .BATHING: The resident is totally dependent on staff to provide a bath . Review of the facility shower schedule revealed Resident #1 should have showers 2 times weekly on Monday and Thursday. Review of the facility Skin Check sheets for April 2024 revealed Resident #1 did not receive showers as scheduled on 4/1/2024, 4/8/2024, and 4/22/2024. During an interview on 5/01/2024 at 2:37 PM, Staff A confirmed residents should get showers 2 times weekly and staff should complete Skin Check sheets when showers are given. During an interview on 5/6/2024 at 11:00 AM, the DON confirmed residents should receive showers 2 times weekly and that Skin Check sheets were not present for Resident #1 for 4/1/2024, 4/8/2024 and 4/22/2024. 3. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Pressure Ulcer Left Heel Unstageable, Pressure Ulcer Right Heel Stage 3, Heart Failure, Diabetes and Adult Failure to Thrive. Review of the admission MDS dated [DATE], revealed Resident #80 had a BIMS score of 15 which indicated he was cognitively intact and required maximal assistance with bathing. Review of the care plan revealed, .has an ADL Self Care Performance Deficit .Interventions .BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . Review of the Skin Check sheets for March 2024 and April 2024 revealed Resident #80 did not receive a bath on the following days 3/23/2024, 3/27/2024, 4/3/2024, 4/10/2024, 4/13/2024, 4/17/2024, 4/20/2024, 4/24/2024 and 4/27/2024. During an interview on 5/2/2024 at 9:40 AM, the DON confirmed the Skin Check sheets are used to document resident showers/baths and Resident #80 should have two baths/showers a week. During an interview on 5/2/2024 on 12:21 PM, the DON was shown Resident #80's Skin Check sheets dated 3/27/2024, 3/30/2024, 4/6/2024 and 5/1/2024 and was asked if that was all of these sheets for this resident. The DON stated, That's all we got .wished we had more . During an interview on 5/06/2024 at 5:42 PM, the DON confirmed Resident #80's scheduled shower days are Wednesday and Saturday.

Based on medical record review and interview the facility failed to accurately assess residents for Brief Interview for Mental Status (BIMS) scores, falls, discharge disposition, and diagnoses for 5 of 32 sampled residents (Resident #41, #47, #66, #86 and #128) reviewed for accuracy of assessments. The findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Congenital Diaphragmatic Hernia, Aphasia, Dysphagia, Dysarthria, Pseudobulbar Affect, Sleep Disorder, and Alcohol and Cocaine Abuse. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a BIMS assessment was indicated and not completed. During an interview on 5/2/2024 at 11:20 AM, the MDS Coordinator confirmed the BIMS should have been completed. 2. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnosis including Diabetes, Kidney Failure, Psychotic Disorder with Delusions, and Heart Failure. Review of the progress note dated 1/12/2024, revealed Resident #47 fell from his wheelchair while in his room. Review of the Care Plan dated 1/23/2024, revealed .I am at risk for falls with dates I am at risk for FALLS and fall related injury r/t requires assistance with transfers, medication regime, limited mobility, incontinence .10/21/23 Unwitnessed fall .11/19/23 Unwitnessed . 11/20/23 Unwitnessed fall . 11/30/23 Witnessed fall . 12/20/23 . 1/12/24 Witnessed fall .3/13/24 Unwitnessed fall . Review of the 5 day Medicare MDS dated [DATE], revealed an entry date 1/16/2024, a BIMS score of 7 indicating severe cognitive impairment, .Section J-Health Conditions .Did the resident have a fall any time in the last month prior to admission/entry or reentry. No. Did the Resident have a fall in the last 2-6 months prior to admission/entry or reentry. No . Review of the annual MDS dated [DATE], revealed an entry date 1/16/2024, a BIMS score of 7 indicating severe cognitive impairment, Section J-Health Conditions .Did the resident have a fall any time in the last month prior to admission/entry or reentry. No. Did the Resident have a fall in the last 2-6 months prior to admission/entry or reentry . [was answered] No . During an interview on 5/2/2024 at 2:27 PM the MDS coordinator confirmed the 1/23/2024 and 2/4/2024 MDS assessments were coded incorrectly for falls. 3. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Cognitive Communication Review of the facility policy titled, Deficit, Dementia, Congestive Heart Failure, Hypertension, History of Falling, and Contracture of Left Hand. Review of a Progress Note dated 2/21/2024 at 5:40 PM revealed .Called to resident room per cna [Certified Nursing Assistant], [resident] noted lying on left side on floor . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 10, which indicated he had moderate cognitive impairment Section J Health Conditions falls since prior Assessment-No. Number of falls since prior Assessment was not answered. Review of the Care Plan dated 3/27/2024, revealed .at risk for falls and fall related injury .2/21/24 Unwitnessed fall . During an interview on 5/01/2024 at 4:56 PM, the MDS coordinator was asked if the MDS should been updated to reflect Resident #66's documented fall with injury on 2/21/2024. The MDS Coordinator stated, .the fall should be on the MDS . 4. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Muscle Wasting and Atrophy and Paraplegia. Review of the quarterly MDS dated [DATE], revealed Section I-Active Diagnoses Paraplegia [was not marked] .Quadriplegia [was marked] . The MDS did not accurately reflect the resident had Paraplegia. 5. Review of the medical record revealed Resident #128 was admitted to the facility on [DATE], and was discharged on [DATE], with diagnoses of Sepsis, Bacteremia, Calculus of Kidney, Obstructive and Reflux Uropathy, Diabetes, Bipolar Disorder, Obstructive Sleep Apnea, and Cognitive Communication Deficit. Review of the discharge MDS dated [DATE], revealed a BIMS of 15, indicating intact cognition and .Section A Identification Information .Discharge Status . [was marked] .Short-Term General Hospital . Review of a Physician's Order dated 3/29/2024 revealed, Discharge home with family along with medications. During an interview on 5/07/2024 at 4:25 PM, the MDS Coordinator was asked, where was this resident discharged to on 3/29/2024. The MDS Coordinator stated, .she was discharged home and not to the hospital .

Based on policy review, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 1 of 1 (Resident #66) sampled residents reviewed for hospitalization . The findings include: 1. Review of the facility's undated policy, .Notice of Discharge to Ombudsman Policy Statement, revealed .A copy of the transfer notice may be sent .such as a list of residents on a monthly basis . 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Dementia, Congestive Heart Failure, Hypertension, and Contracture of Left Hand. Review of the Progress Notes dated 2/21/2024, revealed .Called to resident room .lying on left side of floor .Md [physician] called with new orders to transport to [Named Hospital] for evaluation . Review of the Hospital's ED [Emergency Department] Note dated 2/21/2024, revealed Resident #66 was in the ED for evaluation. The facility was unable to provide documentation that an Ombudsman List for Residents was completed, and that the Ombudsman was not notified of Resident #66's transfer to the hospital. During an interview on 5/7/2024 at 10:50 AM, Staff Member D was asked, prior to today, has the Ombudsman Emergency Transfer List been completed. Staff Member D stated, No. Staff Member D was asked should the list have been completed monthly and sent to the Ombudsman. Staff Member D stated, Yes. Staff Member D was asked since the list had not been completed and sent, when were you informed that they should be completed and sent. Staff Member D stated, Today.

Based on policy review, video footage, hospital record review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent serious injury and elopement 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On [DATE] Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened, the resident fell out of the wheelchair sustaining bilateral leg fractures, and later died . Resident #2 fell to the floor in a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in fractured leg, and Resident #6 fell from a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in no injuries. Resident #15, a cognitively impaired resident with Dementia and a history of wandering and exit seeking behaviors, eloped from the facility for an undetermined length of time and was found by the police when making routine rounds on [DATE] at 3:45 AM. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide a safe environment to prevent serious injuries which resulted in fractures and potential serious injury for Resident #1, #2, and #6, and failed to supervise a cognitively impaired resident with Dementia and a history of wandering behaviors, which resulted in Resident #15's elopement. The facility's failure placed Resident #1, #2, #6, and # 15 in Immediate Jeopardy. The Regional Nurse Consultant, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 4:47 PM, in the Conference Room. F-689 was cited at a scope and severity of J which is Substandard Quality of Care. The IJ began on [DATE] and ended on [DATE]. Noncompliance remains for F-689 at a scope and severity of D The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey/investigation on [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 3:56 PM, and the Removal Plan was validated onsite by the surveyors on [DATE] through observation, medical record review, record review, review of education records and audit tools, and staff interviews on various shifts. The last day the facility was in Immediate jeopardy was [DATE]. The findings include: 1. Review of the facility's undated Safety and Supervision policy revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .The individualized care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment .Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. Thes risk factors and environment factors include the following .Falls .Unsafe wandering . Review of the facility's undated Resident Accident/Incident policy revealed .DEFINITION: An accident is an unexpected, unintended event that can cause a resident bodily injury .PROCEDURE/RESPONSIBILITY/ACTION: 1. All residents will be assessed for fall risk during the initial assessment period. 2. The fall assessment tool will be used as a guide in assessing those residents at risk. 3. If a resident is found to be at risk for an accident or incident a plan of care will be initiated by the IDCP [Interdisciplinary Care Plan] team to prevent such incidents .4. Each resident will be reviewed by the DON/Designee, Unit Manager, and the resident's record, care plan and incident report will be brought to the morning meeting for further review and evaluation .5. The fall assessment will be done initially on admission and readmission, annually and with each significant change in status .DOCUMENTATION .Any resident who sustains an accident or an incident, including Injuries of unknown cause will be assessed and an accident and Incident report will be filled out .A description of the incident is to be noted on the incident report and in the nurse's note .The resident will be questioned (unless resident is not appropriate to interview) as to the cause of the incident and possible corrective action .If the cause is unknown an immediate investigation is to begin and the DON/Designee and administrator are to be notified . Review of the facility's policy titled Unusual Occurrence Reporting revised [DATE], revealed As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident .The administration will keep a copy of written reports on file . Review of the facility's policy Elopement dated ,d+[DATE] and revised ,d+[DATE], revealed .Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . Review of the facility's undated Wandering Policy revealed .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who area at risk for harm because of unsafe wandering [including elopement]. The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering .Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility . 2. Review of the medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Diastolic Heart Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Sacral Decubitus, Pain in Unspecified Hip, Essential Hypertension, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment for daily decision making. Resident #1 was dependent on staff for transfers and used a motorized wheelchair independently for mobility. Review of a nurse's note dated [DATE], revealed .this nurse was called to the elevator by another resident [Resident #3], where he had witnessed the pt [patient- Resident #1] fall from the elevator .pt c/o [complained of] back and knee pain. Resident was transported to [Named hospital] via 911 . Review of the facility's video camera footage for [DATE], revealed the 200 hall elevator doors opened at 4:32:05 PM Resident #1 attempted to exit the elevator in a motorized wheelchair at 4:32:10 PM. The camera footage revealed the front of the motorized wheelchair immediately tilted forward and Resident #1 fell to the floor and was lying on her right side. The wheelchair remained in the doorway of the elevator with the back of the chair raised. Resident #1 was transferred from the scene of the accident by Emergency Medical Services (EMS) at 4:53:30 PM. Continued review of the video footage revealed Certified Nursing Assistant (CNA) #1 and an EMS personnel pushed the motorized wheelchair slightly backwards and then lifted the back of the chair down to the hallway floor. Review of the facility investigation for Resident #1's fall on [DATE], showed no indication the video camera footage was reviewed. Review of the Resident #1's hospital record revealed Resident #1 presented to the hospital Emergency Department (ED) on [DATE], via EMS. Review of the ED Triage assessment dated [DATE] at 6:42 PM, revealed the Chief Complaint was related to a fall out of the scooter (motorized wheelchair) with complaints of pain to bilateral legs at a scale of 10 out of 10 (a scale with 0 being no pain and 10 being the worst pain). Review of the hospital's Computerized Tomography (CT) results of Resident #1's right leg dated [DATE] at 8:04 PM, revealed .IMPRESSION: Comminuted [broken in more than 3 separate pieces, typically caused from severe trauma] and angulated [the two ends of the broken bone are at an angle to each other] distal right femur fracture . Further review of the hospital CT of Resident #1's left leg dated [DATE] at 8:11 PM, revealed .Distal left femur fracture . Review of Resident #1's hospital ED History and Physical Examination dated [DATE] at 12:30 AM, revealed . She [Resident #1] presents to ED today following a fall from 4 feet. She says she was in her wheelchair and was thrown from a faulty elevator 4 feet to the floor below .Was at [Name of nursing facility] where this occurred . In ED she received pain medications . Review of Resident #1's hospital physician consult dated [DATE] at 11:58 PM, revealed .EVALUATE FOR ICU [Intensive Care Unit] TRANSFER .admitted to medicine service and plans per ortho [orthopedic] to take her to surgery for repair. She became hypotensive [low blood pressure] tonight with a blood pressure of ,d+[DATE] [normal ,d+[DATE]]. We were consulted to evaluate her for ICU transfer. She has Albumin [used to treat low albumin levels and low blood volume] ordered that has not yet infused. Her hbg [hemoglobin- protein in blood that carries oxygen] had a marked decrease from the night she presented to the ED to early the next morning .Because of the earlier decrease in her hgb she is going to get one unit PRBCs [packed red blood cells]. She does have a history of chronic Atrial fibrillation . Review of Resident #1's hospital's physician consult dated [DATE] 6:07 PM, revealed .On admission patient was found hypotensive with decreasing hematocrit from initial of 34.7 to 21.2 .Assessment/Plan .Femur fracture .Fall from height of greater than 3 feet .Acute pain due to trauma .Lactic acidosis .IMPRESSION .Acute kidney injury stage 3 in the setting of hypotension due to hemorrhagic shock--most likely etiology is postischemic acute tubular necrosis. --We will rule out post traumatic rhabdomyolysis .Lactic acidosis on presentation [to the ED] . Review of the hospital's physician progress note dated [DATE] at 11:15 AM, revealed .Presents for fall from scooter. Has bilateral femur fractures. Hospital course complicated by hemorrhagic shock [a form in which severe blood loss leads to inadequate oxygen at the cellular level] likely secondary to rhabdomyolysis [occurs when damaged muscle tissue releases proteins and electrolytes into the blood and can be the result of a crush injury]. Nephrology following. Hemorrhagic shock improved, plans to transfer out of ICU today . Review of the hospital's physician progress note dated [DATE] at 5:00 PM, revealed .Went into afib RVR [Atrial Fibrillation with Rapid Ventricular Response-rapid contractions of the atria makes the ventricles beat fast too] and became hypotensive .OR [surgery] cancelled, transfer to ICU . Review of the hospital's Procedure note dated [DATE] at 7:15 PM, revealed .Central line insertion procedure .Indication: medication delivery, need for venous access, resuscitation . Review of the hospital's Discharge Summary for Resident #1 dated [DATE], revealed .DEATH SUMMARY .CAUSE OF DEATH: Multifactorial shock [Shock after traumatic injury] is likely to be hypovolemic [liquid portion of the blood (plasma) is too low], but different types of shock can occur in combination]. SECONDARY DIAGNOSES .Acute on chronic renal failure with refusal to undergo renal replacement therapy .Hyperkalemia [elevated potassium levels] .Severe lactic acidosis [when the body produces too much lactic acid and cannot metabolize it quickly enough-can occur with severe trauma] .Atrial fibrillation with rapid ventricular response .History of fall with bilateral distal femur fractures . HOSPITAL COURSE .In short, the patient came from her care home after a fall. She was found to have bilateral femur fractures. She had multiple comorbid issues that were treated while she was here. She did have severe renal disease with worsening renal function and hyperkalemia .She was stable for a period and went for attempted operative revision of her femur fractures but developed severe hypotension preoperatively with atrial fibrillation with rapid ventricular response. She was intubated for stabilization and transferred to the intensive care unit where she continued to decline .She was made Do Not Resuscitate and unfortunately passed away shortly after. May she rest in peace . 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses, Cardiac Arrhythmias, Muscle Weakness, and Vitamin D Deficiency. The quarterly MDS assessment dated [DATE], documented the resident scored a 9 on the BIMS assessment which indicated moderate cognitive impairment for daily decision making. The Functional Status section of the MDS dated [DATE], documented the resident needed supervision for transfers and dressing. Further review revealed Resident #2 used a wheelchair independently for mobility. Review of an incident report dated [DATE], revealed .Fall .Incident Location Hallway/Corridor .Problem Statement [Resident #2's] Foot caught on opening of the elevator . Review of a nurse's note dated [DATE], revealed .Summoned to first floor per staff member. Informed that resident [Resident #2] was on floor near elevator. Wheelchair was overturned with resident still in it. States he was getting out of elevator when his foot got caught in elevator door. Resident observed lying on right side. Complains of right side, right hip, and head pain. Unable to extend right leg without pain . The resident was transferred to the hospital for evaluation. Review of the hospital records revealed Resident #2 was admitted to the hospital on [DATE], for surgical interventions. Review of the hospital's History and Physical examination dated [DATE], revealed .Chief Complaint pt [Resident #2] fell out of wheelchair, pt c/o right hip and shoulder pain .The patient sustained a fall from his wheelchair at the skilled nursing facility and complained of right hip and right rib pain .IMPRESSION: 1. Acute appearing nondisplaced right lateral 8th rib fracture .2. Acute impacted subcapital right femoral neck fracture [usually caused by a fall of an elderly patient to the side] . Resident #2 was unable to tolerate a surgical intervention and was discharged back to the nursing home on [DATE], with orders for physical therapy. Review of the quarterly MDS assessment dated [DATE], documented Resident #2 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment for daily decision making. The MDS assessment further documented the resident currently required extensive assist for transfers and dressing. Resident #2 used a wheelchair independently for mobility. Observations of Resident #2 on [DATE] at 3:50 PM at Friendship Corner (activities area), revealed Resident #2 seated in a wheelchair. He was alert and oriented and was able to propel himself in the wheelchair throughout the hallways. During an interview on [DATE] at 9:30 PM, when asked if resident had a fall while at the facility, Resident #2 nodded his head to signify yes and stated, That's how I broke my leg .It was the floor. It was raised up and I didn't know it. I went to get out and my foot got caught on the floor somehow. My wheelchair fell over . [Elevator] still messes up sometimes. One woman fell last week and broke her leg. I heard she died . 4. Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis Left Non-Dominant Side, Aphasia, Heart Failure, Atrial Fibrillation, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE] documented the resident scored a 3 on the BIMS assessment which indicated severe cognitive impairment for daily decision making. Resident #6 was dependent upon staff for transfers and used a wheelchair independently for mobility. Review of a nurse's note dated [DATE], revealed .Pt [Resident #6] lying in front of w/c [wheelchair at the elevator] alert and verbal. Pt is oriented to staff though unable to verbalize our names. When asked what happened pt answered with one word 'fell ' .send to ER for eval [evaluation] . Review of the annual MDS assessment dated [DATE] documented the resident scored a 3 on the BIMS assessment which indicated severe cognitive impairment for daily decision making. Resident #6 was dependent upon staff for transfers and used a wheelchair independently for mobility. Observation and interview on [DATE] at 1:15 PM, in the resident's room, revealed Resident #6 lying supine in bed. The resident was alert and oriented, but unable to speak in full sentences. He used hand gestures to attempt to express his thoughts. When asked if he had a fall, Resident #6 stated, Yes, On/off came down Boom! When asked if he was referring to the elevator, Resident #6 stated, Yes, open then Boom! The resident used hand gestures in an up/down motion then stated, Boom! Resident #6 confirmed he fell from his wheelchair on [DATE] when exiting the elevator. 5. Review of facility requests for the Elevator Services Technician for the rear/200 hall elevator revealed the following: a. [DATE] (Requested after the 3rd resident incident) - the rear elevator (rear/200 hall) is not leveling down properly. b. [DATE] (during the survey) - last night the inner/outer doors on the #2/rear (200 hall) elevator were separated, he (Maintenance Director) used key to reset. During a telephone interview with the elevator Service Technician on [DATE] at 12:16 PM, when asked for a summary of the service call made on [DATE], the Service Technician stated, I came out when the call came in to check the elevator because it was not leveling properly. I was not able to duplicate that [unlevel] .With this being an elevator from 1962, the elevator does not store history for me to be reviewed. We don't have the ability to review the previous activity . 6. Observations on [DATE] at 11:01 AM, at the 200 hall elevator, revealed the elevator did not operate when the up/down button was pressed. There was no Out of Order signage on the elevator. 7. During an interview with Resident #3 on [DATE] at 1:10 PM, when asked if he witnessed Resident #1 have a fall, he stated, I heard Help me! Help me! about four times. I saw her on the floor and her wheelchair turned over. I told the nurse .Her wheelchair was up on the elevator floor. I didn't see her fall. During an interview on [DATE] at 1:32 PM, when asked if aware of any facility elevator malfunctioning, CNA #4 stated (regarding the 200 hall elevator), .Elevator is up higher when door opens at times .A few months ago the elevator was higher than the floor when the door opened; I'd estimate 4 to 5 inches. It was a whole step down .They [Maintenance] knew it wasn't working the way it was supposed to . During a telephone interview on [DATE] at 2:30 PM, when asked if Nurse #1 was aware of any problem with the elevator doors opening and closing properly, Nurse #1 stated, I was working on 200 hall when [Named Resident #1] had the fall. Her wheelchair fell forward, and she was on the floor .In the past the elevator would not be even with the floor when the door opened . When asked if the malfunctioning elevator had been reported, Nurse #1 stated, I had not reported it, but everyone knew it was a problem. It had been reported in the past . During a telephone interview on [DATE] at 3:20 PM, when asked if aware of any problems with the 200 hall elevator functioning properly, CNA #5 stated, .It has not been leveling all the way. If going from up here [2nd floor] to 1st floor when the doors open the elevator floor is up about 12 inches. If you are not paying attention, you would fall off. The last time I saw it doing that was on [DATE]th [2023] Maintenance knew it was messing up. Other residents each had a fall because of that elevator. Maintenance would turn it off a couple days and then it would work again. Sometimes it would be shaky and jerky when riding it. When asked if training or inservices had been given since the accident involving Resident #1, CNA #5 stated, We haven't had anything about that. It's hush hush. During an interview on [DATE] at 3:41 PM, when asked if aware of any problems with the 200 hall elevator functioning properly, Resident #5 stated, Sometimes the elevator won't go all the way down. I can't get out and I push the button in the elevator again and the floor [elevator floor] goes down . During an interview on [DATE] at 11:55 AM, the Administrator was asked if he interviewed staff that were working when the [DATE] accident occurred, the Administrator stated, Not at the time. [Named DON] should have. The Administrator stated he was not aware of a malfunction in the elevator when the other 2 falls [ resident #2 and #6] occurred. During an interview on [DATE] at 1:54 PM, with Resident #8, the Resident Council President, when asked if there had been any discussion in Resident Council meetings related to the elevator problems, Resident #8 stated, No, don't think we talked about it. The elevator on 200 hall sometimes doesn't go all the way down when the door opens .There needs to be some way to remind a person to look and make sure the elevator is all the way down to the floor .If it's not even you could fall. Happened to me, but I didn't fall out of my chair .It was a few inches drop off that time. Sometimes it's more. You never know when it might happen. I looked down at the floor, not everyone looks. Resident #8 was asked when the elevator floor was not level with the hallway floor when the door opened occurred. Resident #8 stated, About 3 weeks ago .The nurses knew about it. They said it had been reported. During an interview on [DATE] at 3:18 PM, when asked if he recalled the details of the accident involving a recent fall at the 200 hall elevator. CNA #6 stated he had not witnessed the floors being unlevel prior to the accident on [DATE] but had heard about it being unlevel from other staff. CNA #6 stated on [DATE], . [Named Resident #1] was on the floor. The wheelchair was in the doorway of the elevator kind of tilted .The front of the wheelchair was tilted. When asked if the elevator floor was level with the hallway floor, CNA #6 stated, No, it was kind of cocked about 12 inches. You could tell the wheelchair back was resting on the floor of the elevator. When questioned when he was asked for a statement about the accident CNA #6 stated, Today [[DATE]]. During an interview on [DATE] at 4:05 PM, the Maintenance Director stated, No one had reported to me that the floor was not level [elevator floor not leveling with the hallway floor] .The elevator company always says to update it. It's from the 1960s and needs replaced. That's what they have told us . During a telephone interview on [DATE] at 9:18 AM, when asked if CNA #2 was working on [DATE] when Resident #1 had a fall from the elevator, CNA #2 stated, .I was working on the 200 hall .The wheelchair was stuck on the elevator. The back wheels were hung on the elevator floor. The front wheels were on the actual hall floor. There was a gap between the elevator floor and the hall floor, maybe 8 inches or more. The wheelchair was at a slant. I heard there had been other issues with the elevator with the doors and the floor. During a telephone interview on [DATE] at 9:46 AM, when asked if Registered Nurse (RN)/Unit Manager #1 was working when Resident #1 had a fall from the elevator on [DATE], RN/Unit Manager #1 stated, .I came to the scene .The elevator would jam sometimes. There have been times when you get on the elevator, and it malfunctions. It would be jerking while it was moving . When asked if she had reported the malfunctions, she stated, No, but they all knew about it. RN #1 stated she was aware of the incident on [DATE] with resident #2 falling when exiting the elevator. During a telephone interview on [DATE] at 9:31 AM, when asked if CNA #1 was aware of anyone having a fall when exiting the 200 hall elevator, CNA #1 stated, .A lady fell at the elevator, [Named Resident #1] .I saw the elevator floor was a foot or so gap higher. It wasn't flush with the floor. Her chair [wheelchair] was at an angle. The rear tires were on the elevator floor . When asked when Resident #1's wheelchair was moved away from the elevator, CNA #1 stated, One of the ambulance personnel assisted me to move the chair out of the elevator door once [Named Resident #1] was taken to the ambulance. We lifted the back [back of wheelchair] that was hung on the floor and set it down to the hallway floor . When asked if he had given a statement about the accident to the Administrator, CNA#1 stated, No ma'am. A couple days ago [[DATE]] was the first time I had spoken to anyone about it in an interview for a statement. During an interview on [DATE] at 12:38 PM, when asked if aware of any problems with any facility elevator not functioning properly, CNA #3 stated, Yes ma'am. I've seen the elevator not level. You never know when it's going to happen. I told the Maintenance people before. I've been on it and the door opened and it was not level .I told Maintenance workers .They would walk around in the morning, and I made sure to tell them. You never knew when it would open and there be a drop down . When asked which elevator, CNA #3 stated, The one on 200 hall. During an interview on [DATE] at 1:36 PM, Resident #9 stated, I've seen the elevator [200 hall elevator] door open and not go all the way down. Something needs to be done. I know to always look, but some people don't know or might forget. I've told my nurse about it. When asked when he had seen the 200 hall elevator floor unlevel with the hall floor, Resident #9 stated, About 2 or 3 weeks ago. During an interview on [DATE] at 3:30 PM, when asked if she had noted any malfunctioning of the 200 hall elevator, the Director of Marketing stated, I don't take that elevator [200 hall elevator] if I can help it after the incident with [Named Resident #2]. He had a fracture after that fall. I was on it one time when it [unlevel floors] happened. I took the stairs after that . During an interview on [DATE] at 11:40 AM, when asked if LPN #2 had known of a resident having a fall at the 200 hall elevator, LPN #2 stated, I remember a while back there was a resident that fell getting off the elevator. The elevators have trouble all the time. When asked if she had reported the elevators malfunctioning, LPN # 2 stated, No, but everyone knew. It happened often, just never knew when it would. During an interview on [DATE] at 3:12 PM, when asked if she had witnessed Resident #6's fall on [DATE], CNA #7 stated, .I heard him hit the floor. The elevator wasn't working, half up and half down [the floor of the elevator was not level with the hallway floor]. He went to go out of it and the wheelchair tilted down .The elevator door was open because the wheelchair was stuck [in the doorway of elevator] .The Supervisor saw the elevator . When asked if the malfunctioning elevator was reported, CNA #7 confirmed she reported to the Nurse Supervisor. During an interview [DATE] at 10:13 AM, when asked if she was notified when Resident #1 had a fall, Nurse Practitioner (NP) #1 stated Yes, I was called .That surprised me because Resident #1 was very knowledgeable of the use of her wheelchair. When asked if she had been told the elevator malfunctioned, she stated .I've been told the floors are not level at times . NP #1 stated she could not remember being told the other falls were caused by the unlevel floors of the elevator and hallway. During an interview on [DATE] at 10:25 AM, when asked if the staff working on [DATE], when the accident involving Resident #1 happened, had been interviewed and statements recorded in an investigation of the accident, the Director of Nursing (DON) stated Not sure. I talked to the nurse when she called me. I didn't write anything down. [Named Administrator] and the Social Worker were going to get statements . The DON stated he was not aware of any other falls related to unlevel floors of the elevator and hallway. During an interview on [DATE] at 11:15 AM, when asked if the 200 hall elevator was out of service, the Maintenance Director stated the elevator was taken out of service because It's a safety concern. The techs [Elevator Technicians] always clear it and we always have issues after it's cleared .I just don't feel comfortable. I don't want anyone else to get hurt. When asked if signage was placed on the elevator doors to alert residents and staff the elevator was out of service, the Maintenance Director stated, My fault. I didn't have any caution tape. When asked about an Out of Order sign, the Maintenance Director stated, Yeah, I could put one up; My fault. The Maintenance Director stated the 200 hall elevator was working when he took it out of order, but because of the random malfunctioning he decided not to allow the elevator to be used. When asked how the residents and staff would know it was out of order, the Maintenance Director stated, It's turned off. When they push the button, nothing will happen. It's completely off. During an interview on [DATE] when asked if the incident involving Resident #6's fall on [DATE] was investigated, the DON stated, It was talked about [in the morning meetings] with the DON and Unit Managers. The DON previously stated, in an [DATE] interview at 10:25 AM regarding Resident #1's elevator incident, that he was not aware of any other falls related to unlevel floors of the elevator and hallway. During an interview on [DATE] at 9:54 AM, when asked about the hoistway [an enclosed area that is used to house the elevator as it travels between levels in a building] doors on the 200 hall elevator that had been serviced on the following dates: a. [DATE] - clean and adjusted hoistway doors b. [DATE] - checked operation of hoistway doors c. [DATE] - adjusted hoistway doors - door lock/mechanical d. [DATE] - adjusted hoistway doors - interlock/electrical[TRUNCATED]

Based on facility policy review, job description review, and interview, Administration failed to provide oversight that ensured a safe environment and adequate supervision to prevent serious injuries, failed to ensure a Quality Assurance Performance Improvement (QAPI) process of data collection, analysis, interventions, monitoring and follow up, and failed to ensure the highest practicable wellbeing of residents with wheelchair dependency, dementia and wandering behaviors. The facility Administration failed to ensure the 200 hall elevator functioned in a safe manner, failed to conduct a thorough investigation related to accident/hazards involving the malfunction of the 200 hall elevator, failed to take immediate actions to protect all residents from the 200 hall elevator malfunction, and failed to ensure a safe environment to prevent injuries for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. Residents #1, #2, and #6 experienced falls from their wheelchairs when exiting the 200 hall elevator when the elevator floor was not level with the hallway floor. Resident #6 had a fall exiting the elevator in his wheelchair on [DATE] but did not sustain injuries. Resident #2 sustained a rib fracture and right leg fracture on [DATE]. Resident #1 sustained bilateral leg fractures on [DATE], and later died . The facility Administration failed to ensure oversee that services were implemented and evaluated to meet resident needs to maximize resident quality of life, failed to consult with department directors concerning the operation of their departments to assist in correcting problems and improving services, failed to ensure that a system for maintaining and improving building, grounds, and equipment is planned, implemented and evaluated, failed to oversee the planning, implementation and evaluation of an environmental safety program that will maintain the health, welfare and safety of residents, and failed to maintain responsibility for the facility being maintained in a safe manner for residents by assuring that necessary equipment was maintained to prevent elopement hazards for Resident #15, when a cognitively impaired resident who was at risk for wandering, eloped from the facility on [DATE]. The facility Administration's failure placed Residents #1, #2, #6, and #15 in Immediate, Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 9:00 AM in the Conference Room. F-835 was cited at a scope and severity of J. The Immediate Jeopardy began on [DATE] and ended on [DATE]. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on [DATE] at 5:07 PM, and was validated onsite by the surveyors on [DATE] through observations, medical record review, review of education records, and audit tools, meeting minutes, and staff interviews. F-835 remains at a scope and severity of D. The findings include: 1. Review of the facility's undated Safety and Supervision policy revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Review of the facility's policy Elopement revised ,d+[DATE], revealed .Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . Review of the facility's undated Wandering Policy revealed . Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility . 2. Review of the facility's undated Licensed Nursing Home Administrator job description, revealed .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Consult with department directors concerning the operation of their departments to assist in correcting problems and improving services .Make routine inspections of the facility to assure that established policies and procedures are being followed .Ensure that a system for maintaining and improving building, grounds, and equipment is planned, implemented and evaluated .Oversee the planning, implementation and evaluation of an environmental safety program that will maintain the health, welfare and safety of residents, staff and visitors .Review accident/incident reports and establish an effective accident prevention program .Maintain responsibility for the facility being maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained . Review of the facility's undated Director of Nursing Services job description, revealed .The primary purpose of the Director of Nursing [DON] position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies . Review and insure that charting documentation procedures for nursing are met according to state and federal guidelines .Chair, serve on, participate in, and/or attend various committee meetings of the facility [i.e. Quality Assurance Performance Improvement meetings] .provide written and/or oral reports of the nursing program, as required or directed by the above committees. Evaluate and implement recommendations from established committees as they may pertain to nursing services .Inform nursing personnel of new admissions and include all pertinent logistical information .Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan .Review nurses' notes to determine if the care plan is being followed .Communicates with the medical staff, nursing personnel, and other department supervisors . 3. Review of an emailed Transmittal Form dated [DATE], revealed the facility received a packet of documents from [Named Elevator Company] to be completed for approval for updating the 100 hall and the 200 hall elevators. The documents were not completed and signed by the Administrator until [DATE]. The Administrator stated the cost of the recommended updating for the 200 hall elevator was not approved until [DATE]. During an interview on [DATE] at 11:55 AM, the Administrator was asked what has been put in place since the 3 accidents (On [DATE] Resident #6 fell from a wheelchair when exiting the unleveled floor from the 200 hall elevator. On [DATE], Resident #2 fell to the floor in a wheelchair when exiting the 200 hall elevator and sustained a fractured rib and fractured leg. On [DATE], Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened and the resident sustained bilateral leg fractures, and later died ) involving the 200 hall elevator that will keep it from happening again. He stated, .To my knowledge we have never had issues with leveling .I watched the video [for the incident with Resident #1 on [DATE]], and it appears the front wheels of the motorized chair got caught in the threshold. I did question the level when I first watched it .It's an old elevator from 1960's. They [Elevator Services] tell us it needs replacing or updating . During an interview on [DATE] at 10:00 AM, when the Administrator was asked if the facility conducted a thorough investigation and questioned all staff concerning the elopement of Resident #15, he stated No, we didn't question all staff. When asked if the facility had a copy of the video footage of Resident #15's elopement, he stated No, I don't have a copy and it's gone from the video system. We don't have Cloud for backup storage . When asked if the facility has a summary of the video footage with times and locations or any notes, he stated No. When asked if the facility conducted a root cause analysis, the Administrator stated No. When asked did you or the DON come in when called by staff, he stated No. 4. During an interview on [DATE] at 10:25 AM, when asked if the staff working on [DATE], when the accident involving Resident #1 happened, had been interviewed and statements recorded in an investigation of the accident, the Director of Nursing (DON) stated Not sure. I talked to the nurse when she called me. I didn't write anything down. [Named Administrator] and the Social Worker were going to get statements . During an interview on [DATE] at 4:39 PM, the DON was asked was a root cause analysis completed for the elopement of Resident #15 or the elevator accidents involving Residents #1, #2 and #6, he stated .No . During an interview on [DATE], when asked if the incident involving Resident #6's fall from the elevator on [DATE] was investigated, the DON stated, It was talked about. The DON confirmed the Quality Assurance Performance Improvement committee did not meet and discuss the incident, implement interventions, or determine a root cause. The DON would not give any details about what was discussed or when it was discussed related to the incident. During an interview on [DATE] at 3:08 PM, the DON was asked if the facility put any interventions in place to keep the unsafe operation of the elevator and resident incident/accidents from happening again [since the [DATE] incident], he stated .No . The DON confirmed there has been no process for tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes and developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed for the [DATE] elopement incident or the unsafe operations of the elevator which resulted in resident incidents/accidents [DATE], [DATE] and [DATE]. Refer to F689. The surveyors verified the Removal Plan by: 1. Facility Administration consists of the leadership team including: Administrator, Director of Nursing, Unit Managers, Director of Maintenance, Housekeeping Director, Therapy Director, Activities Director, Dietary Manager, and department heads. The surveyor reviewed the list and interviewed Administration. 2. Regional Nurse educated Facility Administration regarding their individual and specific roles related to administration and oversight of the following corrective action plans. The surveyor reviewed the education material, sign in sheet and interviewed Administration. 3. Regional nurse will provide administrative oversight to ensure corrective actions are properly implemented and evaluate effectiveness by conducting routine facility visits and observations. The surveyor interviewed the Regional Nurse. 4. Director of Nursing and/or Unit Managers will complete a new Baseline Elopement assessment for current residents and reevaluate assessments upon admission/readmission, quarterly, annually and change in condition. Any discrepancies identified will be reevaluated by Interdisciplinary team and necessary corrections will be entered to resident's care plan and implemented. The surveyor reviewed the records, audit review and interviewed staff. 5. Director of Nursing/Unit Manager will ensure accuracy by reviewing wander risk assessments during clinical meetings by comparing entered data in residents' charts and actual residents' behaviors. The surveyor reviewed clinical meeting form, record review and interviewed staff. 6. Director of Nursing/Unit Manager will Implement interventions according to wander risk assessment score and elopement assessment. The surveyor reviewed records and interviewed staff. 7. Director of Nursing/Unit Manager/Administrator will ensure adequate staffing for oversight of dementia and wandering residents daily. The surveyor reviewed staffing matrix form for scheduling and interviewed staff. 8. Administration will evaluate referrals and review hospital records with high potential for elopement prior to admission to determine elopement risk. Preadmission evaluations for high-risk elopement referrals will be conducted by DON or Administrator. A determination on whether the resident is appropriate for admission or potential interventions will be made prior to admission. The surveyor reviewed referral admission criteria matrix and interviewed staff. 9. Nurses will check for wander guard placement daily with visual check and documentation on MAR. The surveyor reviewed medical record and interviewed staff. 10. Director of Nursing and/or Unit Managers will review new admits elopement assessments and exit-seeking behaviors to identify high risk residents and transfer to secure unit for monitoring if appropriate, as discussed by interdisciplinary team. The surveyor reviewed records and interviewed staff. 11. Director of Nursing and/or Unit Managers will place photos of residents identified as high risk for elopement at nurses' stations and front desk binder. The surveyor reviewed the books and interviewed staff. 12. Maintenance/Administrator will conduct Elopement Drill and monthly thereafter. The surveyor reviewed the sign in sheets, drill debriefing information and interviewed staff. 13. Maintenance will perform baseline audit of all exit doors to ensure functionality and security. The surveyor reviewed audit sheets and interviewed staff. 14. 200 Hall back elevator will remain off and prohibited from use until replaced and cleared by elevator company. The surveyor observed the elevator, reviewed the audit forms, and interviewed staff. 15. Out of order sign placed on elevator door. The surveyor observed the sign, reviewed the audit form, /and interviewed staff. 16. Sign placed to direct residents/staff/visitors to use front elevators. The surveyor observed the sign and interviewed staff. 17. Director of Nursing and/or Unit Managers will identify residents that use the elevators via standard or electric wheelchairs. The surveyor reviewed the records and interviewed staff. 18. Therapy will evaluate residents that use elevators via standard or electric wheelchairs for safe entering and exiting. The surveyor reviewed the records and interviewed staff. 19. Maintenance will check elevator functionality daily and maintain log. The surveyor reviewed the log and audit and interviewed staff. 20. Facility will initiate and implement QAPI for F835. The surveyor reviewed the forms and interviewed staff. 21. Regional Nurse will in-service Facility Administration regarding F835 and proper facility oversight. The surveyor reviewed the education material, sign in sheet and interviewed staff. 22. Director of Nursing will in-service nurses including agency on accurate completion of elopement assessments. The surveyor reviewed the education material, sign in sheet and interviewed staff. The surveyor reviewed the education material, sign in sheet and interviewed staff. 23. Director of Nursing will in-service nurses including agency regarding implementation of proper interventions based on wander and elopement assessments. The surveyor reviewed the education material, sign in sheet and interviewed staff. 24. Director of Nursing will in-service nurses including agency regarding Dementia, wandering residents and behavior management. The surveyor reviewed the education material, sign in sheet and interviewed staff. 25. Director of Nursing will in-service staff including agency personnel on elopement policy and protocols. The surveyor reviewed the education material, sign in sheet and interviewed staff. 26. Director of Nursing will in-service staff including agency personnel on abuse/abuse reporting. The surveyor reviewed the education material, sign in sheet and interviewed staff. 27. Director of Nursing will in-service staff including agency personnel to ensure that residents with active exit-seeking behaviors are immediately addressed and placed on 1:1 or transferred to the secured unit. The surveyor reviewed the education material, sign in sheet and interviewed staff. 28. Director of Nursing will in-service staff including agency personnel on providing vulnerable residents (moderate/high risk wanderers, active exit-seekers, cognitively impaired with confusion, high fall risks, wheelchair/power chair users) with adequate supervision and safe environment to prevent accidents and elopements. The surveyor reviewed the education material, sign in sheet and interviewed staff. 29. Director of Nursing/Maintenance will in-service staff including agency personnel to ensure exit doors are properly closed and secure, and not propped open to ensure security of residents. The surveyor reviewed the education material, sign in sheet and interviewed staff. 30. Director of Nursing will in-service staff including agency personnel on immediately reporting to Maintenance and/or facility administration when they observe/notice a faulty or improperly functioning elevator. The surveyor reviewed the education material, sign in sheet and interviewed staff. 31. Director of Nursing/Maintenance will in-service staff including agency on proper use of elevator and ensure carts are carefully placed to prevent potential damage to elevator mechanism. The surveyor reviewed the education material, sign in sheet and interviewed staff. 32. Director of Nursing will in-service staff including agency personnel on F835. The surveyor reviewed the education material, sign in sheet and interviewed staff. 33. Education will be ongoing for all new staff including agency. The surveyor reviewed the education material, sign in sheet and interviewed staff. 34. Staff who have not completed education will not be allowed to work the floor until all education is completed and verified. The surveyor reviewed the employee list and interviewed staff. 35. QAPI meeting minutes will be submitted to Regional Nurse for review and verification of completed performance improvement plans. The surveyor reviewed the minutes and interviewed staff. 36. Maintenance will audit and maintain log binder of all exit doors being checked for proper closure daily at minimum, and random times throughout the day. The surveyor reviewed the audits, log binder and interviewed staff. 37. Maintenance will complete audits daily to ensure facility doors are locking appropriately and wander guard system is working. The surveyor reviewed the audits and interviewed staff. 38. Director of Nursing and/or Unit Managers Audits will complete audits 3 times a week to ensure elopement assessments are completed upon admission, quarterly, annually and change of condition; and ensure appropriate interventions are implemented. The surveyor reviewed the audits and interviewed staff. 39. Facility administration will conduct environmental audits 3 times a week to ensure residents have a safe environment to prevent accidents and elopement incidents. The surveyor reviewed the audits and interviewed staff. 40. Audit results will be submitted to QAPI committee to be reviewed and addressed as needed. The surveyor reviewed audit reports and interviewed staff. Noncompliance of F-835 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, review of Quality Assurance Performance Improvement (QAPI) minutes, and interview, the QAPI committee failed to ensure systems and processes were in place and consistently followed by staff that address quality issues related to a safe environment and adequate supervision to prevent serious injuries. The QAPI Committee failed to identify quality safety deficiencies and failed to implement and monitor effective safety interventions for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On [DATE], Resident #6 fell from a wheelchair when exiting the unlevel floor from the 200 hall elevator. On [DATE], Resident #2 fell to the floor in a wheelchair when exiting the 200 hall elevator and sustained a fractured rib and fractured leg. On [DATE], Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened and the resident sustained bilateral leg fractures, and later died . Additionally, the QAPI committee failed to conduct thorough investigations to determine the root cause of resident accidents related to an unsafe operating elevator and a resident elopement. The QAPI Committee failed to identify quality safety deficiencies, failed to monitor and maintain secure exit doors, identify residents with exit seeking behaviors and implement safety measures, and monitor the effectiveness of any measures implemented related to a cognitively impaired resident with wandering and exit seeking behaviors. Resident #15 exited the facility on [DATE] at approximately 12:00 AM, without staff knowledge, and was found by the police making rounds at 3:45 AM. The facility's QAPI Committee failures placed Residents #1, #2, #6, and #15 in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 4:47 PM in the Conference Room. The facility was cited IJ at F-867 at a scope and severity of J. The IJ began on [DATE] and ended on [DATE]. The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey on [DATE]. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on [DATE] at 5:07 PM, and was validated onsite by the surveyors on [DATE] through observations, medical record and record reviews, review of education records and audit tools, and staff interviews. F-867 remains at a scope and severity of D. The findings include: 1. Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program - Design and Scope revealed .The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of life, resident choice and safety . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program revealed .This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents .The objectives of the QAPI program are to: provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .establish systems through which to monitor and evaluate corrective actions .The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. The QAPI committee reports directly to the administrator .The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. The QAPI plan describes the process for identifying and correcting quality deficiencies. The components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. The committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership revealed .The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body .The responsibilities of the QAPI committee are to: collect and analyze performance indicator data and other information; identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services; identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; utilize root cause analysis to help identify where identified problems point to underlying systematic problems; help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; establish benchmarks and goals by which to measure performance improvement; coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and communicate all phases of the QAPI process to the administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities .Special meetings may be called by the administrator as needed to present issues that need to be addressed before the next regularly scheduled meeting . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Analysis and Action revealed .The QAPI program overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level .The QAPI committee is responsible for analyzing, identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the administrator and governing board . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Feedback, Data and Monitoring revealed .Information is collected, evaluated and monitored by the QAPI committee .The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes .Root cause analysis is conducted to identify problematic processes and systems that need to be addressed. Corrective actions and performance improvement activities are initiated and monitored. The committee tracks and documents the progress of existing initiatives as well as newly identified ones, as part of the ongoing QAPI process . Review of the facility's undated policy titled Safety and Supervision of Residents revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide a commitment to safety at all levels of the organization. When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause[s] of the hazards and develop strategies to mitigate or remove the hazards to the extent possible .The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify and specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards .monitoring the effectiveness of interventions .Resident supervision is a core component of the systems approach to safety . Review of the facility's undated policy titled Accidents/Incidents-Medical Director Review of revealed .The medical director shall review accident and incident reports. The medical director shall consult with the administrator and director of nursing regarding accidents and incidents and make recommendations about preventive approaches and corrective actions. As part of the QA process, the medical director will work with the director of nursing services, administrator, and other department to evaluate trends, patterns, and interventions .QA documentation will include the medical director's input on these issues . 2. Review of the facility's undated Licensed Nursing Home Administrator job description, revealed .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Consult with department directors concerning the operation of their departments to assist in correcting problems and improving services .Make routine inspections of the facility to assure that established policies and procedures are being followed .Review accident/incident reports and establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services job description, revealed .The primary purpose of the Director of nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met according to state and federal guidelines .Chair, serve on, participate in, and/or attend various committee meetings of the facility [i.e. Quality Assurance Performance Improvement meetings] .provide written and/or oral reports of the nursing program, as required or directed by the above committees. Evaluate and implement recommendations from established committees as they may pertain to nursing services .Inform nursing personnel of new admissions and include all pertinent logistical information .Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . Review of the QAPI minutes dated [DATE], revealed team members names in attendance RN #1 Unit Manager, RN #2 Unit Manager, Maintenance Director, Medical Director. During an interview on [DATE] at 11:55 AM, the Administrator was asked about the accidents involving the 200 hall elevator. He stated, .To my knowledge we have never had issues with leveling [the elevator door would open and the elevator floor was not level with the hallway floor] .I watched the video [for the accident with Resident #1 on [DATE]], and it appears the front wheels of the motorized chair got caught in the threshold. I did question the level when I first watched it .It's an old elevator from 1960's. They [Elevator Services] tell us it needs replacing or updating . During an interview on [DATE] at 10:00 AM, the Administrator was asked if the facility did a thorough investigation concerning the elopement of Resident #15, he stated No, we didn't question all staff. When asked if the facility had a copy of the video footage of Resident #15's elopement, The Administrator stated No, I don't have a copy and it's gone from the video system. We don't have Cloud for backup storage . When asked if the facility had a summary of the video footage with times and locations or if there were any notes [related to the elopement], he stated No. When asked if the facility did a root cause analysis [related to Resident #15's elopement], he stated No. When asked if the Administrator or DON came to the facility to begin the investigation to determine the root cause the Administrator said No. During an interview on [DATE] at 4:39 PM, the Director of Nursing (DON) was asked what his role was in QAPI. He stated . [Named Administrator] took control .I did not attend any QAPI meeting .The elopement occurred on a Friday and I was on vacation all the next week .When I came back from vacation, I didn't do anything else related to the elopement . When asked if a root cause analysis was completed for Resident #15's elopement or the elevator accidents involving Resident #1, Resident #2, and Resident #6, he stated .No . During an interview on [DATE] at 4:52 PM, the Director of Social Services was asked what role she had in the investigation of Resident #15's elopement. She stated .My only role was to facilitate a psych [psychiatric] evaluation . When asked about her involvement in meetings, including QAPI, the Director of Social Services stated .no, I had no involvement in any meetings .just notify psych .no QAPI or meeting about it . During a phone interview on [DATE] at 5:05 PM, the RN #2 Unit Manager was asked if a head count was completed after Resident #15's elopement to ensure all residents were accounted, she stated .no . just the room change nothing else . When asked if she participated in meetings about Resident #15's elopement, RN #2 stated .no, no meeting, no monitoring, nothing else comes to mind . During an interview on [DATE] at 5:10 PM, the RN #1 Unit Manager was asked if she participated in meetings about Resident #15's elopement or was asked to monitor anything (resident wandering/elopement screen if completed and accurate, review nurse's notes per shift for resident's behaviors, resident's care plans if completed and accurate), she stated .no meetings .no request to do anything from management .I just know what to do for my patients .no meetings to discuss or investigate what happened .nothing . When asked if she participated in a QAPI meeting, RN #1 stated .no, definitely not . During an interview on [DATE] at 4:04 PM, the Maintenance Director was asked if he was informed of Resident #15's elopement. He stated .No, no one informed me of the elopement until a week later .If [named Administrator] don't want me to know he don't tell me. We close [the Maintenance Director was very close with the previous Administrator], I can't say things if I don't know. We close like that. If you don't know then can't give out information .don't know [the maintenance director stating he doesn't know]. He [previous Administrator] didn't report it to you [State Agency], and he didn't report it to me. A week or so after the elopement happened, he just asked me to copy the video . When asked if he participated in QAPI the Maintenance Director stated .no I don't . When asked if he attended a QAPI meeting about the elopement, he stated .no . When shown the attendance list [for the QAPI minutes dated [DATE]] he stated .no didn't know anything about it and no I did not attend . During the interview the Maintenance Director looked at his phone and said I got a text from him on [DATE] and it said he [Administrator] needed a door audit from me and it needed to be dated [DATE] .Another text was sent to me from him dated [DATE] and it said he [Administrator] needed a weekly wander guard test for last 2 weeks and one needs to be on the 7th . The previous Administrator presented a typed list of attendees to the [DATE] QAPI meeting concerning Resident #15's elopement with the Maintenance Director, Unit Manager #1 and #2 and Medical Director listed as being present. In accordance with the listed attendees interviews, they were not present for a QAPI meeting regarding the elopement nor had any part in an investigation related to the elopement. Review of the [DATE] through [DATE] incident/accident reports revealed no documentation the Medical Director reviewed of the reports. During an interview on [DATE] at 3:08 PM, the DON confirmed there was no electronic signature or hard copy print of the incident/accident reports where the medical director had reviewed and signed. He stated .no signature on the electronic record and we do not print a hard copy everything we do is electronic .The medical director would have signed it electronic if reviewed . During a phone interview on [DATE] at 1:00 PM, the Medical Director stated .I was notified of the elopement. I don't recall the date or time .I do not recall any meeting to discuss the investigation or outcomes. I just heard about it .Same about the elevator and the resident [Resident #1] with two fractured femurs that died . I was notified of it but no meeting to discuss any investigation, plans or outcomes. I just heard about it .When asked if she was notified of Resident #2 and Resident #6's accident involving the 200 hall elevator and/or if she attended a meeting to discuss the accidents, the Medical Director stated .no . During an interview on [DATE] at 3:08 PM, the DON stated, No the facility did not perform a root cause analysis on any incidents from [DATE] - [DATE]. The DON confirmed the facility did not identify problems or potential problem areas, did not track and monitor, set goals and threshold, analyze, or develop action plans and assess if those actions were effective for the [DATE] elopement incident or the unsafe operations of the elevator which resulted in resident incidents and accidents on [DATE], [DATE] and [DATE]. The DON stated .I went on vacation on [DATE] and did not return until [DATE] and did not participate in anything .no I did not have any system in place to analyze the interventions, monitor and assess the effectiveness of those interventions for the elopement .no, we had no QAPI meeting or discussion of the resident's incidents concerning the elevator floor not being level with the hallway floor when the door opened . When asked if the facility put any interventions in place to keep the unsafe operation of the elevator and resident incident/accident from happening again, the DON stated .No . There was no documentation of an effective QAPI program was in place. Refer to F-689 and F-835. The Surveyor verified the Removal Plan by: 1. QAPI committee will meet weekly to discuss corrective actions to ensure compliance and determine effectiveness of improvement plans. The surveyor reviewed the meeting minutes and interviewed Administration. 2. The QAPI process will serve as formal oversight of completed corrective action plans and identify any trends resulting from audits conducted. The surveyor interviewed Administration. 3. QAPI meeting minutes will be submitted to Regional Nurse for review and verification of completed performance improvement plans and audits. The surveyor interviewed Administration. 4. Director of Nursing will update Wandering Risk Assessment to include guidelines to implement appropriate interventions based on total assessment score. The surveyor reviewed records and interviewed staff. 5. Director of Nursing/Unit Manager will Implement interventions according to wander risk assessment score and elopement assessment. The surveyor reviewed records and interviewed staff. 6. Director of Nursing and/or Unit Managers will complete a new Baseline Elopement assessment for current residents and reevaluate assessments upon admission/readmission, quarterly, annually and change in condition. Any discrepancies identified will be reevaluated by Interdisciplinary team and necessary corrections will be entered to resident's care plan and implemented. The surveyor reviewed records and interviewed staff. 7. Director of Nursing/Unit Manager will ensure accuracy and appropriate interventions by reviewing wander risk assessments during clinical meetings and comparing entered data in residents' charts and actual residents' behaviors. The surveyor reviewed records and interviewed staff. 8. Director of Nursing/Unit Manager/Administrator will ensure adequate staffing for oversight of dementia and wandering residents daily. The surveyor reviewed staffing chart and interviewed staff. 9. Administration will evaluate referrals and review hospital records with high potential for elopement prior to admission to determine elopement risk. Preadmission evaluations for high-risk elopement referrals will be conducted by DON or Administrator. A determination on whether the resident is appropriate for admission or potential interventions will be made prior to admission. The surveyor reviewed admission criteria and interviewed Administration. 10. Nurses will check for wander guard placement daily with visual check and documentation on MAR. The surveyor reviewed medical record and interview of staff. 11. Director of Nursing and/or Unit Managers will review new admits elopement assessments and exit-seeking behaviors to identify high risk residents and transfer to secure unit for monitoring if appropriate, as discussed by interdisciplinary team. The surveyor reviewed audit records and interviewed staff. 12. Director of Nursing and/or Unit Managers will place photos of residents identified as high risk for elopement at nurses' stations and front desk binder. The surveyor reviewed all binders and interviewed staff. 13. Maintenance/Administrator will conduct Elopement Drill and monthly thereafter. The surveyor reviewed the elopement drill documentation and interviewed staff. 14. Maintenance will perform baseline audit of all exit doors to ensure functionality and security. The surveyor reviewed audit results and interviewed staff. 15. 200 Hall back elevator will remain off and prohibited from use until replaced and cleared by elevator company. The surveyor verified by observation and interviewed staff. 16. Out of order sign placed on elevator door. The surveyor verified by observation and interviewed staff. 17. Sign placed to direct residents/staff/visitors to use front elevators. The surveyor verified by observation and interviewed staff. 18. Director of Nursing and/or Unit Managers will identify residents that use the elevators via standard or electric wheelchairs. The surveyor reviewed records and interviewed staff. 19. Therapy will evaluate residents that use elevators via standard or electric wheelchairs for safe entering and exiting. The surveyor reviewed records and interviewed staff. 20. Maintenance will check elevator functionality daily and maintain log. The surveyor reviewed log and interviewed staff. 21. Facility will initiate and implement QAPI for F867. The surveyor reviewed records and interviewed Administration. 22. Regional Nurse will in-service Facility Administration (Administrator, Director of Nursing, Unit Managers, Department heads) regarding F867 and QAPI policy. The surveyor reviewed education material, sign in sheets and interview of staff. 23. Director of Nursing will in-service nurses including agency staff regarding QAPI policy, Root Cause Analysis and Completion of Performance Improvement Plans. The surveyors reviewed education material, sign in sheets and interviewed staff. 24. Director of Nursing will in-service nurses including agency on accurate completion of elopement assessments. The surveyors reviewed education material, sign in sheets and interviewed staff. 25. Director of Nursing will in-service nurses including agency regarding implementation of proper interventions based on wander and elopement assessments. The surveyors reviewed education material, sign in sheets and interviewed staff. 26. Director of Nursing will in-service nurses including agency regarding Dementia, wandering residents and behavior management. The surveyors reviewed education material, sign in sheets and interviewed staff. 27. Director of Nursing will in-service staff including agency personnel on elopement policy and protocols. The surveyors reviewed education material, sign in sheets and interviewed staff. 28. Director of Nursing will in-service staff including agency personnel on abuse/abuse reporting. The surveyors reviewed education material, sign in sheets and interviewed staff. 29. Director of Nursing will in-service staff including agency personnel to ensure that residents with active exit-seeking behaviors are immediately addressed and placed on 1:1 or transferred to the secured unit. The surveyors reviewed education material, sign in sheets and interviewed staff. 30. Director of Nursing will in-service staff including agency personnel on providing vulnerable residents (moderate/high risk wanderers, active exit-seekers, cognitively impaired with confusion, high fall risks, wheelchair/power chair users) with adequate supervision and safe environment to prevent accidents and elopements. The surveyors reviewed education material, sign in sheets and interviewed staff. 31. Director of Nursing/Maintenance will in-service staff including agency personnel to ensure exit doors are properly closed and secure, and not propped open to ensure security of residents. The surveyors reviewed education material, sign in sheets and interviewed staff. 32. Director of Nursing will in-service staff including agency personnel on immediately reporting to Maintenance and/or facility administration when they observe/notice a faulty or improperly functioning elevator. The surveyors reviewed education material, sign in sheets and interviewed staff. 33. Director of Nursing/Maintenance will in-service staff including agency on proper use of elevator and ensure carts are carefully placed to prevent potential damage to elevator mechanism. The surveyors reviewed education material, sign in sheets and interviewed staff. 34. Director of Nursing will in-service staff including agency personnel on F835. The surveyors reviewed education material, sign in sheets and interviewed staff. 35. Education will be ongoing for all new staff including agency. The surveyor reviewed material and interviewed staff. 36. Staff who have not completed education will not be allowed to work the floor until all education is completed and verified. The surveyor reviewed list of employees and interviewed staff. 37. Maintenance will audit and maintain log binder of all exit doors being checked for proper closure daily at minimum, and random times throughout the day. The surveyor reviewed audit tools, results and binders and interviewed staff. 38. Maintenance will complete audits daily to ensure facility doors are locking appropriately and wander guard system is working. The surveyor reviewed audits and interviewed staff. 39. Director of Nursing and/or Unit Managers will complete audits 3 times a week to ensure elopement assessments are completed upon admission, quarterly, annually and change of condition; and ensure appropriate interventions are implemented. The surveyor reviewed audit tools and results and interviewed staff. 40. Facility administration will conduct environmental audits 3 times a week to ensure residents have a safe environment to prevent accidents and elopement incidents. The surveyor reviewed audit tools, results and interviewed staff. 41. Audit results will be submitted to QAPI committee to be reviewed and addressed as needed. The surveyor reviewed audit results and interviewed staff. Noncompliance of F-867 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, policy review, document review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to provide oversight that established and implemented policies and procedures to assure the facility was administered in a manner to use its resources effectively and efficiently. The QAPI committee failed to ensure a QAPI program that identified opportunities for improvement related to accurate wandering/elopement assessments and failed to implement performance improvement activities to provide a safe environment for residents, identify, report, investigate and prevent incidents of elopement and failed to ensure systemic processes were in place and consistently followed by staff and administration. The QAPI committee failed to implement a systematic approach to accurately identify and assess, implement interventions, monitor the implementation of and the effectiveness of its performance improvement activities to ensure improvements are sustained in identifying processes to identify deviations and adverse events when a resident exited the facility without staff knowledge, failed to provide adequate supervision to prevent elopement and failed to ensure a safe environment for 1 of 14 sampled residents (Resident #1) in Immediate Jeopardy when Resident #1, a severely cognitively impaired, vulnerable resident with Dementia, confusion, and wandering behaviors, eloped from the on 1/2/2023 at an unknown time after 1:15 PM, walked across the employee back parking lot and was found near the street. Resident #1 was unsupervised outside the building which resulted in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-867 was cited at a scope and severity of J. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's undated Quality Assurance and Performance Improvement [QAPI] Policy and Procedure, revealed .To ensure that [Name of the facility] implements a comprehensive QAPI program which addresses all the care and unique services that the Facility provides. To ensure continuous evaluation of the Facility's systems .It is the policy of the Facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life .The facility will maintain a QAPI program that will ensure that the Facility obtains feedback, uses data, and takes action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting Facility-wide processes that impacts quality of care, quality of life, and resident safety .The facility shall develop and implement policies and procedures .These approaches may include root cause analysis, reverse tracker methodology, or healthcare failure and effects analysis .The Facility shall collect and monitor data reflecting its performance, including adverse events. Data collection can be done by audit tools, direct observations, interview, or testing .The Facility will take actions aimed at performance improvement, which includes implementation of corrective actions, measuring success, and tracking performance, to ensure improvements are achieved and sustained .The performance improvement activities will track medical errors and adverse resident events, analyze their causes, implement preventive actions and mechanisms to prevent future events .Responsibilities of QAA [Quality Assurance] Committee .is responsible for .Regularly reviewing and analyzing data .acting on available data to make improvements; identifying and responding to quality deficiencies throughout the facility; .developing and implementing corrective action, and monitoring to ensure performance goals or targets are achieved; revising corrective action when necessary . Review of the facility's policy Quality Assurance Performance Improvement dated 12/15/2020 and reviewed 12/15/2022, revealed .The facility shall implement a QAPI program that addresses all the care and unique services the facility provides .The Administration of this facility will develop and lead the QAPI program .This facility will implement and maintain systems to monitor care and services, drawing data from multiple sources .It also includes tracking, investigating, and monitoring Adverse Events that will be investigated every time they occur, and action plans implemented to prevent recurrences .This facility will conduct Performance Improvements Projects [PIPs] to examine and improve care or services in areas that are identified as needing attention .This facility will use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its root causes, and implications of a change .This facility has policies and procedures to demonstrate proficiency in the use of Root Cause Analysis . 2. Review of the facility's undated Licensed Nursing Home Administrator job description revealed, .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Make routine inspections of the facility to assure that established policies and procedures are being followed .establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services (DON) job description revealed, .The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . 3. Resident #1 was admitted to the facility from the hospital on 12/30/2022. The hospital's History and physical was sent to the facility upon the resident's admission and revealed Resident #1 had lived with his nephew, had falls at home, and was having more confusion with periods of sundowning and wandering at night. A staff interview revealed that cognitively impaired Resident #1 exhibited exit seeking behaviors prior to exiting/eloping from the facility. On 1/2/2023 on the 3:00 PM -11:00 PM shift, Certified Nursing Assistant (CNA) #3 stated, .I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He said I am trying to go to [Name of a street]. I said ok well, let me go down here and see what is going on. I came back up front and he was gone . There were no interventions implemented for Resident #1's exit seeking behaviors at that time. Resident #1 exited/eloped on 1/2/2023 at an unknown time and was out of the facility unknown to staff and unsupervised by staff for an unknown period of time. The resident was later found by Registered Nurse (RN) #2. RN #2 stated, . I can't remember what time I found him on the far side of the back employee parking lot located near the street [Name of the street] and the apartments .He was walking and looking left and right like didn't know where to go, not sure .Just me and him I don't remember any other staff around when I found him. He had on pants and a shirt .It was a little rainy, wet but not cold .I called his name and he said Hey baby I'm glad to see you . The facility's investigation dated 1/3/2023 of Resident #1's elopement on 1/2/2023 revealed he was found outside on the sidewalk beside the street, a 1,000 feet from the building. The facility documented Resident #1 exited the courtyard either thru a gap between a chain link fence and gate (that was loosely locked with a bike type rope lock) or through a gap that was between the chain link fence and the building wall. The facility failed to save the video as part of the investigation and did not include a summary of the video with times and locations in the investigation. The surveyor was unable to view the video and the Administrator did not keep notes from review of the video. 4. The facility Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI was established to oversee the facility, failed to identify the root cause of concerns identified, and failed to ensure systems and processes were developed and consistently followed by facility staff related to a safe environment. Review of facility data and information obtained during the survey revealed the QAPI committee members consist of at the Administrator, DON, Minimum Data Set (MDS) Nurse, Social Services, Medical Director, Medical Director designee, and Consultant. The facility developed an improvement plan dated 1/2/2023 to address Resident #1's elopement incident. The facility failed to ensure the following interventions were implemented: The Improvement plan to review new admits' elopement assessments for appropriate interventions failed to be implemented as evidenced by the wander/elopement assessments not containing all data. The Improvement plan to audit all elopement assessments was not implemented as the facility was unable to provide the audits, audit results and the assessments that were conducted were not accurate. The Improvement plan to submit all audit results to the QAPI committee to be reviewed and address as needed was not completed as the facility could not provide evidence. The facility's QAPI committee failed to ensure the facility developed, implemented, monitored and sustained appropriate actions to prevent resident elopements and failed to ensure policies and procedures were followed in accordance with the facility QAPI policy. 5. During an interview on 3/7/2023 at 2:30 PM, the DON revealed, .As part of our Performance Improvement [PIP] we audited all residents for wandering risk screen/assessments on 1/3 and 1/4 [2023] to see if anyone was at risk for wandering or elopement or if anyone new . When the DON was asked what was learned and what the outcome was, he stated .Well I don't know .We did the audit .No, I don't have any quantitative data to show . When asked how you would know your outcome and if you needed to work on something, he stated, .We wouldn't know .We didn't evaluate it or look at the results . When asked did you do 100% of the residents, he stated .Yes . When asked about QAPI and the elopement discussion he stated, .I just get into the clinical side how everyone was .didn't get involved in investigation or how he got out. That was administrator and maintenance director . The Surveyor requested every day during the survey for the DON to provide the Performance Improvement Project (PIP) results of an audit of all new admits elopement assessment after 1/4/2023. The DON did not provide documentation of the audit or results during the survey. Review of the facility's census on 1/3/2023, revealed 131 residents. Review of the list of residents with a wander risk screen provided by the DON revealed 48 out of 131 were not completed for a 36.6%. When the DON was asked did you do quantitative results he stated .No .we didn't do that . When asked why were only 63.4% completed, He stated, .I didn't know all [resident screens] were not done .two of my unit managers were to do them . When asked what the analysis and interventions put into place, and were the interventions monitored and evaluated, he stated .We didn't do any of that . During an interview on 3/6/2023 at 12:53 PM, RN #2 was asked what interventions were implemented after the elopement. She stated, .everything stayed the same .I [RN #2] have no knowledge of anything implemented since . When she was asked were you part of a QAPI meeting to discuss the elopement and part of a root cause analysis, she stated, .I was not part of a root cause analysis or QAPI meeting .yes that is my signature on the QAPI paper, but I was not part of a meeting .nothing was implemented that I am aware of . During an interview on 3/15/2023 at 1:00 PM, RN #2 was asked did you participate in the wander risk screen audit for all residents, she stated .I just did what I was told .I did 100 hall .I don't recall anything we did in response to the audit .my process is the same I don't do anything different .it's the same . When she was asked did you audit all residents on 100 hall, she stated .I guess I missed some . During an interview on 3/6/2023 at 2:32 PM, the Director of Maintenance revealed .I don't go to QAPI .I am not part of the QAPI meeting . During an interview on 3/7/2023 at 7:50 AM, RN #1 was asked about her role in QAPI, she stated .Yes that is my signature [QAPI signature sheet] but I can't remember anything about it [meeting about elopement 1/2/2023] .No, don't know how he got out or what interventions put in place after that .I don't know anything about any root cause analysis or analysis . During an interview on 3/8/2023 at 12:30 PM, the Nurse Practitioner revealed, .I got a call when he [Resident #1] got out .I came in the next day examined [named person Resident #1] and met with administrator and I can't remember who else was in there in [named DON] office .I was told he got out through the basement door .I don't know who said that . When asked if she received any follow up from the 1/3/2023 meeting, she stated, .No, I have received no follow up .No discussion .He got out through the basement as far as I know . During an interview on 3/14/2023 at 3:16 PM, the Administrator was asked if a root cause analysis was performed. He stated, .I thought my PIP was a root cause analysis .No, I didn't include in the analysis people involved .If something is nursing, I let [named person DON] speak to that .I watched the video and concluded how he got out . When the Administrator was asked did you ask the staff about any behaviors or triggers the resident may have experienced prior to the incident, the Administrator stated, .I didn't think about that .No, I didn't include direct care staff . When the Administrator was asked did you follow up, what did you do with the audit results or learn from the audit, he stated .No, I see what you are saying . During an interview on 3/15/2023 at 1:00 PM, the Administrator was asked about the Quality Assessment & Performance Improvement (QAPI) PIP dated 1/2/2023, the audit results of all residents wander risk screen/assessments dated 1/3/2023 and 1/4/2023 and the audit results of all new admits after 1/4/2023 wandering risk screen/elopement assessments. He stated, .If it's not there, it is not there .No proof it [audit, analysis, interventions, follow up] was done .I understand not done . Refer to F 689 and F835.

Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment, provide adequate supervision, and accurately assess a severely cognitively impaired resident with Dementia, confusion and a history of wandering to prevent elopement for 1 of 14 sampled residents (Resident #1) reviewed with wandering behaviors and elopement. Resident #1 eloped from the facility on 1/2/2023 at approximately 1:15 PM, walked across the employee back parking lot and was found near the street. The Weather History web site revealed the recorded temperature for Memphis, TN on 1/2/2023 at 4:00 PM, was 65 degrees Fahrenheit and raining. Resident #1 was unsupervised outside the building without staff knowledge, which resulted in Immediate Jeopardy (IJ) for Resident #1. The facility failed to conduct accurate assessments that ensured a safe environment, provide adequate supervision, and accurately assess 14 of 14 (Residents #1, #4, #6, #7, #8, #10, #12, #18, #19, #20, #21, 23, 24, and #25) residents reviewed with wandering and/or elopement behaviors. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-689 was cited at a scope and severity of J which is Substandard Quality of Care. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's Wandering, Unsafe Resident policy initiated 6/2017 and reviewed 1/2023, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility. Review of the Wandering Risk Screen system revealed a computerized assessment system (Point Click Care) that listed applicable sections titled, Orientation, Behavior/Mood, Recent Experiences, Mobility, Diagnosis, Medications, and History of Wandering. Based on the accuracy of the data entered by the nurse, the system would designate the resident's level for unsafe wandering risk. Review of the facility's Wander Guard Policy policy initiated 6/2017 and reviewed 1/2023 revealed, Wander Guards are put in place to detect when a resident is near a protected exit and alert staff. The exit can then be secured, or the resident can be assisted by a member of staff. Placement of wander guards are determined through nursing assessment and can be added once exit seeking behavior is observed at any time after admission. All wander guards require a physician order for implementation. Weekly monitoring of wander guards and doors equipped with wander guard system. Residents at risk of wandering wear a wrist or ankle transmitter or tag which allows them free movement within the facility but prevents them from exiting monitored doors. Current system is configured to create an audible alert at the door where resident is attempting to exit that has a wander guard on their person. Wander guard is also integrated with Access Control so that the door will lock as the resident approaches and unlock again as they move away from the area. Review of the facility's Admission/Assessment Policy policy dated 4/1/2020 and reviewed 1/5/2023 revealed, Facility shall complete resident assessment upon admission. Residents shall be assessed by nurse and complete a head to toe evaluation including all systems upon admission. Nurse shall complete following assessments: Wandering .Baseline Care plan shall be created within 48 hours of admission based on admission assessments. Appropriate interventions shall be provided to ensure resident safety and maintain functional independence .Nursing shall document admission assessment findings in EMR [electronic medical record] .Wander Guard Orders/Elopement Risk and Documented on Medical Record [if applicable] . 2. Review of the hospital's History and Physical (which was dated 12/19/2022) and received by the facility upon the Resident #1's admission on 12/30/2022 revealed Resident #1, .lived with [his] nephew .fell at home few times .more confused with periods of sundowning and wandering at night . Resident #1 had diagnoses that included Dementia with Behaviors, Diabetes Mellitus Type 2, Syncope and Collapse. Review of Resident #1's Admit/Readmit Information that included the Wandering Risk assessment dated [DATE], revealed there was no documentation the resident's known history of wandering was included. Review of the Instant Care Plan dated 12/30/2022, revealed no documentation Resident #1 had Dementia or wandering behaviors. Review of the Nurse Practitioner note dated 12/30/2022, revealed Resident #1 was had previously been a patient at, .[named hospital] after fall at home .Dementia with increased confusion and sundowning . Review of the physician's order dated 12/31/2022, revealed, .Trazadone HCL [Hydrochloride] [an antidepressant/sedative medication] oral tablet 50 mg [milligrams] give 1 tablet by mouth at bedtime for depression . Review of the Wandering Risk Screen assessment dated [DATE], revealed Resident #1's scored was an 8, which indicated a moderate risk for wandering. There was no documentation in the screen assessment of the resident having the diagnosis of Dementia or the antidepressant medication of Trazadone. Review of the Nurse's notes dated 1/2/2023 at 4:43 PM, revealed, .1322 [1:22 PM] noted pt [Resident #1] not in his room on nurse rounds. last visual on pt was at 1315 [1:15 PM] by nurses in report. Staff sent to check the therapy gym, 100 hall sunroom therapy gym, pt not found. Code Purple [Alert for a missing resident] initiated [at approximately 4:30 PM per Certified Nursing Assistant (CNA) #3's interview] .Pt located by staff approx 1,000 ft [feet] from the building, he was noted alert and w/o [without] s/s [signs and symptoms] of distress and no visual injuries noted. Pt escorted back to the building and was placed on the 400 hall in room [ROOM NUMBER] . Based on the Memphis, TN Weather History web site, the recorded temperature for Memphis, TN on 1/2/2023 at 4:00 PM was 65 degrees Fahrenheit and raining. Review of the Nurse's notes dated 1/2/2023 at 7:39 PM, revealed, Pt wandering in the halls. Wander guard [a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors] placed to the R [right] ankle for safety . During an interview on 3/15/2023 at 8:36 AM, Registered Nurse (RN) #2 was asked when the wander guard was placed on Resident #1. RN #2 stated, .After the elopement I put the wander guard on, not before . Review of the facility's investigation dated 1/3/2023 of Resident #1's elopement on 1/2/2023, revealed the facility reviewed a video (Camera #1) showing the resident exiting the building through the 100 hall unit door out to a courtyard area and rounded the corner. Camera #1 lost view after the resident rounded the corner. Another camera (Camera #2) positioned at the ambulance door aimed at the back parking lot revealed Resident #1 walking toward the street. The ambulance door camera (Camera #2) then lost sight of Resident #1. The facility's investigation documentation revealed he was found outside on the sidewalk beside the street, a 1,000 feet from the building. The facility documented Resident #1 exited the courtyard either thru a gap between a chain link fence and gate (that was loosely locked with a bike type rope lock) or through a gap that was between the chain link fence and the building wall. The facility failed to save the video as part of the investigation and did not include a summary of the video with times and locations in the investigation. The surveyor was unable to view the video and the Administrator did not keep notes from review of the video. During an interview on 3/6/2023 at 12:53 PM, RN #2 stated, .[Resident #1] would walk around a lot, walk to the Friendship corner, sit in the lobby, anywhere there was a TV .[Resident #1] would look at .[Resident #1] would ask why was he here, where is the food, who paid for him to be here, what were we going to do for him .When we couldn't find him [Resident #1] we called a Code Purple and looked everywhere inside the building then looked outside .I can't remember what time I found him on the far side of the back employee parking lot located near the street and the apartments .Resident #1 was walking and looking left and right like didn't know where to go, not sure .Just me and him I don't remember any other staff around when I found him. Resident #1 had on pants and a shirt .It was a little rainy, wet but not cold .I called his name and he said 'Hey baby I'm glad to see you'. I told [Resident #1] let's go back inside and he went with me with no problems . During an interview on 3/6/2023 at 3:04 PM, CNA #1 stated, .I came to work on 200 hall about 3:12 PM to 3:25 PM and was in room [ROOM NUMBER] and looked out the window facing [name of the street, a two lane neighborhood street entering to a busy 6 lane major street] and saw a tall male standing on the sidewalk wearing blue sweatshirt and match blue pants with yellow socks, dark shoes like brown/black house slippers and had a Reacher [a reaching device to maintain independence] hanging on his left arm .[Resident #1] was facing the employee parking lot looking around. He had a clear plastic bag [trash bag] with eyes poked out over his head .the fire department truck was across the street at those [NAME] apartments .An aide told me a person was missing. I said on [Name of the street] .Me [CNA #1] and another employee then got in my truck and started driving slow around to try and find him .I was driving slow and looking everywhere as we drove .It was misting rain and you needed long sleeves .We turned right from the parking lot and drove up to [Name of a busy street] and over to [Name of another street] .when we got a call all clear patient [Resident #1] located outside . During an interview on 3/7/2023 at 3:20 PM, CNA #3 stated, .[On 1/2/2023] I work three to eleven and I was here at 3:00 PM. I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He [Resident #1] said I am trying to go to [name of a street] street. I said ok well, let me go down here and see what is going on. I came back up front and he [Resident #1] was gone .It was about 4:30 PM when Code Purple was paged .It was around 6:00 PM before tray pass when someone said he was found in the basement .I never saw him [Resident #1] again that day . The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1's Brief Interview of Mental Status (BIMS) score was 4, which indicated Resident #1 had severely impaired cognition for daily decision making. Continued review revealed Resident #1 had an unsteady gait and could stabilize without staff assistance. Review of the Wander Guard Bracelet Weekly Inspection form dated January 2023 through March 2023, revealed no documentation Resident #1's wander guard functionality had been inspected in accordance with the facility's wander guard policy. During an interview on 3/7/2023 at 1:40 PM, DON stated, .Maintenance does the resident's wander guard functionality inspection weekly .No, I don't see any documentation where [Named Resident #1] wander guard was inspected for functionality . During an interview on 3/7/2023 at 1:46 PM, the Administrator was asked if there was any documentation of [Resident #1's] wander guard functionality being checked January, February, and March 2023. He stated, .I don't see it .that's all I have, do what you got to do . Observations on 3/8/2023 at 1:30 PM, revealed the 2nd floor activity room/office was unlocked and unattended, and there were residents in the hallway near the entrance. In the activity room/office was another door that led to the roof top of the facility. The door that led onto the facility roof top was not locked and had no alarms to signal when opened. Observations of exit door #9 located between resident dining room and Therapy gym on 3/15/2023 at 11:34 AM, revealed the door opened with employee badge and would remain unlocked until someone could activate the door lock button located on the left top frame of the door. Continued observations revealed the Administrator stated to the employee, .Be sure you press the red button to lock once you go through . Observations of exit door #11, with an indicating exit sign above, located on the 200 hall near the nurse's station on 3/15/2023 at 11:40 AM, revealed the door was not latched and ajar (slightly open) no alarm sounding. This exit door leads to a stair well and to an outside exit door that is not locked and does not alarm when opened. Observations on 3/15/2023 at 11:55 AM revealed exit door #19, with an indicating exit sign above, located on the 2nd floor Memory Care Unit the revealed door was opened by an employee with an employee badge, did not latch, and stayed unlocked with green light on. This exit door leads to a stair well and to an outside exit door that is not locked and does not alarm when opened. During an interview on 3/14/2023 at 1:55 PM, the Maintenance Director stated, .We have two doors that have the wander guard system. The front door and the ambulance entry door .they are the only doors that can detect the wander guard . During an interview on 3/15/2023 at 1:00 PM, the Administrator stated, .That's [doors] definitely got to be fixed .this old building when the weather changes sometimes have to shave the door, things like this . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with a diagnosis of Dementia with Psychosis. Review of Resident #4's care plan dated 1/18/2023 revealed there was no documentation of the resident's wandering behaviors. Review of the physician's order dated 1/18/2023 revealed, .Oxycodone Acetaminophen 5-325 mg [a narcotic medication to treat pain] 1 by mouth every 4 hours prn [as needed] for pain . Review of the admission Wander Risk assessment dated [DATE], revealed Resident #4 scored a 10 indicating moderate risk for wandering. There was no documentation the assessment included the resident's diagnosis of Dementia, and narcotic medication prescribed. Review of the Resident #4's admission MDS assessment dated [DATE], revealed Resident #4 scored a 11 on the BIMS assessment which indicated moderately impaired cognition. The assessment documented Resident #4 had the behaviors of wandering 1 to 3 days of the assessment period. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated 3/10/2023, revealed there was no documentation that Resident #4's wander guard functionality had been tested . Observations in Resident #4's room on 3/8/2023 at 1:45 PM, revealed Resident #4 to be sitting in a chair, alert and oriented to self, wander guard device on left ankle. 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses Dementia with Behaviors, Anxiety and Alcohol Dementia. Review of the Nurse's note dated 1/18/2023 at 7:55 PM, revealed .Resident [#6] arrived by stretcher with 3 EMT [Emergency Medical Technician] at side upon enter building resident unfasten belt to stretcher and jumped off stretcher. Staff and EMTs caught resident. Resident became violent started swinging and trying to hit staff and EMTs. They assisted resident to room [Resident #4's room number] he started stripping all clothing off, refused to allow staff to place gown on, continued to try and ambulate out of the room, gait very unsteady. Resident AAO x1 [alert, oriented] name only .limited assist with ambulation. Independent with bed mobility and transfer .resident continued to try and ambulate throwing bed sheets and pillows on floor . The admission Minimum Data Set (MDS) 1/25/2023, documented the resident scored a 0 on the BIMS indicating the resident had severely impaired cognition for daily decision making. The assessment documented the resident had the behaviors of wandering 1 to 3 days during the assessment period. Review of the Care Plan dated 1/18/2023, revealed there was no documentation of a wandering/elopement risk. Review of the admission Wander Risk assessment dated [DATE], revealed Resident #6 scored a 13 which indicated a high risk for wandering. There was no documentation the assessment included the resident's diagnosis of Dementia. 6. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Dementia Without Behavioral Disturbance, End Stage Renal Disease, Dependence on Renal Dialysis, and Essential Hypertension. Review of the hospital History and Physical dated 10/31/2022, received by the facility upon admission, revealed .the patient [Resident #7] has wandered off. Family with concerns regarding the patient's confusion, anxiousness and wandering off . Review of the Instant Care Plan dated 11/16/2022 revealed there was no documentation the care plan included the resident had Dementia or wandering behaviors. Review of the Wandering Risk Screen dated 11/17/2022, revealed Resident #7 scored a 3 which indicated a low risk for wandering. There was no documentation the screen/assessment included the resident having the diagnosis of Dementia and known history of wandering. Review of the Wandering Risk Screen dated 1/4/2023 revealed there was no documentation the screen was completed. Review of a Plan of Care Note dated 1/8/2023, revealed .[Named Resident #7] has packed his clothes and shoes this morning. He stated that he is going to leave the facility. He began walking toward the exit door with his belongings .[Resident #7] has a wander-guard placed on lower extremity . Record review revealed there was no order for a wander guard for Resident #7 and there was no documentation the facility had determined the wander guard functionality. Review of the Care Plan dated 2/7/2023, revealed .Resident was seen by this nurse and a CNA walking towards the side door to outside with a bag in his hand and his cane . Review of the comprehensive care plan with a target date of 5/13/2023, revealed there was no documentation Resident #7 had behaviors of wandering or the use of a wander guard device. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 scored a 10 on the BIMS assessment which indicated moderately impaired cognition. The resident required limited assistance for ambulation. Resident #7 had an unsteady gait and could stabilize without staff assistance. Observations in the resident's room on 3/8/2023 at 9:59 AM, revealed Resident #7 was seated on the side of the bed and transferred himself to a standing position. A wander guard was in place on the resident's right ankle. He ambulated independently in his room using a cane. The resident stated, I like to walk to the door every morning and would go out, but they put this thing [wander guard] on my leg . During an interview on 3/7/2023 at 2:38 PM, when asked if Resident #7 had a wander guard placed due to wandering/exit seeking behaviors, The DON stated, No one has ever told me he was a wanderer .He doesn't have a wander guard. During an interview on 3/14/2023 at 8:55 AM, when asked if there were any residents on the 100 hall with a wander guard in place, LPN #1 stated, I don't have any resident with a wander guard that I'm aware of . Resident #7 resided on the 100 hall. 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Depression, End Stage Renal Disease, Dependence on Renal Dialysis, Aphasia, Essential Hypertension, and Lack of Coordination. Review of the Admission Summary dated 2/14/2023, revealed .Pt [patient, (Resident #8)] is ambulatory and has some confusion, wander guard to R [right] ankle placed . Review of the Admit/Readmit Information assessment dated [DATE], revealed there was no documentation of the resident's cognitive status and taking antidepressants was included in the assessment. Resident #8 had a physician's order dated 2/15/2023 for Zoloft 50 mg daily (an antidepressant medication). The wandering risk assessment was not revised to reflect the Zoloft medication. Review of the Wandering Risk Screen dated 2/15/2023, revealed Resident #8 scored a 4 which indicated a low risk for wandering. The screen/assessment revealed the resident's history of wandering was not included in the screen. Review of the physician's orders dated 2/18/2023, revealed .Check Placement of Wander Guard to right ankle every shift for wandering . Continued review revealed there was no documentation the facility had determined the wander guard was functioning properly. Review of the Plan of Care Note dated 2/18/2023, revealed .Resident is displaying exit seeking behavior. Packing up his belongings and continuing to walk up to exit doors with belongings in his hand . Review of the admission MDS assessment dated [DATE] revealed Resident #8 scored a 6 on the BIMS assessment which indicated severely impaired cognition. The resident required supervision with ambulation and had an unsteady gait and needed staff assistance to stabilize. Review of the Plan of Care Note dated 2/22/2023, revealed Resident #8 was .pacing facility with his belongings in his arms trying to exit facility. Attempted to reorient patient [Resident #8], was unsuccessful . Review of the Wandering Risk Screen dated 2/27/2023, revealed an inaccurate assessment. The screen/assessment did not include the resident's history of wandering. Review of the Plan of Care Note dated 2/27/2023, revealed .resident in the front lobby telling the receptionist that he needed to get out of this place . Observations in the resident's room on 3/13/2023 at 3:25 PM, revealed Resident #8 walking in his room. There was a wander guard on his left ankle. During an interview on 3/13/2023 at 3:29 PM, when asked if Resident #8 had behaviors of wandering and a wander guard placed, RN #4 stated, I don't know. He came to this floor [300 Hall] yesterday. 8. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, Delirium, Hypertension and Encephalopathy. Review of physician's orders with a start date 10/18/2022 revealed, .Wander guard monitoring: wander guard on at all times check placement every shift . Review of physician's orders with a start date 10/19/2022 revealed, .Quetiapine Fumarate 50 mg [an antipsychotic medication] 1 by mouth twice daily for psychotic disorder with delusions . The quarterly MDS dated [DATE] documented the resident scored an 8 on the BIMS assessment which indicated moderately impaired cognition for daily decision making. Review of the Wandering Risk Screen dated 1/3/2022 revealed a score of NA (not applicable) low risk, there was no documentation the screen was completed. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated February and March 2023 revealed there was no documentation of Resident #10's wander guard functionality tested . Observations in room [ROOM NUMBER] B on 3/8/2023 at 1:26 PM revealed Resident #10 lying in bed, alert and oriented to self, wander guard on left ankle. During an interview on 3/13/2023 at 1:19 PM, the Director of Nursing (DON) confirmed Resident #10's wandering risk screen dated 1/3/2023 was not completed. He stated, .all the areas are blank .It is not completed .This was when we were to review all residents on 1/3 [1/3/2023] and 1/4 [1/4/2023] as part of our performance improvement plan .It should have been completed . 9. Review of the medical record revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia Without Behavioral Disturbance, Bipolar Disorder, Schizoaffective Disorder, Personality Disorder, and Type 2 Diabetes Mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 scored a 10 on the BIMS assessment which indicated moderately impaired cognition. The resident required limited assistance with ambulation. Resident #12 had an unsteady gait and was able to steady self without staff assistance. Review of the Admit/Readmit Information assessment dated [DATE] revealed an inaccurate assessment. The wandering risk assessment section had no documentation of the resident's diagnosis of Dementia. Review of the Admit/Readmit Information assessment dated [DATE] revealed a score of 2 which indicated low risk for wandering. The assessment revealed there was no documentation of the resident's diagnosis of Dementia. Review of the Wandering Risk Screen dated 1/3/2023 revealed no documentation the screen/assessment was completed. Observation in the resident's room on 3/7/2023 at 2:21 PM revealed Resident #12 was not in her room or in the hallway near her room. During an interview on 3/7/2023 at 2:23 PM, when asked where Resident #12 was, LPN #3 stated, I don't know where she is. She is somewhere. She goes around the halls all the time. When asked if the resident had any exit seeking behaviors, the LPN stated, Leave? She might try. She is very confused and has random thoughts . 10. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses Alzheimer's Disease and Dementia without Behaviors. Review of Resident #18's Wandering Risk Screen dated 1/13/2023 revealed the resident had a known history of wandering. Review of physician's orders with a start date 1/25/2023 revealed, .Wander guard in place every shift for wandering . The admission MDS 1/26/2023 documented the Resident #18 scored a 2 on the BIMS assessment which indicated severely impaired cognition for daily decision making. Review of the care plan dated January 2023 revealed Resident #18 had wandering behaviors with wander guard. Review of Resident #18's MARs dated February through March 2023 revealed the wander guard in was place every shift for wandering was checked as completed on all shifts every day. Review of the maintenance record Wander Guard Bracelet Weekly Inspection revealed on 2/3/2023, 2/17/2023, 3/3/2023 and 3/10/2023 no tag was marked as resident not having a wander guard. Continued review revealed on 2/24/2023 the pass/fail was marked related to Resident #18's wander guard. During an interview on 3/14/2023 at 1:45 PM the Maintenance Assistant was asked about the wander guard bracelet weekly inspection report. The Maintenance Assistant stated . ' no tag ' means not on him .I told nurse [named person] he didn't have one [wander guard] on . Observations on 3/14/2023 at 9:30 AM, revealed Resident #18 had no wander guard on. During an interview on 3/14/2023 at 9:30 AM, CNA #2 confirmed Resident #18 had no wander guard. She stated, .no, he doesn't have one [wander guard] on . 11. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Dementia without Behaviors, Diabetes Mellitus Type 2, Anxiety, and Major Depression. The quarterly MDS 2/4/2023 for resident #19 documented the resident scored a 5 on the BIMS which indicated severely impaired cognition for daily decision making. Review of the physician's orders with a start date 7/29/2022 revealed .Buspirone HCL 10 mg [medication for anxiety] 1 by mouth twice daily anxiety .Escitalopram Oxalate 10 mg [a medication to treat depression and anxiety] 1 by mouth every am .Trazodone HCL 50 mg [antidepressant] give 25 mg by mouth at hs [bedtime] depression . Review of the physician's orders with a start date 11/30/2022 revealed .Wander guard in place every shift for Wandering . Review of the Wandering Risk Screen dated 1/3/2023 revealed Resident #19 scored a 2 which indicated a low risk for wandering. There was no documentation in the screen/assessment that included the resident's diagnosis of Dementia, no documentation the medications for depression or anxiety were included, and no documentation of the resident's history of wandering included in the screen assessment. Review of Resident #19's MARs dated February and March 2023, revealed Wander guard in place every shift for wandering was checked as completed on all shifts every day. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated 3/10/23, revealed .pass . During an interview on 3/14/2023 at 1:45 PM, the Maintenance assistant revealed, .pass means they had a wander guard on, and it passed the test . Observations on 3/14/2023 at 9:35 AM, revealed Resident #19 with had no wander guard on. During an interview on 3/13/2023 at 1:19 PM, the DON confirmed Resident #19's wandering risk screen dated 1/3/2023 was not accurate. He stated, .some areas are blank .It is not accurate .This was when we were to review all residents on 1/3 and 1/4 as part of our performance improvement plan .It should have been completed correctly . During an interview on 3/14/2023 at 9:35 AM, CNA #2 confirmed Resident #19 did not have a wander guard. She stated, .No, he doesn't have one [wander guard] on . 12. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses Dementia with Agitation and Psychotic Disorder with Delusions. The quarterly MDS 2/9/2023 documented the resident scored a 3 on the BIMS which indicated severely impaired cognition for daily decision making. Review of the physician's orders dated 8/29/2022 revealed, .Seroquel oral tab 50 mg 1 by mouth hs . Review of the physician's orders dated 12/6/2022 revealed, .Wander guard in place . Review of the Wandering Risk Screen dated 1/3/2023 revealed Resident #20 scored a 2 which indicated a low risk for wandering. There was no documentation the resident's orientation, behavior/mood, diagnosis of Dementia, Seroquel medication, or history of wandering was included in the screening. Review of the physician's orders dated 3/9/2023 revealed, .check wander guard function every week . Review of the care plan revision dated 3/28/2022 revealed, .is an elopement risk wanderer .wander alert wander guard per MD orders . Review of Resident #20's MARs dated February 2023[TRUNCATED]

Based on job description review, interview, and document review, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of residents with Dementia and wandering behaviors. Administration failed to provide appropriate oversight to ensure residents with Dementia and wandering behaviors received care in a safe and supervised environment, failed to ensure the facility conducted accurate resident assessments. The facility Administration failed to be accountable for to the Quality Assurance and Performance Improvement (QAPI) developed by the facility to ensure appropriate actions were implemented after a resident eloped from the facility without staff knowledge and supervision. The Administration's failure to ensure a safe environment placed 1 of 14 sampled residents (Resident #1) in Immediate Jeopardy (IJ) when Resident #1, a severely cognitively impaired, vulnerable resident with Dementia, confusion, and wandering behaviors, eloped from the facility on 1/2/2023 at approximately 1:15 PM, walked across the employee back parking lot and was found near the street. Resident #1 was unsupervised outside the building which resulted in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-835 was cited at a scope and severity of J. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's undated Licensed Nursing Home Administrator job description revealed, .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Make routine inspections of the facility to assure that established policies and procedures are being followed .establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services (DON) job description revealed, .The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . 2. The facility Administration failed to provide oversight that established and implemented policies and procedures to ensure a safe environment for all residents. On 1/2/2023 Resident #1, a cognitively impaired resident, eloped from the facility without staff knowledge or supervision and was found approximately 1000 feet from the facility on a street sidewalk. The facility Administration failed to ensure all wander/elopement assessments were accurate for 14 of 14 (Residents #1, #4, #6, #7, #8, #10, #12, #18, #19, #20, #21, 23, 24, and #25) sampled residents with wandering behaviors. 3. The facility Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI was established to oversee the facility, failed to identify the root cause of concerns identified, and failed to ensure systems and processes were developed and consistently followed by facility staff related to a safe environment. The facility Administration developed an improvement plan dated 1/2/2023 to address Resident #1 ' s elopement incident. The facility Administration failed to ensure all interventions in the plan were implemented and were accurate as follows: The Improvement plan to review new admits' elopement assessments for appropriate interventions was not accurate as evidenced by the inaccurate wander/elopement assessments. The Improvement plan to audit all elopement assessments was not implemented as the facility was unable to provide the audits, audit results and the assessments that were conducted were not accurate. The Improvement plan to submit all audit results to the QAPI committee to be reviewed and address as needed was not completed. The facility was unable to provide evidence that the QAPI committee received and reviewed the plan and had not had a meeting. During an interview on 3/7/2023 at 2:30 PM, the DON revealed, .As part of our Performance Improvement [PIP] we audited all residents for wandering risk screen/assessments on 1/3 and 1/4 [2023] to see if anyone was at risk for wandering or elopement or if anyone new . When the DON was asked what they learned and about the outcome, he stated .Well I don't know .We did the audit .No, I don't have any quantitative data to show . When asked how you would know your outcome and if you needed to work on something, he stated, .We wouldn't know .We didn't evaluate it or look at the results . 4. During an interview on 3/7/2023 at 9:09 AM, the DON was asked what he did and his role concerning Resident #1's elopement. The DON stated the staff called and told him that Resident #1 was missing from the facility. The DON stated, .I told them to check the parking lot and the basement. I texted the Administrator .I did not come in until the next day .Once he was found I told them to put a wander guard on him and take him upstairs to the secure unit . The DON stated he was not aware of the resident's wandering history based on the information sent from the hospital. The DON stated he did not participate in a Root Cause Analysis (RCA) related to the elopement incident of Resident #1. The DON stated he did not interview all staff involved related to the elopement incident, only Certified Nursing Assistant (CNA) #1 that saw the resident outside and Registered Nurse (RN) #2 that was the Unit Manager for the hall that Resident #1 resided on. During an interview on 3/7/2023 at 2:50 PM the DON was asked about the Performance Improvement Plan (PIP) interventions that included the Audit Elopement Assessments data related to Resident #1's elopement. The DON stated Review new admits elopement assessment and transfer to secure unit for 7-day monitoring if triggered . The DON stated, .I don't have a tool .I don't have results . When asked if there was documentation of an audit with quantitative results, analysis, interventions, evaluation and follow up, The DON stated, .No . The DON was asked did nursing implement anything because of this elopement to keep it from happening again to residents with wandering behaviors. He stated, .No . During an interview on 3/7/2023 at 3:20 PM, CNA #3 revealed, .I work three to eleven and I was here at 3:00 PM. I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He said I am trying to go to [Name of a street]. I said OK well, let me go down here and see what is going on. I came back up front and he was gone . During an interview on 3/15/2023 at 1:00 PM the Administrator was asked what had been put in place since the elopement that will prevent it from happening again. The Administrator stated, .We fixed the gate and the courtyard fence . When the surveyor reviewed the inaccurate wander risk screen assessments with the Administrator, the Administrator stated, .That has definitely got to be fixed . The Administrator was asked about discrepancies with the wander guard system, the ineffective the interventions of checking the functionality of the wander guards, not following or obtaining a physician's order for the wander guards, staff being unaware of the policies/interventions for wander guards, and the non-secure exit doors on the 3/15/2023 tour, The Administrator stated .Yeah .Yes .that has to be fixed . Refer to F689 and F867.

Based on a Life Safety Code (LSC) violation complaint, weather website review, observation, and interview, the facility failed to maintain the air conditioning units, maintain comfortable temperatures throughout the facility, and placed the 150 residents residing in the facility at risk for heat related negative outcomes, and created a disruption in their day-to-day routines. The facility's failure to maintain comfortable temperatures resulted in Immediate Jeopardy when the facility did not evacuate residents to prevent extreme temperatures in the facility's resident rooms when facility administration and staff were aware the air conditioning system was not functioning adequately on 6/16/2022 Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 6/28/2022 at 3:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-584. The facility was cited at F-584 at a scope and severity of L, which is Substandard Quality of Care. The IJ existed 6/1/2022 through 6/20/2022. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on 6/21/2022. The facility is required to submit a Plan of Correction. The findings include: The facility was constructed in 1930. The facility is constructed of masonry blocks and is a 2 story building with a basement. The 1st floor consists of the 100 and 200 Halls and 49 resident rooms. The 2nd floor consists of the 300 and 400 Halls and 62 resident rooms. The facility has 169 licensed beds which are all certified for Medicare/Medicaid recipients. Initial State licensure was in 1992. The resident census on 6/18/2022 was 150. Life Safety Code (LSC) surveyors entered the facility on 6/18/2022 at 11:00 AM in response to a LSC complaint dated 6/17/2022 alleging the air conditioning system in the facility was not working which placed residents at risk for heat related health problems. The Health surveyor entered later in the day on 6/18/2022 at the request of the LSC surveyors. Review of the 6/2022 National Weather Service reporting system at www.weather.gov revealed high temperatures in Fahrenheit (F) from the 80 degrees to low 90 degrees from 6/1/2022-6/11/2022, temperatures greater than 95 degrees beginning 6/12/2022 with recorded highs of 100 degrees on 6/16/2022 and 6/17/2022. On Saturday, 6/18/2022, the recorded high was 98 degrees with continued record high temperatures in the upper 90-100 degrees through 6/26/2022, then rising again to upper 90 degrees on 6/29/2022 and 6/30/2022. Temperatures of residents' rooms taken by laser thermometer on 6/18/2022 beginning at 12:00 PM, revealed 18 of 27 assessed rooms had a temperature above 81 degrees F and 15 of 27 rooms were above 85 degrees F. Documentation revealed the LSC surveyor had notified the Administrator on 6/18/2022 at 1:30 PM, that all 150 residents residing in the building should be evacuated due to the failure of the facility's air conditioning system, inability for the system to be immediately repaired, and the forecasted high temperatures in the area for the next week. During an interview on 6/18/2022 at 2:50 PM, Family Member #1 revealed that her family member residing in the facility was being transported to another local facility and they were appreciative of the State Agency's presence and actions taken to have the residents evacuated due to the air conditioning failure. Observations on 6/18/2022 at 2:50 PM, revealed the Front Lobby was uncomfortably warm. Facility administrative staff, the Ombudsman, and other local facility long-term care staff were gathered in the Conference Room and in the process of organizing and coordinating evacuation of all 150 residents from the facility due to the identified failure of the facility's air conditioning system, due to the LSC surveyor determination on 6/18/2022 at 1:30 PM, and the likelihood of serious health related outcomes to residents related to warm room and hall temperatures. Observations during tour on 6/18/2022 at 3:20 PM, revealed 27 of the 36 rooms assessed had a temperature greater than 81 degrees F; 24 of the 36 rooms assessed had a temperature greater than 85 degrees F; 11 of the 36 rooms assessed had a temperature greater than 88 degrees F. A resident's room with a temperature of 90.2 degrees F was the highest temperature. Observations confirmed the use of large portable air conditioning units that had been rented, shop fans utilized in the halls, and small portable air units had been placed in some of the residents' rooms. During an interview on 6/18/2022 at 3:00 PM, the Administrator confirmed the air conditioning system had failed on Thursday, 6/16/2022. During an interview on 6/18/2022 at 3:35 PM, Licensed Practical Nurse (LPN) #1 was asked if she felt that it was too warm on the Memory Care Unit for the residents and staff. LPN #1 stated, .I'm not going to answer that . During an interview on 6/18/2022 at 3:50 PM, LPN #2 stated, .the air has been off for a month . During an interview on 6/18/2022 at 3:50 PM, Certified Nursing Assistant (CNA) #1 stated that .the air has been off every year when it gets hot outside . Multiple resident interviews on 6/18/2022 validated the uncomfortable temperatures. Direct care staff and family were contacted by telephone for interview and confirmed the presence of ongoing problems with the air conditioning system cooling adequately since the beginning of 6/2022. Staff interviews revealed the necessity of moving residents around in the building during the day and trying to keep them up out of their rooms because of the heat. Interviews revealed family members brought in fans to try to keep their loved ones cool. During a telephone interview on 6/21/2022 at 3:22 PM, Family Member #1 confirmed she or another family member made daily visits to the facility. When asked about the air conditioning in the building, the family member stated that for the 4 years the resident had been in the facility, the air conditioning had not been adequate, but it had been .around the beginning of 6/2022 when the air on the 400 Hall had gone out and they had put fans in the halls . During a telephone interview on 6/22/2022 at 4:25 PM, the Director of Maintenance (DOM) confirmed the facility's chiller system failed on Thursday, 6/16/2022. He revealed the facility building was [AGE] years old and had prior problems with the air system during the summer. When asked if he had taken room temperatures after the air system failed, he revealed he had not done so other than random temperatures. When asked if he had documentation of which rooms had required portable air units, he confirmed he did not. When asked if the facility had planned to evacuate the residents because of the air system failure prior to the LSC surveyor arriving on Saturday, 6/18/2022, he stated, No ma'am. Disaster preparedness plans for worst case scenario and hadn't been necessary . During a telephone interview on 6/22/2022 at 4:00 PM, the facility owner confirmed he was responsible for facility operations. The facility owner confirmed he was aware of problems with the air in the past but had never had a system failure before. However, the heat index had been between 100 and 105 degrees F. During a telephone interview on 6/27/2022 at 1:20 PM, the Administrator confirmed the air conditioning system had failed on Thursday, 6/16/2022. The air conditioning repair vendor had evaluated the system, did not have the parts needed for the repair and had to place an order, which was supposed to be in on Monday, 6/20/2022. He stated they .had put supplemental portable air conditioning units throughout the facility and tried to keep residents out of their rooms during the warmest hours during the day . The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on 6/21/2022. The facility's noncompliance at F-584 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. Refer to F-600.

Based on National Weather Service Reporting System, Board of Examiners for Nursing Home Administration (BENHA) review, job description review, observation, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively to attain and maintain the highest practicable well-being of residents susceptible to lack of comfortable and safe temperature levels. Failure of Administration to effectively plan and develop strategies in the event the facility air conditioning system was unable to maintain comfortable temperatures for the residents, and failure to provide education to staff to ensure residents were more frequently assessed for symptoms of heat intolerance and the importance of monitoring and providing necessary hydration placed the 150 residents residing in the facility in Immediate Jeopardy when the facility air conditioning system failed. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 6/28/2022 at 3:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-584, F-600, F-835, F-837, and F-867. The facility was cited at F-584 and F-600 at a scope and severity of L, which is Substandard Quality of Care (SQC). The IJ existed from 6/1/2022 through 6/20/2022. The Immediate Jeopardy was removed onsite when the facility evacuated all residents on 6/21/2022. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated job description titled, Administrator Job Description, revealed .The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements . Review of the facility's job description titled, ROLE OF THE DIRECTOR OF NURSING SERVICES, revised 7/2021, revealed .Duties and Responsibilities .Developing and participating in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on 'how to do the job,' and ensure a well-educated Nursing Services Department . Review of the BENHA form revealed the current Administrator had been employed by the facility since 2/2017. Historical review of Life Safety Code (LSC), and Health complaints revealed 8 LSC and Health visits to the facility related to uncomfortable air temperatures in resident rooms. The complaints related to uncomfortable temperatures in the resident rooms were as follows: a. Health visit on 7/19/2018 b. Health visit on 8/21/2018 and 8/29/2018 c. LSC visit on 7/14/2020 d. Health visit on 7/20/2020 e. Health visit on 7/19/2021 f. LSC visit on 6/18/2022. Review of the complaint summary findings revealed immediate repairs were possible. However, the historical data shows a pattern of concerns and problems related to the facility's air conditioning system. Review of the 6/2022 National Weather Service reporting system at www.weather.gov revealed high temperatures of 80 degrees Fahrenheit (F) to low 90 degrees F from 6/1/2022 through 6/11/2022, temperatures greater than 95 degrees F beginning 6/12/2022 with recorded high temperatures of 100 degrees F on 6/16/2022 and 6/17/2022. On 6/18/2022, the high temperature was 98 degrees F with continued record high temperatures in the upper 90-100 degrees F through 6/26/2022 and then the upper 90 degrees F on 6/29/2022 and 6/30/2022. Medical record review and interview confirmed that on 6/17/2022, Resident #1 suffered from symptoms of heat related distress. LSC surveyors entered the facility unannounced on Saturday 6/18/2022 at 11:00 AM, related to an anonymous complaint submitted on 6/17/2022 regarding the air conditioning system was not working in the building. The allegation was substantiated during the LSC survey inspection and observation of random temperatures in resident rooms. The Health surveyor entered later in the day on 6/18/2022 at the request of the LSC surveyors. The recorded temperatures by the LSC surveyor were elevated above federal regulatory guidelines. Interviews onsite with residents and facility staff confirmed the temperatures were uncomfortable. Interviews with the Administrator and Director of Maintenance confirmed the air conditioning system had failed on 6/16/2022. The LSC surveyors determined evacuation of all 150 residents was necessary for their health and safety and notified the Administrator on 6/18/2022 at 1:30 PM. The evacuation process was then implemented. All residents were evacuated by 3:00 PM on 6/21/2022. Interviews with residents and staff on 6/18/2022 and telephone interviews with staff and family confirmed the air conditioning system had not been able to maintain comfortable air temperatures, especially on the 200 and 400 Halls, since the first of 6/2022. During a telephone interview on 6/27/2022 at 1:20 PM, the Administrator was unable to provide information on strategic planning in the event the facility's air conditioning unit was unable to maintain comfortable temperatures. When asked about staff education on hydration needs and resident assessment, he stated, .Not sure if formal in-services .Just do it . During a telephone interview on 6/27/2022 at 2:43 PM, the Director of Nursing (DON) was asked if staff training, and in-services had been completed as the facility prepared for warmer weather conditions. The DON was unable to provide confirmation of training or documentation of any in-services related to preparation for the cooling system failure in the event of elevated weather temperatures. Administration's failure to plan and develop plans in the event the cooling system failed when the outside temperatures were elevated or provide training for staff related to the monitoring and care of vulnerable residents during the hot summer months placed all 150 residents in Immediate Jeopardy when the air conditioning system failed, and the vicinity temperature was a recorded high temperature of 100-degree F. Refer to F-584, F-600, F-837, and F-867. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on 6/21/2022. The facility's noncompliance at F-835 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, and interview, the Governing Body failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of administration and nursing staff ensuring that residents at risk for negative outcomes related to heat exhaustion were frequently assessed and given necessary hydration for their health and safety, and failed to provide oversight in the development of plans for evacuation of the residents in the event the facility's historically unreliable air conditioning system failed to provide comfortable temperatures for residents enabling the residents to continue in their activities of daily living without discomfort and without risk of serious health related outcomes due to excessive heat. The Governing Body's failure to provide oversight and ensure systems and processes were in place resulted in Immediate Jeopardy for the 150 residents residing in the facility when the air conditioning unit failed. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 6/28/2022 at 3:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-584, F-600, F-835, and F-867. The facility was cited F-584 and F-600 at a scope and severity of L, which is Substandard Quality of Care. The IJ existed from 6/1/2022 through 6/20/2022. The Immediate Jeopardy was removed onsite when the facility evacuated all residents on 6/21/2022. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Quality Assessment Performance Improvement Program, revealed .A Quality Assessment Performance Improvement (QAPI) program must be ongoing and comprehensive, dealing with the full range of services offered by this facility, including all the departments .This facility will conduct Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention .This facility will use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its root causes, and implications of a change .Systemic Actions will look comprehensively across all involved systems to prevent future events and promote sustained improvement with a focus on continual educational in-servicing and continuous improvement . Review of the facility's undated job description titled, Administrator Job Description, revealed .The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements . Review of the facility's job description titled, ROLE OF THE DIRECTOR OF NURSING SERVICES, revised 7/2021, revealed .Duties and Responsibilities .Developing and participating in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on 'how to do the job,' and ensure a well-educated Nursing Services Department . Historical review of complaints and Life Safety Code (LSC) and Health visits to the facility revealed 8 visits related to alleged uncomfortable air temperatures in resident rooms as follows: a. Health visit on 7/19/2018 b. Health visit on 8/21/2018 and Health 8/29/2018 c. LSC visit on 7/14/2020 d. Health visit on 7/20/2020 e. Health visit on 7/19/2021 f. LSC visit on 6/18/2022. Review of the complaints' summary findings revealed immediate repairs were possible, however, the historical data shows a pattern of concerns and problems related to the facility's air conditioning system. LSC surveyors entered the facility unannounced on Saturday, 6/18/2022, at 11:00 AM, related to allegations submitted by an anonymous complainant on 6/17/2022 that the air conditioning system was not working in the building. The Health surveyor entered later in the day on 6/18/2022 at the request of the LSC surveyors. The allegation was substantiated with random temperatures in resident rooms and interviews with facility staff that the air conditioning system had failed on 6/16/2022. LSC surveyors determined evacuations of all 150 residents was necessary for their health and safety and notified the Administrator on 6/18/2022 at 1:30 PM. The evacuation process was implemented. All residents were evacuated by 3:00 PM on 6/21/2022. During a telephone interview on 6/22/2022 at 4:00 PM, the owner, who is the acting Governing Body for the facility, revealed he was aware the facility had problems with the air conditioning system in the past but had never had a system failure before like this and referenced the 100-105 degrees Fahrenheit (F) heat index in the city where the facility was located. During a telephone interview on 6/27/2022 at 12:22 PM, the Medical Director confirmed the air conditioning system in the facility was an ongoing issue and that potential concerns with the system and the residents impacted by the failure had not been on the QAPI agenda or discussed at the QAPI meetings. During a telephone interview on 6/27/2022 at 1:20 PM, the Administrator confirmed the QAPI committee had not formally discussed or developed a written plan of action related to the possibility of the air conditioning system failing during the summer months. The Administrator stated, .If it goes down, we fix it . When asked about staff education on hydration needs and resident assessment, he stated, .Not sure if formal in-services .Just do it . During a telephone interview on 6/27/2022 at 2:43 PM, the Director of Nursing (DON) was asked if staff training, and in-services had been completed regarding care of the residents during the summer months as the facility prepared for warmer weather conditions. The DON was unable to provide confirmation of training or documentation of in-services. The failure of the Governing Body to provide oversight and ensure systems and processes were in place in the event the facility's air conditioning system failure during the summer months placed the 150 residents residing in the facility in Immediate Jeopardy when the air conditioning system failed, and residents were evacuated to other facilities for their health and safety. Refer to F-584, F-600, F-835, and F-867. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on 6/21/2022. The facility's noncompliance at F-837 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, observation, and interview, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to set priorities for its performance improvement activities that focused on the high risk and problem-prone air conditioning system and develop strategies based on consideration of the potential negative health outcomes, resident safety, and quality of care concerns, which placed the 150 residents residing in the facility in Immediate Jeopardy when the air conditioning system failed. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 6/28/2022 at 3:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-584, F-600, F-835, F-837, and F-867. The facility was cited F-584 and F-600 at a scope and severity of L which is Substandard Quality of Care (SQC). The IJ existed from 6/1/2022 through 6/20/2022. The Immediate Jeopardy was removed onsite when the facility evacuated all residents on 6/21/2022. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Quality Assessment Performance Improvement Program, revealed .A Quality Assessment Performance Improvement (QAPI) program must be ongoing and comprehensive, dealing with the full range of services offered by this facility, including all the departments .This facility will conduct Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention .This facility will use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its root causes, and implications of a change .Systemic Actions will look comprehensively across all involved systems to prevent future events and promote sustained improvement with a focus on continual educational in-servicing and continuous improvement . Historical review of complaints and Life Safety Code (LSC) and Health visits to the facility revealed 8 visits related to alleged uncomfortable air temperatures in resident rooms as follows: a. Health on 7/19/2018, b. Health on 8/21/2018 and 8/29/2018, c. LSC on 7/14/2020, d. Health on 7/20/2020, e. Health on 7/19/2021, and f. LSC on 6/18/2022. Review of the complaints' summary findings revealed immediate repairs were possible, however, the historical data shows a pattern of concerns and continued problems related to the facility's air conditioning system. Medical record review and interview confirmed that on 6/17/2022, Resident #1 suffered from symptoms of heat related distress. LSC surveyors entered the facility unannounced on Saturday 6/18/2022 at 11:00 AM related to allegations submitted by an anonymous complainant on 6/17/2022 that the air conditioning system was not working in the building. The Health surveyor also entered later in the day on 6/18/2022, at the request of the LSC surveyors. The allegations were substantiated by the LSC surveyor inspection and observations of random temperatures in resident rooms that were above both state and federal regulatory guidelines. Interviews onsite with residents and facility staff confirmed the temperatures were uncomfortable. Interviews with the Administrator and Director of Maintenance confirmed the air conditioning system had failed on 6/16/2022. LSC surveyors determined the evacuation of all 150 residents was necessary for their health and safety and notified the Administrator on 6/18/2022 at 1:30 PM. The evacuation process was then implemented. All residents were evacuated by 3:00 PM on 6/21/2022. Interviews with residents and staff on 6/18/2022 and telephone interviews with staff and family confirmed the air conditioning system had not been capable of maintaining comfortable air temperatures, especially on the 200 and 400 Halls, since the first of June. The facility was unable to provide documentation of PIPs, preparations, contingent evacuation plans, staff education for assessment, monitoring, interventions for the likelihood of the air conditioner failure, and ensuring resident health and safety. During a telephone interview on 6/27/2022 at 12:22 PM, the Medical Director confirmed the air conditioning system in the facility was an ongoing issue and that potential concerns with the system had not been on the QAPI agenda the last 2 months they had met. The Medical Director confirmed she was notified on 6/18/2022 when the residents were evacuating. During a telephone interview on 6/27/2022 at 1:20 PM, the Administrator confirmed the QAPI committee had not formally discussed or developed a written plan of action related to the possibility of the air conditioning system failing during the summer months. The Administrator stated, .If it goes down, we fix it . The QAPI committee's failure to address the ongoing concern with the air conditioner failure each summer, plan and provide education for staff focused on care needs in the event of the air conditioner failing, precautions and safety measures to implement in the event the facility's antiquated air conditioning system failed during the hot weather months placed the 150 residents in the facility in Immediate Jeopardy when the system failed. Refer to F-584, F-600, F-835, and F-837. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on 6/21/2022. The facility's noncompliance at F-867 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, a Life Safety Code violation complaint, weather website review, medical record review, observation, and interview, the facility failed to prevent neglect as evidenced by 1 of 150 residents that lived in the facility (Resident #1) exhibited symptoms of distress from heat exposure. The facility's failure to provide a safe and comfortable environment to prevent the likelihood of neglect for all 150 residents in the facility resulted in Immediate Jeopardy when the facility failed to evacuate residents when the air conditioning system was not functioning adequately. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of L, which is Substandard Quality of Care. The IJ existed [DATE] through [DATE]. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on [DATE]. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, ABUSE PREVENTION AND INTERVENTION STRATEGIES NURSING POLICY AND PROCEDURE, revealed .It is the policy of the facility to protect its residents from abuse, neglect .Ways to recognize abuse .Resident and Staff reports .Actions when abuse is suspected .ensure resident safety by removing resident from unsafe/hazardous environment . Review of an anonymous Life Safety Code (LSC) complaint dated [DATE], revealed allegations there was no air conditioning in the facility, especially on the memory care unit [400 Hall]. Fans were running in the hallway, however, residents who were confined to their beds and rooms were suffocating . Review of the ,d+[DATE] National Weather Service reporting system at www.weather.gov revealed high temperatures of 80 degrees Fahrenheit (F) to low 90 degrees F from [DATE]-[DATE], temperatures greater than 95 degrees F beginning [DATE] with recorded high temperatures of 100 degrees F on [DATE] and [DATE]. On [DATE] the high temperature was 98 degrees F with continued record high temperatures in the upper ,d+[DATE] degrees F through [DATE] and then the upper 90 degrees F on [DATE]-[DATE]. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed clear speech, understood/understands, a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 had moderate cognitive impairment, no mood or behavior symptoms, required supervision with activities of daily living (ADL), and extensive assistance with bathing. Review of the ,d+[DATE] Physician Orders, revealed .[DATE] .Hospice r/t [related to] End Stage [CONDITION(S)] [Chronic Obstructive Pulmonary Disease] .Oxygen by Nasal Cannula at ,d+[DATE] L [liters] to keep O2 [oxygen] sats [saturation] equal to or greater than 90% . Review of a Hospice Note dated [DATE] at 2:04 PM, revealed Resident #1's family called requesting a hospice visit that day and reported Resident #1 vomited his food after eating which was .potentially caused by heat exhaustion due to the memory care unit not having a working air conditioner . The hospice nurse documented, .the resident was in his room, it was hot, his skin was cool and clammy, he was [CONDITION(S)] with a heart rate of 100 beats per minute .short of breath at rest with an O2 sat on 3 L of oxygen of ,d+[DATE]% . Safety issues were identified related to inadequate cooling in the facility. The hospice nurse documented she talked to the facility nurse who told her they were working on the air conditioner. Therefore, she advised the nurse of the resident's signs and symptoms. His family was advised to send the resident to the emergency room if his symptoms persisted. The resident's family returned the hospice nurse's call and informed her facility Administration was putting an air conditioning unit in Resident #1's room. A list of in-house transfers for the week of [DATE] was requested. The following residents were transferred from the 2nd floor 400 hall to the 1st floor 100 hall: a. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed a cognitive score of 3 which indicated severe impairment, was not ambulatory, and required extensive assistance to dependence on staff for all ADLs. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed a BIMS score of 8, which indicated moderate cognitive impairment, was not ambulatory, and required extensive assistance to dependence on staff for all ADLs. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #11's status change and there were no orders for the resident's transfer from the 400 Hall to the 100 Hall. c. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .to maintain O2 levels at or above 90% . Review of the MDS dated [DATE], revealed a BIMS score of 6, which indicated severe cognitive impairment, was not ambulatory, required extensive assistance to dependence on staff for all ADLs, and received oxygen and hospice services. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #12's status change and there were no orders for the resident's transfer from the 400 Hall to the 100 Hall. d. Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed a BIMS score of 1, which indicated severe cognitive impairment, had mood symptoms which included decreased pleasure in things, had sleep and appetite disturbance, and trouble concentrating, was non-ambulatory, and required extensive assistance to dependence on staff for ADLs. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #13's status change and there were no orders for the resident's transfer from the 400 Hall to the 100 Hall. e. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS dated [DATE], revealed a BIMS score of 2, which indicated severe impairment, was not ambulatory, and required extensive assistance to dependence on staff for all ADLs. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #14's status change and there were no orders for the resident's transfer from the 400 Hall to the 100 Hall. f. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed a BIMS score of 3, which indicated severe cognitive impairment, was not ambulatory, and required extensive assistance to dependence on staff for all ADLs with limited assistance when using the wheelchair. Review of the Nursing Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #15's status change and there were no orders for the resident's transfer from the 400 Hall to the 100 Hall. Review of the LSC surveyor notes dated [DATE] at 11:55 AM, revealed the temperature in the city where the facility was located was 91 degrees F and felt like 100 degrees F with a humidity of 49%. Review of the LSC surveyor's recorded temperatures on [DATE] at 12:00 PM on the Memory Care Unit, revealed 12 of the 14 rooms registered temperatures greater than 85 degrees F and one of the rooms registered a temperature of 89.1 degrees F. Documentation revealed the LSC surveyor notified the Administrator on [DATE] at 1:30 PM, that all 150 residents in the building should be evacuated due to the failure of the facility's air conditioning system, inability for the system to be immediately repaired, and the forecasted high temperatures in the area for the upcoming week. During an interview on [DATE] at 2:50 PM, Family Member #1 stated her family member was being transported to another local facility and they were .appreciative of [State Agency's] presence and actions taken to have the residents evacuated due to the air conditioning failure . During an interview on [DATE] at 3:00 PM, the Administrator confirmed the air conditioning system had .failed on Thursday [DATE] . Observations and interviews with residents and staff on [DATE] beginning at 3:20 PM, revealed the following temperatures (temp) and resident interviews: Observations upon entering the Memory Care Unit on the 400 Hall revealed the hall temperature ranged from ,d+[DATE] degrees F with a portable air conditioning unit set at 65 degrees F and a large shop fan in the hall. a. Random Resident (RR) #1's room was 88 degrees F and the resident stated, .It's hot . b. RR #2, was seated in his wheelchair in the hall outside his room. The temperature in his room was 90.2 degrees F. When asked how he was doing, he stated, .Hot . c. RR #3 was in his wheelchair and able to self-propel the wheelchair without difficulty. The temperature in his room was 89.2 degrees F. He stated he had gone down to the 100-Hall Day Room where it was cooler. He further stated, .It's been hot on the 400 Hall for almost a week . d. RR #4 was in bed and the temperature in the room was 79 degrees F. RR #4 stated, .hope the air comes back on .it's hot . e. RR #5 was in bed and the temperature in the room was 84 degrees F and RR #5 asked if there where hospital gowns available for tonight because they are cooler. f. RR #6 was in bed and the temperature in the room was 86 degrees F. The family was at the bedside and had brought her a fan. RR #6 stated, .It's hot . g. RR #7 was in bed and the temperature in the room was 88.9 degrees F. RR #7 stated, .It's hard to stay cool .I got a fan or wouldn't have made it .miserable in the heat .so sweaty my hair needs to be washed . h. RR #8 was in his room. The temperature in the room was 90 degrees F and he stated he was hot. i. RR #9 was in his room. The temperature was 86 degrees F and he stated he was hot. j. RR #10's room temperature was 89 degrees. She was seated outside the room door, dressed in a lightweight gown and non-skid socks. She stated she was hot and .It'd help if the air was fixed and cooler in the building . k. RR #11's room temperature was 89 degrees F and the resident stated, .hot is an understatement . l. RR #12's room temperature was 88.9 degrees F and the resident stated, .It's hot . m. RR #13 was in her room and the temperature was 85 degrees F and she stated she was hot. n. RR #14's room temperature was 85 degrees F and the resident stated, .very, very, very hot . During an interview on [DATE] at 3:35 PM Licensed Practical Nurse (LPN) #1 was asked if she felt the temperature was too warm on the Memory Care Unit for the residents and staff. She stated, .I'm not going to answer that . During an interview on [DATE] at 3:50 PM, LPN #2 stated, .the air has been off for a month . During an interview on [DATE] at 3:50 PM, Certified Nursing Assistant (CNA) #1 stated, .the air has been off every year when it gets hot outside . During a telephone interview on [DATE] at 3:22 PM, Family Member #1 confirmed she or another family member made daily visits to the facility. When asked about the air conditioning in the building, the family member stated that for the 4 years the resident had been in the facility, the air conditioning had not been adequate, but .it had been around the beginning of June when the air on the 400 Hall had gone out and they had put fans in the halls . During a telephone interview on [DATE] at 4:25 PM, the Director of Maintenance (DOM) confirmed the facility's chiller system failed on Thursday [DATE]. He stated the facility building was [AGE] years old and the facility had prior problems with the air system during the summer months. When asked if he had taken room temperatures after the air system failed, he revealed he had not done so other than random temperatures. When asked if he had documentation of which rooms had required portable air units, he confirmed he did not have any documentation. When asked if the facility had planned to evacuate the residents because of the air system failure prior to the LSC surveyor arriving on Saturday [DATE]. He stated, No ma'am. Disaster preparedness plans for worst case scenario and hadn't been necessary . During a telephone interview on [DATE] at 4:00 PM, the facility owner confirmed he was responsible for the facility operations. The facility owner confirmed he was aware of problems with the air in the past but had never had a system failure before, however, the heat index had been between 100 and 105 degrees F. During a telephone interview on [DATE] at 10:53 AM, the Hospice nurse who visited Resident #1 on [DATE], revealed the resident's family called her on Friday, [DATE], frantic because it was so hot in his room. The family stated he had eaten, threw it back up, and looked like he was in distress. The room was hot and his skin was cool and clammy. The Hospice nurse stated he was stabilized on O2 at 3 L with an oxygen saturation of 92% and vital signs were within normal limits for him so she went to find the nurse. She went downstairs to the Receptionist desk and asked if the facility was going to get any air soon and was told they were working on it. A woman came out of the administration offices and the Hospice nurse informed her that Resident #1 needed to be sent to the emergency room (ER) as he needed air conditioning, and the ER would hold him there. The woman sent her to the large Conference Room where ,d+[DATE] people were eating lunch and she told his nurse that Resident #1 was in distress, he needed to be under air conditioning, and his sister was on her way. She walked out of the building to her car and documented her visit. The resident's sister called and an air conditioner was to be placed in his room and she declined transfer to the ER at that time. During a telephone interview on [DATE] at 1:20 PM, the Administrator confirmed the air conditioning system had failed on Thursday, [DATE]. The air conditioning vendor had evaluated the system, did not have the parts needed for repair, had to place an order, and the parts were scheduled to arrive on Monday, [DATE]. He stated they had put supplemental portable air conditioning units throughout the facility and kept residents out of their rooms during the warmest hours during the day. The Administrator stated that if they had not been able to fix the air they would have evacuated. During a telephone interview on [DATE] at 2:30 PM, CNA #2 confirmed that approximately 2 weeks prior to the State Agency entering the facility on [DATE] and the residents being evacuated, the air was out on the 400 Hall. They tried to put portable air conditioning units from the [local home improvement store] in some rooms, but the residents unplugged them. They brought a large fan and portable air conditioner for the 400 Hall. One family member brought a fan for his mother's room. The CNA revealed they tried to get the residents out of their rooms into the hall and to stay in the activity/dining area at the end of the hall where the facility had placed portable air conditioning units. Some residents would do this but others would not. The CNA stated the Administrator walked the halls and when he was asked about the air conditioning, he would tell them they were working on it. When asked if anyone in the facility was checking the room and hall temperatures regularly, the CNA stated, I didn't see it. During a telephone interview on [DATE] at 3:09 PM, CNA #3 confirmed she had worked on the 400 Hall. The CNA confirmed Monday, [DATE], and Tuesday, [DATE], three CNAs had walked out because it was so hot and stated, .It was hot, and the heat index was high outside .We're in the midsouth and it happens every year . Other staff scheduled on the 400 Hall said it got hot on the unit every year. CNA #3 stated they tried to keep residents up and out of their rooms, family members brought in fans, and on Friday, [DATE], they took some of the total care residents down to the 1st floor to cool off in the afternoon. The CNA confirmed that on Friday [DATE], 4 or 5 residents were moved from the 400 Hall to the 1st floor but didn't know what had happened. During a telephone interview on [DATE] at 8:04 AM, CNA #4 confirmed working the scheduled shift of 7:00 AM-3:00 PM the week of [DATE]. CNA #4 confirmed it was hot all that week on the 400 Hall, and the heat was draining. When asked if her resident had been affected by the heat, the CNA reported that on Friday, [DATE], one of her residents was slumped down in bed. LPN #1, had checked her and moved her downstairs. The CNA reported hearing a family member complain about how hot it was. Administrative staff said they were placing a stand-up air unit in her brother's room, and she asked, What about the other patients. What about the staff. The CNA revealed that during orientation they said, .'Watch what you say when the State comes around' but what if a patient or staff died ? . During a telephone interview on [DATE] at 9:53 AM, Family Member #2 was asked about the air conditioning in the facility and stated that after visiting the facility on [DATE], she had reported to a facility staff member that the air wasn't working in her family member's room and further stated, .That's just not right having uncomfortable air temperatures .Residents in the hall would say 'It's hot' and I'd respond 'Yeah. It is' . During a telephone interview on [DATE] at 1:28 PM, Family Member #3 stated she had been in the facility visiting her family member on [DATE] and the air in the room was not working. She had told the facility it was too hot in the room, her family member was sweating, and they put a portable air conditioner in the room. The Immediate Jeopardy was removed onsite when the facility evacuated all the residents on [DATE]. The facility's noncompliance at F-600 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, hospital record review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring weights, failed to consistently record the percentage of the meal intake, failed to base nutritional needs on reliable data, and failed to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions due to identified weight loss in a timely manner for 1 of 8 sampled residents (Resident #4) reviewed with a Percutaneous Endoscopic Gastrostomy (PEG) feeding. The facility's failure to monitor weights, record meal intake consistently, base nutritional needs on reliable data, and follow the RD recommendations for nutritional interventions resulted in Actual Harm when Resident #4 had significant weight loss. The findings include: Review of the facility's undated policy titled, Weights, revealed .All residents must be weighed upon admission, then weekly x [times] 4 weeks and then monthly .Any resident with 5% [percent] weight loss in 30 days will be placed on weekly weights, and meal accountability . Review of the facility's undated policy titled, WEIGHT LOSS/GAIN - A CHANGE IN CONDITION, revealed .Significant weight loss/gain is .2-3% in 1 week .5% or greater in 30 days .7.5% or greater in 3 months .10% or greater in 6 months . Review of the preadmission hospital records revealed on 12/3/2021, Resident #4 presented to the emergency department with shock trauma after being run over by a backhoe. The resident had a prolonged and complicated acute hospitalization which included dependence on mechanical ventilation and [CONDITION(S)] placement; cardiac asystole (cessation of electrical activity of the heart) and resuscitation; pelvic and sacral fractures; partial and deep thickness skin loss and friction [CONDITION(S)] to left thigh, left flank and right thigh; sepsis; and soon after hospital admission, placement of a hemodialysis (HD) catheter for treatment due to failed kidney function which required intermittent HD treatments followed by regular HD treatments 3 times each week beginning 12/7/2021. The resident was discharged from the acute hospital setting to an extended care hospital on 1/21/2022 where his tracheotomy was eventually discontinued,. The resident was stabilized on HD 3 times each week, stabilized on continuous PEG feedings nightly, and pureed meal trays during the day. The resident was discharged from the extended care hospital and admitted to the facility on [DATE]. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's surgical history included Coronary Artery Bypass Grafting prior to the trauma. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's RD note dated 3/23/2022, revealed Resident #4's tube feedings were based on a 3/14/2022 hospital weight of 162 pounds (lbs.). The RD recommendations for tube feeding was Nepro at 98 ml/h x 12 h which provided 2116 calories and 95 grams (G) of protein. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of an order to change the feedings to daytime hours. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluids were of regular consistency. A 1,000 ml fluid restriction was also ordered which was not to include the fluid in the tube feedings. The resident was to have no breads, sugar free snacks twice daily and double protein with all meals. On 3/24/2022, he was also started on a physician prescribed protein supplement of 30 ml twice daily to provide additional calories and protein for wound healing. Review of the comprehensive Care Plan initiated on 3/25/2022, revealed Resident #4 was at nutritional risk related to receiving a mechanically altered therapeutic diet, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assessing weights and food intake as needed/indicated, assess, record, and report to the physician as needed for significant weight loss of 3 lb. in 1 week and greater than 5% in 1 month. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had clear speech, understood/understands, had moderate cognitive impairment, required extensive assistance with activities of daily living which included eating, was 68 inches tall, weighed 173 lbs., was on a mechanically altered and therapeutic diet, received greater than 51% of the calories per feeding tube, and received greater than 501 ml water via feeding tube. Review of Resident #4's weight record revealed the resident's admission weight was not obtained until 3/28/2022, 5 days after admission. Review of the resident's weight record revealed the following: 1. Admission: 3/23/2022: No admission weight obtained. 2. Week #2: documented an initial weight was obtained on 3/28/2022 of 173.4 lb. 3. Week #3 (4/3-4/9/2022) there was no weight obtained. 4. Week #4 (4/10 - 4/16/2022) there was no weight obtained. 5. Week #5 on 4/21/2022 documented a weight of 158.4 lbs., which was a 15 lb. loss, 8.7% since the first weight obtained on 3/28/2022. 6. Week #6 on 4/30/2022 documented a weight of 151 lbs. which was a loss of 22.4 lbs., 12.9% in 30 days. 7. Week #7 on 5/5/2022 documented a weight of 145 lbs., a 28.4 lb. loss, 16.4% since the first weight obtained on 3/28/2022. 8. Week #8 on 5/12/2022 documented a weight of 142 lbs., a 31.4 lb. loss, an 18.1% weight loss since 3/28/2022 Review of the HD clinic's pre and post HD treatment weights revealed the following: 1. 3/24/2022: pre and post 176.9 lbs. following 3.3 hours of HD. 2. 3/26/2022: pre-175.6 lbs., post-172.9 lbs. following 3.3 hours of HD. 3. 3/29/2022: pre-174.7, post-174 lbs. following 3.3 hours of HD. 4. 3/31/2022: pre-169.4, post-169.2 lbs. following 3.3 hours of HD. 5. 4/2/2022: pre-169.2, post-169.6 lbs. following 3.34 hours of HD. 6. 4/5/2022: pre-176, post-162.8 lbs. following 3.3 hours of HD. 7. 4/7/2022: pre-163.7, post-162.1 lbs. following 3.3 hours of HD. 8. 4/9/2022: pre-161.3, post-157.5 lbs. following 3.31 hours of HD. 9. 4/12/2022: pre-158.4, post-157.6 lbs. following 3.3 hours of HD. Continued review of Resident #4's weights and HD times until the resident was discharged on [DATE], revealed a continued gradual weight loss as noted on 5/12/2022: a weight of 142 lbs. HD treatment times ranged from 2.47-3.4 hours with documented weight gain post HD treatment on 4/19/2022 and 4/26/2022 related to low pre weight of 149.8 lbs. and 150.5 lbs. respectively. Review of the meal intake records recorded by the Certified Nursing Assistants (CNA) for 4/2022, revealed the percentage of meal intake was recorded for 39 of 90 possible meals and 27 of the 39 recorded meals documented 0-25% of the meal eaten. Review of the facility's RD note dated 4/4/2022, revealed nursing's request that Resident #4 be changed to bolus feedings instead of continuous PEG feeding via pump due to the resident pulling on the feeding pump and pulling at his PEG tube . Upon admission to the facility, the resident's nocturnal (nighttime) PEG feedings had been changed to daytime hours for infusion. Review of the RD recommendations dated 4/4/2022 revealed the resident was to be changed to 1 can of Nepro 4 times daily followed by 150 ml of free water bolus to follow each feeding. The 4 cans of Nepro daily provided 1700 calories and 76 Grams (G) of protein. The RD documented a reported meal intake of 25-75%. Review of the pre and post HD weights provided by the facility revealed on 4/12/2022 Resident #4 weighed 158 lbs. The facility was unable to provide documentation that the resident's 15 lbs./8.7% weight loss in 3 weeks was identified or addressed. Review of the MAR for 4/2022 and 5/2022 revealed, Resident #2 was out of the facility for hemodialysis every Tuesday, Thursday, and Saturday as ordered. Therefore, 3 days each week the resident did not receive one of the cans of Nepro which was calculated as 450 calories and 19 G of protein needed to sustain the resident's nutritional status. Review of the facility's RD note dated 4/25/2022, revealed the RD had conferred with the HD clinic RD and recommended, in addition to the interventions in place, and a multivitamin supplement, the resident's diet be liberalized to a mechanically altered regular diet, discontinue the 1,000 ml fluid restriction, and add sugar free house shakes with all meals with the goal to improve his by mouth nutritional intake. Review of the 4/2022 and 5/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 7/7/2022 at 11:20 PM, the Director of Nursing (DON) confirmed the facility was not weighing the resident and the resident's weights were not documented. During telephone interview on 7/7/2022 at 11:44 AM, the RD at the HD center confirmed Resident #4 was sent to the facility from the extended care hospital on a maintenance PEG feeding and had been stabilized on HD prior to discharge to the facility. The RD confirmed he should not have continued to lose weight, especially not 31 lbs. in the 7 weeks that he was a resident at the facility, if he was receiving the necessary nutrition to meet his needs. She confirmed the [CONDITION(S)] clinic did not give his bolus PEG feeding the 3 days a week that he was at the HD center for the HD treatment which would amount to a deficit of 450 calories and 19 grams of protein for each missed feeding. The RD confirmed an approximate 500 calorie decrease in the nutritional feeding daily, due to the change from a continuous feeding to bolus feedings. The loss of another 450 calories 3 times weekly due to the resident not receiving a bolus feeding on the days in [CONDITION(S)] could result in a gradual weight loss. The RD stated her facility contact was the Certified Dietary Manager (CDM) until when she talked with the facility's RD on (4/25/2022). The RD stated that the CDM informed her she .could only pass recommendations along to nursing . During telephone interview on 7/7/2022 at 2:09 PM, Resident #4's Responsible Party (RP) confirmed she had brought her husband home as she could make sure he was clean and dry, had something to eat and drink, and that the facility was a [explicit word] hole .they wouldn't assist him with eating .couldn't get an answer to questions .nobody answers the phone .always bull [explicit word] . During telephone interview on 7/7/2022 at 3:28 PM, the facility RD reviewed her nutritional assessment and calculations and confirmed bolus feedings of 4 cans daily provided 1700 calories and 76 G of protein. When asked about the decreased nutrition provided by the continuous feedings, 2116 calories and 95 G protein to 1700 calories and 76 G protein, the RD stated she accounted for 377 extra calories daily from the 25% eaten at meals daily and the 200 calories provided by the protein supplement. The resident had been receiving the protein supplement with the continuous feeding, and a diet as of 3/24/2022. Therefore, the 377 calories received from the food consumed and the 200 protein calories were already in place which resulted in the resident having a 516 calorie deficit in the caloric intake daily due to the order of changing the feedings from continuous to bolus and placed the resident at risk for weight loss. During a telephone interview on 7/7/2022 at 3:28 PM, the Director of Nursing (DON) confirmed the facility sent a sack lunch with the resident on [CONDITION(S)] days, and they did not make up for the missed bolus feedings when Resident #4 went to [CONDITION(S)]. During a telephone interview on 7/11/2022 at 12:04 PM, the DON confirmed the CDM was responsible for monitoring resident weights. The facility's failure to monitor weights, document consistent percentages of the intake at meals, and follow the RD recommendations for nutritional interventions resulted in Actual Harm when Resident #4 had significant weight loss.

Based on policy review, Quality Assessment and Assurance Committee (QAA) meeting minutes, and interview, the QAA Committee failed to identify ineffective policy and procedures related to Leave of Absence (LOA), Against Medical Advice (AMA), Planned/Unplanned discharges, and visitation for vulnerable residents, failed to maintain a process for monitoring and recognizing effective policies and protocols for vulnerable residents, to identify and screen visitors, and the authorizations of Responsible Parties and safety during visitation. The QAA committee's failure to identify areas of safety concerns including validation of a visitor's identity, notification of a resident's Responsible Party related to visitation, Leave of Absence, and Against Medical Advice, resulted in Immediate Jeopardy and actual Harm when a cognitively impaired resident left the facility for an outdoor visit, got in a car, and left the premises without authorization from the Responsible Party. Resident #1 was found in a (Named) hospital in another state, located approximately 1,922 miles from the facility. Resident #1 required medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the resident's location for 12 days. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to the resident. The Administrator was notified of the Immediate Jeopardy on 3/11/2022 at 11:51 AM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689, F-835, and F-867. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/13/2022 through 3/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/12/2022 at 8:24 PM, and was validated onsite by the surveyors on 3/13/2022 through 3/14/2022 through observations, review of meeting minutes, education, audits, policies, medical record reviews, and staff interviews conducted on all shifts The findings include: Review of the facility's undated policy titled, Quality Assessment and Assurance Committee revealed .establish and maintain a Quality Assessment and Quality Assurance Committee that oversees the identification and handling of quality issues .help identify negative outcomes .develop implementation, monitoring and evaluation of action to correct quality concerns and promote overall quality of care and services .actions that may be implemented to help address quality issues may include .educational training programs, new or revised policies and procedures .adjustment in .discharge practices .develop and implement plans of correction and monitoring approaches .should include specific timeframes for implementation and follow up .advise the administration of the need for policy or procedural changes .monitor to ensure that such changes are implemented . Review of the facility's Quality Assessment and Assurance Committee Emergency Meeting dated 2/14/2022, revealed .Purpose: To discuss occurrence related to resident leaving facility and to determine further actions needed .discuss current LOA [leave of Absence], AMA [Against Medical Advice], Planned/Unplanned discharge procedures .how to address unusual instances where the resident/representative choose not to participate in established practices and the measures to gather information related to said occurrence .Review/Actions: current LOA, AMA, Planned/unplanned discharge procedures are deemed to be effective and applicable . The QI (Quality Improvement) sign-in sheet showed signatures of the following attendees Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Nurse, Medical Director (via phone), and Social Services. Review of the facility's Quality Assessment and Assurance Committee Emergency Meeting dated 2/21/2022, revealed .Purpose: To discuss potential actions/interventions to strengthen LOA procedures as it relates discharges related to LOA's, planned discharges, unplanned discharges, and resident who choose to not return and refuse to sign LOA, participate in teaching, and/or not participate in pre/post discharge teaching. Current LOA,AMA, Planned/Unplanned discharge procedures are deemed to be effective and applicable .unusual instances where the resident/representative choose not to participate in established practices and the measures to gather information related to said occurrence .the facility will exhaust all avenues and will contact RP [Responsible Party] .make report to appropriate agencies and document based on status of discharge .facility will take into consideration BIMS[Brief Interview for Mental Status] scores and elopement/wander risk during admission and discharge planning .Review/Actions: current LOA, AMA, Planned/unplanned discharge procedures are deemed to be effective and applicable .explore plan to identify documented representatives and/or notify those parties of visitors not on list of representatives when warranted . The QI sign-in sheet showed signatures of the following attendees: Administrator, DON, MDS Nurse, Medical Director (via phone), and Social Services. During the QAA meetings conducted on 2/14/2022 and 2/21/2022, the QA committee failed to identify this incident as an elopement, did not review the elopement policy/procedure, and did not review the visitation policy to ensure cognitively impaired residents were safe during visitation. The QAA committee failed to identify how the staff would be educated on the actions concerning the LOA policy. The QAA committee failed to identify when staff education would be provided and failed to identify a timeframe for completion of the education related to elopement, LOA, AMA, and Planned/Unplanned discharge. During an interview on 3/8/2022 at 11:43 AM, the Nurse Practitioner (NP) stated, .went back and forth about if it was an AMA or not because he called someone to get him .they called me that night in a panic, trying to figure out where he was and who the daughter was .there were no AMA orders given, no AMA paperwork signed .he's functional but something isn't quite right .he is not safe . During an interview on 3/8/2022 at 3:35 PM, the DON stated, .no one signed him out because he said was going to the car to visit his grandkids .that night I told the Unit Manager to call and report the resident missing when we found out the visitor was not his Responsible Party. We began the investigation as he went out with his daughter .I didn't go over the statements until the next morning .it was clear this was not an AMA .he did not go out LOA .he left when he got the opportunity .we did not consider his low BIMS score when we started the investigation .nothing has changed for visitation since this happened .residents can go outside to visit without supervision .the Administrator and I were talking today about how to revise the policy to ensure family members are who they say they are .just not sure how we are going to do that .ask for driver's license for identification .not sure how to proceed .no, there is not an incident report because we thought it was an AMA . During an interview on 3/10/2022 at 4:45 PM, the Administrator stated, .the 11:00 PM-7:00 AM shift is not familiar with the AMA procedure .most AMA discharges happen during the day when administrative staff is [are] here .this was a real gut punch for me .did not consider the resident's BIMS [Brief Interview for Mental Status] assessment of 9 in determining if the resident was safe to make the decision to leave for himself .did not think about if we had additional means to confirm the identity of the visitor .did not identify when the facility staff should contact the Responsible Party before the resident is released . During an interview on 3/13/2022 at 6:24 PM, the DON confirmed there was no documentation of the incident in Resident #1's medical record on 2/13/2022, the documentation was added on 2/15/2022 and 2/16/2022. On 3/3/2022, after a chart audit, Resident #1's evening medications were not documented as administered on 2/14/2022. The DON further confirmed that since there was no documentation the night of the incident, it would not have been on the 24-hour report which prompts the information used to conduct the Interdisciplinary Team Meetings. During an telephone interview on 3/14/2022 at 11:09 AM, the Governing Body member stated, .I believe we have had this conversation before about my role for the facility .I am not involved in any type of committee .I was notified .my direction was to try and locate the resident .he left AMA from the facility with his daughter .it is still an AMA from our perspective .resident expressed he wanted to leave without proper discharge instructions .he can leave without his belongings and discharge himself .my understanding is that he is capable of making those decisions .I haven't evaluated him and neither have you .you cannot establish the fact that he is not capable of making those decisions .no, he shouldn't have left the facility .not good for his health .BIMS 9 .he shouldn't have been out of the nursing home . The surveyors verified the Removal Plan by: 1. On 3/11/2022, an AdHoc (As needed) meeting was conducted to review, educate, and update policies in relation to: LOA, AMA, planned/unplanned discharges, visitation for vulnerable residents, to identify and screen visitors, and authorizations of Responsible Parties and safety during visitation. The surveyors interviewed the Administrator, DON, Agency, and Facility staff on all shifts. 2. AdHoc meeting education was done covering events that warrant AdHoc meeting, which are reportable events, breaches of policy and procedure, and any upward trend in events affecting wellbeing of residents. The surveyors reviewed the education and interviewed the Administrator and the DON. 3. QAPI education was done for the Interdisciplinary Team (IDT). The surveyors reviewed the education and interviewed the Administrator, DON, Unit Manager, and Care Plan Coordinator. 4. Policies and procedures have been reviewed and updated for LOA, AMA, planned/unplanned discharges, and visitation for a vulnerable resident. The surveyors reviewed the updated policies and interviewed Agency and Facility staff on all shifts. 5. QA committee will meet monthly for 3 months and as needed to review any findings as related to breaches of policy and reportable events. The surveyors interviewed with Administrator and DON. 6. In-service was done for all staff on all policy and procedure updates. The surveyors reviewed the education and interviewed Agency and Facility staff on all shifts. 7. Corrective actions will be monitored for 30 days for effectiveness; all findings will be shared with QA for evaluation. The surveyors reviewed audit forms and interviewed the Administrator and DON. 8. All visitors must provide proof of Identification (ID) prior to a Leave of Absence or AMA discharge. If the visitor isn't the Responsible Party, the Responsible Party will be contacted prior to resident being released. The surveyors reviewed the updated policies and interviewed agency and facility staff on all shifts. 9. The QA committee will meet quarterly to review and update policies and procedures as related to vulnerable residents, visitor screening, authorization of Responsible Parties, and safety during visitation. Vulnerable resident's visitation will be care planned and adjusted depending upon the identified vulnerability. The surveyors interviewed the Administrator, DON, and Care plan Coordinator. 10. All the above steps were initiated on 3/11/2022, will be monitored for 30 days for effectiveness, and all findings will be shared with QA for evaluation. The surveyors reviewed meeting minutes and interviewed the Administrator and DON. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, police report review, hospital record review, medical record review, and interview, the facility failed to ensure a safe environment to prevent an incident of elopement for 1 of 5 sampled residents (Resident #1) reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) and actual Harm when a vulnerable cognitively impaired resident exited the facility without authorization or staff supervision. The facility was unaware of Resident #1's location for 12 days. Resident #1 called the facility and stated that he was in a (Named) hospital, in another state, located approximately 1,922 miles from the facility. Resident #1 required medical treatment for elevated blood sugar and blood pressure (the resident was without his prescribed medications for blood pressure and blood sugar when he left the facility). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 3/9/2022 at 5:25 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 2/13/2022 through 3/13/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/10/2022 at 11:06 AM. The corrective actions were validated onsite by the surveyors on 3/10/2022 through 3/14/2022 through observations, policy review, medical record review, review of education records, auditing tools, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, ELOPEMENT, revealed .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the departure in a courteous manner; Get help from other staff members in the immediate vicinity, if necessary; and Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .complete and file Report of Accident/Incident . Review of the facility's undated policy titled, Discharge of Resident: Against Medical Advice [AMA], revealed .Purpose: To describe the discharge process for a patient departing from the center against medical advice .Discuss with patient or legal representative the desire to leave the center against medical advice .inform physician of patient's intent to discharge against medical advice .physician orders as needed .assist in fully explaining .the risk of discharge against medical advice .Provide written and verbal education to the patient and legal representative .Inform patient .that leaving the center prevents the provision of necessary care and services and that the physician and center are not responsible for the welfare and wellbeing of a patient .Complete Release for Discharge Against Medical Advice form with patient or legal representative's signature .Ensure that all belongings are packed and sent with patient .escort and assist patient to transport vehicle . Review of the facility's undated policy titled, Leave of Absence Policy (LOA), revealed .permit residents to leave the Facility premises for designated time periods and (2) ensure that the Facility is aware of the whereabouts of its residents .All residents leaving the Facility premises must be appropriately signed out and signed in upon return .Staff members should promptly inform supervisor for any requests received for a LOA .The Resident and/or the Resident Responsible Party shall sign the LOA form and Release .if staff has any concerns with regard to the Resident leaving with a specific individual, staff should contact one of their supervisors . Review of the closed medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Cerebral Infarction, Acute Kidney Failure, [CONDITION(S)] with Behavioral Disturbance, Disorder of Prostate, History of Falling, (Past Surgical) Absence of Left Toes, and Personal History of COVID-19. Review of the DESIGNATION OF RESIDENT REPRESENTATIVE form dated 11/18/2021, revealed .The individual(s) whose name(s), address(es) and telephone number(s) are listed below has/have been authorized to be the Resident's Representative. This authorization was determined as follows .(X) The Resident (with capacity) has made the designation .Resident Representative Designation: I understand the above and hereby designate: (X) I ELECT TO HAVE A RESIDENT REPRESENTATIVE AT THIS TIME .Name of Representative [Daughter's Name] .Duties: Power of Attorney [POA] . This document was signed by Resident#1's daughter. Review of the Physician Orders dated 12/27/2021, revealed medication orders for Aspirin once daily (preventative to thin the blood), [MEDICATION(S)] two times a day (used to treat blood pressure), [MEDICATION(S)] two times a day (used to treat seizures), [MEDICATION(S)] Sulfate once daily (used to treat [CONDITION(S)]), [MEDICATION(S)] once daily (used to treat enlarged prostate), [MEDICATION(S)] every 8 hours (used to treat [CONDITION(S)], nerve pain) , Insulin inject 32 units twice a day morning and bedtime (used to treat diabetes), [MEDICATION(S)] twice a day (used to treat diabetes), [MEDICATION(S)] once daily at bedtime (used to treat elevated cholesterol), Tamsulosin once daily (used to treat enlarged prostate), and an Accucheck (bedside test that checks the blood sugar level) every morning and night. There were no orders for LOA or AMA. Review of the Care Plan dated 12/28/2021, revealed .Focus .The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] dementia .Focus .The resident has an ADL [Activity of Daily Living] Self Care Performance Deficit r/t disease process . Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was assessed with a Brief Interview of Mental Status (BIMS) of 8, indicating moderate cognitive impairment. Resident #1 required supervision with bed mobility, limited assistance with one person assistance with transfers, ambulating in room and corridor, locomotion on and off unit, dressing, and toilet use. Resident #1 required extensive assistance with personal hygiene. Review of a Psychiatric Note dated 1/6/2022, revealed .referred for evaluation and review of meds [medications] .Mental Status Exam .disoriented, ST [short term] impaired .confusion .Clinical Status and Impressions: [CONDITION(S)]-patient is confused .monitor for changes in mood and behaviors. Redirect as needed . Review of a BIMS assessment dated [DATE], revealed Resident #1 was assessed with a BIMS of 9, indicating moderate cognitive impairment. Review of a Late Entry Plan of Care Note dated 2/13/2022 at 11:00 PM (with a created date of 2/16/2022 at 11:33 AM), written by Registered Nurse (RN) #2, revealed .found [Named Resident #1] not in the room .went to front door .couldn't find the patient .CNA [Certified Nursing Assistant #1] stated patient in parking lot with daughter in the car .I went to the parking lot, couldn't find the patient .asked CNA [CNA #1] who opened the door .CNA [CNA #1] said she opened the door for the patient .I told her he was not in the parking lot . Review of a Late Entry Plan of Care Note dated 2/13/2022 at 11:25 PM (created on 2/15/2022 at 1:22 PM), written by RN #1, revealed .Arrived for shift and was reported to this nurse that pt [patient] [Resident #1] left AMA .reported left with a friend . Review of a discharge assessment-return not anticipated MDS dated [DATE], revealed the Staff Assessment for Mental Status was assessed with short-term memory problems and modified independence with regards to daily life. Resident #1 required supervision with bed mobility, transfers, ambulating in room and corridor, locomotion on and off unit, toilet use, and supervision with dressing and personal hygiene. Review of Social Services Progress Note dated 2/14/2022, revealed .[Named Resident #1] left AMA on 2/13/22 [2022] .Called [Named Sergeant] with .Police Department about an open APS [Adult Protective Services] case to inform that [Named Resident #1] left AMA on 2/13/22 [2022] . Review of the Police Report narrative dated 2/14/2022 at 2:45 AM, revealed .responded to a Missing Person .Victim [Resident #1] was last seen leaving the premises with an unknown female .is noted as being diagnosed with early stages of dementia .was informed by his daughter that the female in question was not her .If located, complainant wishes victim to be returned to [facility's address] . Resident #1 walked out of the Long-Term Care Facility (LTCF) unsupervised by facility staff and was later located in another state 1,922 miles from the LTCF in a hospital requiring medical care. Review of the Hospital Emergency Department Notes dated 2/17/2022, revealed .Pt [Resident #1] was at [Named Restaurant] and staff noticed he was there for a long time acting strange .the PD [Police Department] was called .admitted [DATE] .Daughter [Named] called [the hospital] to give her contact info [information]. She states that she recently learned the client has shown up in [Named City]. He has been missing from [Named State] for several days. She states the client has dementia, but he will deny this Patient presents with Hypertension [elevated blood pressure] .Patient on 5150 hold [allows a clinician to involuntarily confine a person who is deemed to have a mental disorder that makes him or her danger to themselves or others] is missing person from [Named City and State] .gravely disabled and missing person from skilled nursing facility .Pt is poor historian .he thought he was in a different state and did not realize he was in [Named City and State] .also missed his [Named] bus to [Named City and State] and did not have any luggage or personal belongings has no form of ID [identification], large sum of cash [$]692.00 .Per family, he walked out of the rehabilitation center in [Named city and state] without letting family know .elevated BP [blood pressure] 181/99, Initial blood glucose > [greater than] 600, A1c [measures the average blood glucose over the past 3 months] 10.2 [target for people with diabetes is usually less than 7%] .admitted for placement .Physical Examination .AO [alert and oriented] x 2 [person and place] .Extremities .2+ [plus] swelling R [Right] > L [Left] .Neurological .follows simple command .states can ambulate but appears weak .Forgets limitations .During course of hospital stay, [Named Resident #1] pulled IV [Intravenous line to deliver fluids and medicines through the veins] out after receiving 1 liter of Normal Saline infusion, was evaluated by a psychiatrist to have a diagnoses of Neurocognitive impairment [decreased mental function due to medical disease other than psychiatric illness], [CONDITION(S)] . Review of a Hospital Case Management note dated 2/18/2022, revealed disoriented to date and situation .He [Resident #1] states that he plans to stay in [Named State] because he will be staying momentarily with family that resides in [Named State] but they are unsure he is here and that he was planning to stay. He does not have their contact information .he took a [Named] bus from [Named state] to [Named state] .missed his second bus and does not have a plan to take care of himself .has no medications, luggage, no address/residence to where he was trying to find family .does not have contact information to the siblings he reports residing in [Named State] and has not spoken to them recent .Discharge plan: Pt [Patient] is expected to discharge to custodial care [non-medical assistance for activities of daily living care] once medically clear . Review of the LTCF Social Service Note dated 2/25/2022, revealed .[Named Resident #1] called facility today and SW [Social Worker] and Unit Manager spoke with him .stated he is in [Named City and State] .tried to call daughter .was unsuccessful .texted and asked daughter to call SW [Social Worker] because [Named Resident #1] and SW have talked to each other . Review of the Social Service Note dated 3/1/2022 and 3/2/2022, revealed that Resident #1 had called the facility from the hospital in the other state. During an interview on 3/2/2022 at 3:30 PM, the Administrator stated, .I was notified that [Named Resident #1] had left the facility .he walked out behind a visitor who the resident said was his daughter .he told staff that he was going to the parking lot to see his grandkids .he did not come back .he has called the facility and said he was in [Named city and state] and he was doing fine .This was not elopement .he just left .he was not impaired, he knew exactly what he was doing, he wanted to leave .he did not elope from the facility, he left AMA .we reported it to the police that he left the facility .he planned to leave .I don't see this incident as an elopement . The Administrator confirmed that Resident #1 and Resident #1's responsible party did not sign the AMA or LOA paperwork prior to him leaving the facility. The Administrator confirmed that AMA and LOA paperwork had not been completed prior to him leaving the facility. During an interview on 3/3/2022 at 3:22 PM, the Social Service Director stated, .his daughter has always been his responsible party .we discussed all care with her .I've never met his children .he discharged home in December and was readmitted from the hospital after getting into a fight with his son .an APS case was opened .APS said the resident had to be discharged to a licensed home .I couldn't just discharge him to the street or put him back in that home, that would be an unsafe discharge .he was agreeable to go to the licensed home until he got that card [Social Security] .then he said that's not where I want to go .I got a text message the next morning [after the incident] telling me he left .the police had already been notified .he talked about leaving often .he left out the building with a visitor saying he was going to see his grandkids .he decided he would leave .staff looked for him and could not find him .concerned about his safety because the visitor was not his daughter .his BIMS was 9 .we were trying to safely discharge him, could not discharge him out on the street, he could not go home with his son .Against Medical Advice or Leave of Absence had not been discussed or paperwork signed . During an interview on 3/2/2022 at 3:30 PM, the Administrator stated, .the resident's [Resident #1] girlfriend came to the facility to visit that night she was posing as his daughter, he [Resident #1] stated he wanted to go outside to see his grandchildren .staff let him out, he got in the car and they drove off .he called the facility and said he was ok, he is living in [Named State] with his family .the only reason we reported it was because we didn't want you [surveyors] to come in here and say it was an elopement .he just left . During an interview on 3/4/2022 at 10:13 AM, Registered Nurse (RN) #1 stated, .he [Resident #1] didn't tell anybody he was leaving that night .is his own responsible party so he can do what he wants to do .he left, I was on break away from the facility, when I returned, staff had looked for him and was not able to find him in the parking lot .I looked for him around the facility and parking lot I did not see him .I notified his daughter, I told her the resident had left the facility .the daughter stated he was not with her .I called the police because we were concerned wanted to make sure he was safe .there was a APS case going on with him and a son .he might have had a low BIMS but he was able to make that decision to leave .he wanted to leave, he made the decision .we can't hold him here against his will . RN #1 was asked if Resident #1 was safe to be outside unsupervised and RN #1 stated, .not for me to decide .it's a matter of opinion .whether he was safe or not .he could make his own decisions he was his own RP [Responsible Party] .I have talked with him since he left .he is in [Named state] . During a telephone interview on 3/4/2022 at 1:53 PM, RN #2 stated, .was rounding with oncoming nurse .[Named Resident #1] was not in his room .went to the front lobby did not see him .[Named CNA #1] said he went to the parking lot to see his grandchildren, she told me she scanned the door to let his daughter out and he went out behind her, saying he was going to see his grandkids in the car in the parking lot .I looked in the driveway alongside the building and parking lot did not see him .called the daughter (RP) asked if he was with her and she said 'no he is not with me, it was not me I'm in [Named State] .went outside again and searched the parking lot, and we did not see the car or the resident .I called the Unit manager and the Director of Nursing [DON] .told them [Named Resident #1] had left the facility . During an interview on 3/4/2022 at 4:16 PM, CNA #1 stated, .I was in the front lobby waiting on my ride home .a little before 11:00 [PM] .[Named Resident #1] was in the lobby told me to let his daughter in .I scanned the door to let her in and after a few minutes she wanted to be let out, I scanned the door she went out and he went behind her saying he was going to the parking lot to see his grandkids .I told him he could not do that, but he kept walking, so I came back in .it was dark did not see him get into a car .went with nurse to parking lot .did not see him .I did not initiate the elopement drill or notify nurse when [Named Resident #1] went out the door .I did not ask the visitor to sign in . During a telephone interview on 3/7/2022 at 1:26 PM, Resident #1's daughter (the Responsible Representative, POA) stated, .I am his Responsible party and only daughter .my father has dementia .in the facility because he was not taking care of himself .I was notified that my father had left the facility with someone who said they were his daughter .scared me to death because I'm here in [Named State] and only daughter .was told he left the facility .did not know who he left with or where he was .3 days later I was notified by a friend that my father was in the hospital in [Named City and State] .I contacted the police in [Named State] and was told my father was found confused at a restaurant, they had taken him to the hospital to be checked out. I called the hospital and he had been admitted .he [Resident #1] told me he had caught the bus to [Named State] with the intention to get to [Named City], he didn't remember much about how he ended up at the hospital. I notified the [Named] Police and APS to let them know where he was located . During an interview on 3/8/2022 at 11:43 AM, the Nurse Practitioner (NP) stated, .they called me that night in a panic, trying to figure out where he was and who the daughter was .there were no AMA orders given, no AMA paperwork signed .he's functional but something isn't quite right .he is not safe . During a telephone interview on 3/8/2022 at 11:45 PM, the Police Investigator stated, .a call came in for a missing person around 2:45 AM, an officer responded to the facility and made a report .I had a problem with how he [Resident #1] got out of the building because someone had to scan the door to come in or out .wondered why he was allowed to go out that time of night to visit because he has a diagnoses of dementia .he had a case with Adult Protective Service where he was assaulted by his son .yes it concerned me. Someone let him out the door with someone that posed as his daughter .we were instructed to return resident to the facility if found .the daughter called and reported he was in [Named City and State] on 2/18 [2022] .she said he had money in his pocket and was confused when he was found . During an interview on 3/8/2022 at 3:35 PM, the DON stated, .no one signed him out .he said was going to the car to visit his grandkids .We didn't look at this as an elopement because he called someone he knew to come and get him .we didn't think about his BIMS score .this was not a AMA incident, no paperwork for AMA was completed by the resident or RP .we were concerned about his safety .a staff member scanned the visitor in and out .we do not restrict visiting and we do not monitor if visiting takes place outside . During an interview on 3/8/2022 at 4:08 PM, the DON stated, .if AMA there would have been an AMA paper signed, his [Resident #1's] medications and his clothing would have went [gone] with him .I called the daughter to see when he would be returning to the facility since he had left all of his belongings .she informed me that he was not with her . During a telephone interview on 3/9/2022 at 10:46 AM, Resident #1 stated, .called a close friend to come pick me up from the facility that night. She took me to a hotel where I spent the night. The next morning, I caught the city bus to the [Named] bus terminal to go to [Named City]. There was a 3-hour layover in [Named City and State], the bus left me and 6 others at the terminal and did not return. I caught rides with different people and ended up in [Named City and State]. I was lost and trying to find the bus station to get to [Named City], I flagged the police down to ask directions, the next thing I remember here I am in the hospital .I did not sign any papers [for LOA or AMA] .the visitor I left with was not my daughter, I did not receive any medications before I left the facility .My daughter [Named his daughter] is my RP . The surveyors verified the Removal Plan by: 1. Residents will be educated during the initial discharge planning on the AMA process. The surveyors verified by chart review and interviewed the Social Service Director. 2. AMA forms will be available for staff access at each Nursing Station. The surveyors made observations and interviewed agency and facility staff on all shifts. 3. Residents will be required to sign-out when leaving the facility via AMA form with education or LOA form which will be provided by the attending nurse or designee. The surveyors reviewed education and interviewed agency and facility staff on all shifts. 4. LOA sign out log will be located at each Nursing Station. The surveyors made observations and interviewed agency and facility staff on all shifts. 5. Any Leave of Absence or AMA discharge will be authorized by the resident responsible party if BIMS is below 12 or has a diagnosis of Dementia or Alzheimer's. The surveyors made observations and interviewed agency and facility staff on all shifts. 6. Staff In-services will be inclusive to full-time, part-time, and agency staff. In-services will include AMA policy and procedure, location of AMA discharge forms, LOA policy and procedure, location of LOA sign out log, proper supervision of resident visitation, BIMS education including PCC (electronic medical record) EMAR (Electronic Medication Administration Record). All staff will be required to complete the in-services prior to their next shift. The surveyors made observations and interviewed agency and facility staff on all. 7. All visitors will be required to sign in and complete COVID screening forms when entering the building. The surveyors made observations and interviewed agency and facility staff on all shifts. 8. Identification (ID) will be required for LOA and AMA discharges. If ID does not match information of the Responsible Party, the Responsible Party will be contacted prior to the resident being released. The surveyors made observations and interviewed agency and facility staff on all shifts. 9. Staff in-services will be inclusive to full-time, part-time and agency staff and will include the screening and sign in process, requirement for ID for LOA and AMA discharges, and visitation policy. All staff will be required to complete the in-services prior to their next shift. The surveyors made observations and interviewed agency and facility staff on all shifts. 10. Dedicated locations for outside visits will be held in a secured interior courtyard. The surveyors made observations and interviewed agency and facility staff on all shifts. 11. Staff in-services will be inclusive to full-time, part-time and agency staff and will include outside visit protocol and location, and elopement policy and procedure. All staff will be required to complete the in-services prior to their next shift. The surveyors made observations and interviewed agency and facility staff on all shifts. 12. All policies and corrective actions will be monitored daily for 30 days; all findings will be addressed/shared with the Quality Assurance (QA) committee. The surveyors made observations and interviewed agency and facility staff on all shifts. 13. Staff will be educated to contact Administrator, Director of Nursing, or Social Worker if at any time they hear a resident mention leaving the facility. Elopement risk assessment will be updated and discharge planning with the Responsible Party/resident will begin. All staff will be required to complete the in-services prior to their next shift. The surveyors made observations and interviewed agency and facility staff on all shifts. 14. All corrective actions and in-services were initiated on 3/9/2022. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Board of Examiners for Nursing Home (BENHA) Form, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively to attain and maintain the highest practicable well-being of vulnerable moderately impaired residents with dementia. The Administration failed to provide oversight to monitor and ensure resident safety and supervision to prevent an incident of elopement when Resident #1, a vulnerable resident with dementia, left the facility's premises without authorization, with a visitor, posing as the resident's representative. Administration failed to provide oversight and guidance of nursing and facility staff to ensure vulnerable residents were provided with a safe environment for visitation. The facility's failure resulted in Immediate Jeopardy and actual Harm when Resident #1 was found in a (Named) hospital in another state, located approximately 1,922 miles from the facility. Resident #1 required medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unaware of the resident's location for 12 days. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to the resident. The Administrator was notified of the Immediate Jeopardy on 3/11/2022 at 11:51 AM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689, F-835, and F-867. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/13/2022 through 3/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/12/2022 at 8:24 PM, and was validated onsite by the surveyors on 3/13/2022 through 3/14/2022 through observations, review of meeting minutes, education, audits, policies, medical record reviews, and staff interviews conducted on all shifts. The findings include: Review of the facility's undated policy titled, ELOPEMENT, revealed .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the departure in a courteous manner; Get help from other staff members in the immediate vicinity, if necessary; and Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .complete and file Report of Accident/Incident . Review of the facility's undated policy titled, Discharge of Resident: Against Medical Advice [AMA], revealed .Purpose: To describe the discharge process for a patient departing from the center against medical advice .Discuss with patient or legal representative the desire to leave the center against medical advice .inform physician of patient's intent to discharge against medical advice .physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .the risk of discharge against medical advice .Provide written and verbal education to the patient and legal representative .Inform patient .that leaving the center prevents the provision of necessary care and services and that the physician and center are not responsible for the welfare and wellbeing of a patient .Complete Release for Discharge Against Medical Advice form with patient or legal representative's signature .Ensure that all belongings are packed and sent with patient .escort and assist patient to transport vehicle . Review of the facility's undated policy titled, Leave of Absence Policy (LOA), revealed .permit residents to leave the Facility premises for designated time periods and (2) ensure that the Facility is aware of the whereabouts of its residents .All residents leaving the Facility premises must be appropriately signed out and signed in upon return .Staff members should promptly inform supervisor for any requests received for a LOA .The Resident and/or the Resident Responsible Party shall sign the LOA form and Release .if staff has any concerns with regard to the Resident leaving with a specific individual, staff should contact one of their supervisors . Review of the undated Administrator Job Description revealed .the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs .define problems, collect data, establish facts, and draw conclusions .develop, maintain, and implement operational policies and procedures to meet residents' needs develop a monitoring system to assure compliance . Review of the undated Social Services Coordinator Job Description revealed .assure that each resident attains .maintains his/her highest practicable physical, mental, and/or psychosocial wellbeing .maintaining contact with the resident's family members, involving them in the resident's total plan of care . Review of the undated Director of Nursing Services Job Description revealed .plan, organize, develop, and direct the overall operation .to ensure that the highest degree of quality care is maintained .developing appropriate plans of action to correct identified deficiencies . Review of the BENHA form revealed the Administrator was hired in 2/2017. During an interview on 3/2/2022 at 3:30 PM, the Administrator stated, .the resident's [Resident #1's] girlfriend came to the facility to visit that night she was posing as his daughter he stated he wanted to go outside to see his grandchildren .staff let him out, he got in the car and they drove off .he called the facility and said he was ok, he is living in [Named State] with his family .the only reason we reported it was because we didn't want you [surveyors] to come in here and say it was an elopement .he was going to be discharged but he just left . During an interview on 3/3/2022 at 3:22 PM, the Social Services Director stated, .his daughter has always been his Responsible Party .we discussed all care with her .he was our responsibility .we didn't know where he was until he called us .[on 2/25/2022] he told me he got in the car with her .got on a bus to go to [Named state] .was left at the bus station, he started walking, the police saw him walking I guess they thought he was crazy and they took him to the hospital .He said he was in the hospital in [Named state] .he said he had pulled a caper on us . During an interview on 3/4/2022 at 10:13 AM, Registered Nurse (RN) #1 stated, .he [Resident #1] didn't tell anybody he was leaving that night . During a telephone interview on 3/4/2022 at 1:53 PM, RN #2 stated, .I didn't know where he was .I went outside to look for him . During an interview on 3/8/2022 at 4:08 PM, the Director of Nursing (DON) stated, .this was not an AMA [Against Medical Advice] discharge .[Named RN #1] documented an AMA discharge because she didn't know what else to call it .there was not an AMA paper signed, no education related to AMA, he didn't take his medications or his clothing .the next day [2/14/2022] I thought he had went out on LOA .I called the daughter to see when he would be returning to the facility .she informed me that he was not with her . During an interview on 3/9/2022 at 3:27 PM, the Administrator stated, .not an elopement .we are not responsible because he is alert and oriented .he called someone to come get him and he left with them .he left AMA .I don't know if any staff asked the visitor for identification or if they told them to sign in .I don't know if the AMA education was given or if the paperwork was signed .I was not here .he planned the whole thing .it was a ploy to get out of here . The Administrator confirmed staff did not follow the facility's AMA policy. During an interview on 3/10/2022 at 4:45 PM, the Administrator stated, .the 11:00 PM-7:00 AM shift is not familiar with the AMA procedure .most AMA discharges happen during the day when administrative staff is [are] here .this was a real gut punch for me .did not consider the resident's BIMS [Brief Interview for Mental Status] assessment of 9 in determining if the resident was safe to make the decision to leave for himself .did not think about if we had used additional means to confirm the identity of the visitor .did not identify when the facility staff should contact the Responsible Party before the resident is released . The Administrator would not confirm that staff did not follow the facility's AMA policy. Refer to F-689. The surveyors verified the Removal Plan by: 1. The facility Administration will receive annual training from the Governing Body/Regional Clinical Director as related to resident safety and elopement. The surveyors reviewed education and interviewed the Administrator. 2. The Administration will provide in-service education to all staff on the necessary steps, authorizations, and supervision when interacting with cognitively impaired residents, all discharges will be to a safe/known location, LOA, and AMA process. The surveyors reviewed education and interviewed the Administrative staff, Agency staff, and Facility staff on all shifts. 3. Visitation for vulnerable residents will be adjusted according to risk factors directly related to each individual resident's needs. The surveyors interviewed the administrative staff, Care plan Coordinator, Agency, and Facility staff on all shifts. 4. All visitors must provide proof of Identification (ID) prior to a Leave of Absence or AMA discharge. If the visitor isn't the Responsible Party, the Responsible Party will be contacted prior to resident being released. The surveyors interviewed the Facility and Agency staff on all shifts. 5. Administrative staff will be in-serviced on safe discharge practices. The surveyors reviewed the education and interviewed the DON, the Unit Manager, and Social Services Director. 6. All reportable events and safety related breaches will be reported to the Governing Body for guidance and correction. The surveyors interviewed the Administrator. 7. Oversight will be provided monthly for 3 months in house for a Administration and Nursing with the Governing Body or designee. The surveyors interviewed the Administrator. 8. All the above steps were initiated on 3/11/2022 and will be monitored for 30 days for effectiveness and will be shared with Quality Assurance (QA) for evaluation. The surveyors interviewed the Administrator. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, review of the facility investigation, and interview, the facility failed to prevent further potential sexual abuse while the investigation was in progress; and failed to report a potential allegation of sexual abuse to the state survey agency for 1 of 26 (Resident #25) sample residents, which resulted in immediate jeopardy (IJ). The facility has 52 female residents residing in the facility. Immediate Jeopardy is a situation in which the provider's noncompliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator and Director of Nursing of Poplar Point Health and Rehabilitation were informed of the Immediate Jeopardy on 10/29/15 at 7:00 PM. The IJ for F225 constitutes Substandard Quality of Care. A partial extended survey was completed on 10/29/15. The facility provided an acceptable Allegation of compliance (AOC) on 10/29/15. It was determined on 10/29/15 the corrective actions implemented on 10/29/15, removed the IJ. The IJ existed from 8/13/15 through 10/28/15. The IJ was removed on 10/29/15. Noncompliance for F225 continues at an E level citation. The facility is required to submit a Plan of Correction. The findings included: 1. The facility's Reporting and Investigation / Response policy documented, any complaint, allegation, observation or suspicion of resident abuse, mistreatment whether physical, verbal, mental, or sexual, involuntary, or voluntary it to be thoroughly investigated, reported and documented in a uniform manner. 2. Medical record review for Resident #25 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored 00 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. The resident scored 1 for Mood with no behaviors exhibited during the assessment period. The resident was coded as having unclear speech and sometimes able to make herself understood by others. The resident required limited assistance with one person physical assist with bed mobility and eating. The resident required extensive assistance with two person assist on transfers, toilet use; supervision with one physical assist for locomotion on and off the unit; and extensive assistance with one person assist with personal hygiene and dressing. The resident was totally dependent on the staff with two assist for baths. The resident was not steady when transferring moving on and off the toilet. For functional limitation in range of motion the resident is affect one side in upper and lower extremity. The resident utilizes a wheelchair for mobility. The Care Area Assessment (CAAs) summary dated 7/1/15 revealed the resident triggered for cognitive loss/dementia, communication, urinary incontinence, falls, nutritional status, pressure ulcers, and [MEDICAL CONDITION] drug use. Resident #25's care plan revision date 6/24/15 included the following problems identified with interventions: Resident's speech was impaired had with difficulty expressing self and understanding what is said to her at times. Interventions included: ask yes or no questions; anticipate resident's needs; allow resident time to respond to questions; assist resident as needed and monitor for any changes in activity involvement. Encourage Resident #25 to use hand gestures when responding. A review of the physician progress notes [REDACTED].#25 was alert and oriented times two or three with [MEDICAL CONDITION]. Normal physical exam. 3. Medical record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's quarterly MDS date 8/21/15 revealed the resident scored 13 on the BIMS indicating the resident was cognitively intact; the resident did not exhibit any aggressive behaviors during the assessment period. The resident required limited assistance with one person physical assist with bed mobility; for transfers extensive assistance with two plus persons physical assistance; locomotion on unit-limited assistance with one person physical assistance; locomotion off the unit - limited assistance with one person physical assistance; for toileting - extensive assistance with two persons physical assistance; personal hygiene limited assistance with one person assist. A nurses note for Resident #22 dated 8/13/15 at 1:52 AM documented, certified nursing assistant (CNA) reported she observed the male perpetrator (Resident #22) on top of Resident #25 having sex. The CNA stated the female resident had tears in her eyes. The CNA said the residents stopped when the CNA entered the room. The female resident was examined for injuries and none were noted. The nurse document when asked about the incident the resident denied it happened to the nurse and the supervisor. Assistant Director of Nursing (ADON) and Director of Nursing (DON) notified. Supervisor notified attending physician. 4. Review of the facility's investigations of the incident revealed on 8/12/15 at approximately 10:00 PM a CNA was making rounds and observed Resident #22 (alleged perpetrator) in Resident #25's room. The CNA informed Resident #22 that it was getting late and he should return to his room. The CNA proceeded with rounds but returned later to Resident #25's room and noticed the door was closed. The CNA entered the room and observed Resident #22 on top of Resident #25. Resident #22's pants were pulled down and his buttocks exposed. The CNA observed Resident #22's buttocks making up and down motions. Resident #25's genitalia were exposed. The CNA observed a tear coming from Resident #25's eye and the female resident looked sad. Resident #22 stopped as soon as he realized the CNA entered in the room. The CNA immediately went to get help from the nurses. The CNA continued to tell the nurses the resident was crying only then did the nurses get up to check on the resident. Resident #25 was identified with severely impaired cognition. An interview conducted by Social Services on 8/13/15 revealed Resident #22 was involved in a sexual act with Resident #25 and did not give consent. The facility failed to protect Resident #25 and other cognitively impaired female residents during and after the investigation. The facility's investigation included a statement from the male perpetrator (Resident #22) in which the resident denies any sexual contact with the female resident (Resident #25). The Social Services representative obtained a statement from Resident #25 on 8/13/15 regarding the incident. The resident was asked the following questions: Did a man come into your room last night? Resident #25 responded yes. Did you have sex? Resident #25 responded yes. Did you give consent? Resident #25 responded no. Did you say stop or no? Resident #25 responded yes. A review of the progress notes dated 8/13/15 at 9:30 AM confirmed Resident #25 was interviewed by the ADON and DON (who is no longer at the facility). The DON documented Resident #25 was aphasic and denied any male intimate contact. The facility provided a hand written note documenting the police interviewed Resident #25 on 8/13/15 (no time documented). The hand written note stated the police interviewed Resident #25 and the resident told the police officers it was not rape and she would do it again if she wanted too. 5. Interviews with ADON on 10/29/15/at 4:45 PM, revealed although the resident was assessed as having severely impaired cognition, Resident #25 was able to make her needs known. The resident's statement taken by the Social worker was read to the ADON. The ADON was not sure about that statement but could only go by what the resident told her on 8/13/15, that she did not have sexual contact with Resident #22 and she was going by what the resident told the police officers during their interview. The surveyors brought up the concern of Resident's #25's ability to consent to sex with impaired cognition. The ADON stated the resident did not change her response regarding the incident. The ADON stated after reviewing the statements, that she determined sexual activity did occur between both resident but it was consensual. The facility developed a care plan for both residents that stated both residents enjoyed sex and should be counseled on the pros and cons of safe sex; and facility to provide a quiet and private setting for both residents. The ADON felt since the sexual encounter was consensual the facility determined this was not abuse and it was not necessary to report it to the State Agency. The ADON also revealed the facility did not ensure Resident #22 was supervised around cognitively impaired residents during or after this investigation. The facility also failed to ensure Resident #25 was protected during this investigation. The surveyor reviewed the National Sex Offender Registry and identified Resident #22 was listed as a sexual offender. After this incident occurred the facility never reviewed the Sex Offender Registry as a part of their investigation. The facility failed to report the 8/13/15 sexual encounter with Resident #22 and Resident #25 to the state survey agency which resulted in IJ. The facility submitted an acceptable allegation of compliance which included the following interventions: Resident #22 was immediately placed on 1 on (:) 1 monitoring and will be on 1:1 until removed from facility. Several behavioral health units were called with one stating that they would send a nurse out tonight (10/29/15) to evaluate the resident for placement. Staff and residents were interviewed to see if they had observed any inappropriate touching or behaviors. An updated care plan was done on Resident #22 and Resident #25 completed on 10/29/15. Staff was being in-serviced on sexual abuse and neglect. Residents will be checked on abuse registry to see if anyone else is on the registry. The Admissions Team will be educated on the admission process to include reviewing the abuse registry. This will be monitored by the Administrator. In-service will be done on how to report and investigate allegations of abuse. All in-services will be done by Nursing Administration. Allegations of abuse (including sexual) will be reviewed daily in the morning meeting to the Administrator and Director of Nursing (DON) or designee. Administrator / Director of Nursing will monitor to see if incidents are reported and investigated properly. Incidents will be reported to Quality Assurance Committee (QA) monthly by the Director of Nursing. The Quality Assurance Performance Improvement (QAPI) Committee will track and trend incidents. The surveyors verified the AOC by completing record reviews and interviews. The Immediate Jeopardy was removed on 10/29/15 at 10:00 PM.

Based on policy review, medical record review, review of facility investigation, and interview, the facility failed to address an incident resulting in a sexual encounter for 1 of 26 (Resident #25) sampled residents. The surveyor found that Resident #22 was identified to be on the National Sex Offender Registry. Resident #22 was allowed to roam the facility unsupervised. This placed Resident #25 and other cognitively impaired female residents in immediate jeopardy (IJ). The facility has 52 female residents residing in the facility. Immediate Jeopardy is a situation in which the provider's noncompliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator and Director of Nursing of Poplar Point Health and Rehabilitation were informed of the Immediate Jeopardy on 10/29/15 at 7:00 PM. The IJ for F223 constitutes Substandard Quality of Care. A partial extended survey was completed on 10/29/15. The facility provided an acceptable Allegation of compliance (AOC) on 10/29/15. It was determined on 10/29/15 the corrective actions implemented on 10/29/15, removed the IJ. The IJ existed from 8/13/15 through 10/28/15. The IJ was removed on 10/29/15. Noncompliance for F223 continues at an E level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's Abuse Policy, with a revision date of 9/2015, revealed the definition for sexual abuse was any abuse of sexual nature including harassment, coercion or assault. The policy also stated all allegations of abuse or neglect must be thoroughly investigated by the facility and a verbal notification to the State Department of Health and other regulatory agencies. 2. Medical record review for Resident #25 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored 00 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. The resident scored 1 for Mood with no behaviors exhibited during the assessment period. The resident was coded as having unclear speech and sometimes able to make herself understood by others. The resident required limited assistance with one person physical assist with bed mobility and eating. The resident required extensive assistance with two person assist on transfers, toilet use; supervision with one physical assist for locomotion on and off the unit; and extensive assistance with one person assist with personal hygiene and dressing. The resident was totally dependent on the staff with two assist for baths. The resident was not steady when transferring moving on and off the toilet. For functional limitation in range of motion the resident is affect one side in upper and lower extremity. The resident utilizes a wheelchair for mobility. The Care Area Assessment (CAAs) summary dated 7/1/15 revealed the resident triggered for cognitive loss/dementia, communication, urinary incontinence, falls, nutritional status, pressure ulcers, and [MEDICAL CONDITION] drug use. Resident #25's care plan revision date 6/24/15 included the following problems identified with interventions: Resident's speech was impaired had with difficulty expressing self and understanding what is said to her at times. Interventions included: ask yes or no questions; anticipate resident's needs; allow resident time to respond to questions; assist resident as needed and monitor for any changes in activity involvement. Encourage Resident #25 to use hand gestures when responding. A review of the physician progress notes [REDACTED].#25 was alert and oriented times two or three with [MEDICAL CONDITION]. Normal physical exam. 3. Medical record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's quarterly MDS date 8/21/15 revealed the resident scored 13 on the BIMS indicating the resident was cognitively intact; the resident did not exhibit any aggressive behaviors during the assessment period. The resident required limited assistance with one person physical assist with bed mobility; for transfers extensive assistance with two plus persons physical assistance; locomotion on unit-limited assistance with one person physical assistance; locomotion off the unit - limited assistance with one person physical assistance; for toileting - extensive assistance with two persons physical assistance; personal hygiene limited assistance with one person assist. A nurses note for Resident #22 dated 8/13/15 at 1:52 AM documented, a certified nursing assistant (CNA) reported she observed the male perpetrator (Resident #22) on top of Resident #25 having sex. The CNA stated the female resident had tears in her eyes. The CNA said the residents stopped when the CNA entered the room. The female resident was examined for injuries and none were noted. The nurse document when asked about the incident the Resident #22 denied it happened to the nurse and the supervisor. Assistant Director of Nursing (ADON) and Director of Nursing (DON) notified. Supervisor notified attending physician. 4. Review of the facility's investigations of the incident revealed on 8/12/15 at approximately 10:00 PM a CNA was making rounds and observed Resident #22 (alleged perpetrator) in Resident #25's room. The CNA informed Resident #22 that it was getting late and he should return to his room. The CNA proceeded with rounds but returned later (8/13/15 at 1:52 AM) to Resident #25's room and noticed the door was closed. The CNA entered the room and observed Resident #22 on top of Resident #25. Resident #22's pants were pulled down and his buttocks exposed. The CNA observed Resident #22's buttocks making up and down motions. Resident #25's genitalia were exposed. The CNA observed a tear coming from Resident #25's eye and the female resident looked sad. Resident #22 stopped as soon as he realized the CNA entered in the room. The CNA immediately went to get help from the nurses. The CNA continued to tell the nurses the resident was crying only then did the nurses get up to check on the resident. Resident #25 was identified with severely impaired cognition. An interview conducted by Social Services on 8/13/15 revealed Resident #22 was involved in a sexual act with Resident #25 and did not give consent. The facility failed to protect Resident #25 and other cognitively impaired female residents during and after the investigation. The facility's investigation included a statement from the male perpetrator (Resident #22) in which the resident denies any sexual contact with the female resident (Resident #25). The Social Services representative obtained a statement from Resident #25 on 8/13/15 regarding the incident. The resident was asked the following questions: Did a man come into your room last night? Resident #25 responded yes. Did you have sex? Resident #25 responded yes. Did you give consent? Resident #25 responded no. Did you say stop or no? Resident #25 responded yes. A review of the progress notes dated 8/13/15 at 9:30 AM confirmed Resident #25 was interviewed by the ADON and DON (who is no longer at the facility). The DON documented Resident #25 was aphasic and denied any male intimate contact. The facility provided a hand written note documenting the police interviewed Resident #25 on 8/13/15 (no time documented). The hand written note stated the police interviewed Resident #25 and the resident told the police officers it was not rape and she would do it again if she wanted too. 5. Interviews with ADON on 10/29/15/at 4:45 PM, revealed although the resident was assessed as having severely impaired cognition, Resident #25 was able to make her needs known. The resident's statement taken by the Social worker was read to the ADON. The ADON was not sure about that statement but could only go by what the resident told her on 8/13/15, that she did not have sexual contact with Resident #22 and she was going by what the resident told the police officers during their interview. The surveyors brought up the concern of Resident's #25's ability to consent to sex with impaired cognition. The ADON stated the resident did not change her response regarding the incident. The ADON stated after reviewing the statements, that she determined sexual activity did occur between both resident but it was consensual. The facility developed a care plan for both residents that stated both residents enjoyed sex and should be counseled on the pros and cons of safe sex; and facility to provide a quiet and private setting for both residents. The ADON felt since the sexual encounter was consensual the facility determined this was not abuse and it was not necessary to report it to the State Agency. The ADON also revealed the facility did not ensure Resident #22 was supervised around cognitively impaired residents during or after this investigation. The facility also failed to ensure Resident #25 was protected during this investigation. Interview with the Social Service (SS) representative on 10/29/15 at 5:00 PM, revealed Resident #25 was now scored 03 on the BIMS which still indicated severe cognition impairment. The SS representative confirmed Resident #25 during her 8/13/15 interview with the resident said the sexual encounter was rape. However, the SS representative felt the resident's interviews with the DON, ADON and the Police Officers were more reliable. And even though the resident was cognitively impaired the SS representative felt the resident was able to make her needs known. Surveyor attempted an interview with Resident #25 on 10/29/15 at 5:15 PM. Resident #25 was in bed with right sided [MEDICAL CONDITION]. The surveyor asked the resident her name and the resident made grunting and gurgling sounds. After a few minutes the resident took her left hand and pulled up her arm and pointed to her name bracelet. The surveyor read the resident's name bracelet and asked if that was her name. The resident nodded yes. The surveyor informed the resident of the date and time. Later in the conversation the surveyor asked the resident the date (in a yes and no format) and the resident was unable to remember the date. The surveyor asked the Resident #25 if any other residents had bothered her and if the resident knew Resident #22. Resident #25 looked away and would not respond. The surveyor asked the resident if she remembered talking to the police and again the resident looked away and did not respond. During the remainder of the conversation the surveyor asked if she was okay and the resident responded yes. Resident #25 was also asked if she was afraid of anyone in the facility and the resident responded no. The interview was ended. The surveyor reviewed the National Sex Offender Registry and identified Resident #22 was listed as a sexual offender. After this incident occurred the facility never reviewed the Sex Offender Registry as a part of their investigation. It was determined the facility failed to respond appropriately to the 8/13/15 incident involving Residents #22 and #25. The facility failed to protect Resident #22 from Resident #25 during the investigation. The facility also failed to supervise Resident #22 around the other cognitively impaired female residents in the facility which resulted in an immediate jeopardy. The facility submitted an acceptable allegation of compliance which included the following interventions: Resident #22 was immediately placed on 1 on (:) 1 monitoring and will be on 1:1 until removed from facility. Several behavioral health units were called with one stating that they would send a nurse out tonight (10/29/15) to evaluate the resident for placement. Staff and residents were interviewed to see if they had observed any inappropriate touching or behaviors. An updated care plan was done on Resident #22 and Resident #25 completed on 10/29/15. Staff was being in-serviced on sexual abuse and neglect. Residents will be checked on abuse registry to see if anyone else is on the registry. The Admissions Team will be educated on the admission process to include reviewing the abuse registry. This will be monitored by the Administrator. In-service will be done on how to report and investigate allegations of abuse. All in-services will be done by Nursing Administration. Allegations of abuse (including sexual) will be reviewed daily in the morning meeting to the Administrator and Director of Nursing (DON) or designee. Administrator / Director of Nursing will monitor to see if incidents are reported and investigated properly. Incidents will be reported to Quality Assurance Committee (QA) monthly by the Director of Nursing. The Quality Assurance Performance Improvement (QAPI) Committee will track and trend incidents. The surveyors verified the AOC by completing record reviews and interviews. The Immediate Jeopardy was removed on 10/29/15 at 10:00 PM.

Based on policy review, medical record review, review of facility investigation, observation and interview, the facility failed to ensure the quality assessment (QA) and assurance committee identified and implemented plans of actions to address identified concerns. The QA committee facility failed to address an incident resulting in a sexual encounter for 1 of 26 (Resident #25) sampled residents and failed to prevent further potential sexual abuse while the investigation was in progress; and failed to report a potential allegation of sexual abuse to the state survey agency for 1 of 26 (Resident #25) sample residents, which resulted in immediate jeopardy (IJ). The surveyor found that Resident #22 was identified to be on the National Sex Offender Registry. Resident #22 was allowed to roam the facility unsupervised. This placed Resident #25 and other cognitively impaired female residents in immediate jeopardy (IJ). Immediate Jeopardy is a situation in which the provider's noncompliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator and Director of Nursing of Poplar Point Health and Rehabilitation were informed of the Immediate Jeopardy on 10/29/15 at 7:00 PM. The facility provided an acceptable Allegation of compliance (AOC) on 10/29/15. It was determined on 10/29/15 the corrective actions implemented on 10/29/15, removed the IJ. The IJ existed from 8/13/15 through 10/28/15. The IJ was removed on 10/29/15. Noncompliance for F520 continues at an E level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Interview with administrative staff A on 10/29/15 at 9:58 PM, revealed every month the QA committee looked at their own bench marks and compared them to the bench marks the corporation has set. If the facility's bench marks go over the corporation's bench marks then the facility looks to see if they need to change their system. 2. The QA committee facility failed to address an incident resulting in a sexual encounter for 1 of 26 (Resident #25) sampled residents and failed to prevent further potential sexual abuse while the investigation was in progress; and failed to report a potential allegation of sexual abuse to the state survey agency for 1 of 26 (Resident #25) sample residents, which resulted in immediate jeopardy (IJ). The surveyor found that Resident #22 was identified to be on the National Sex Offender Registry. Resident #22 was allowed to roam the facility unsupervised. This placed Resident #25 and other cognitively impaired female residents in immediate jeopardy (IJ). The facility has 52 female residents residing in the facility. Refer to F223 and F225. The facility submitted an acceptable allegation of compliance which included the following interventions: Resident #22 was immediately placed on 1 on (:) 1 monitoring and will be on 1:1 until removed from facility. Several behavioral health units were called with one stating that they would send a nurse out tonight (10/29/15) to evaluate the resident for placement. Staff and residents were interviewed to see if they had observed any inappropriate touching or behaviors. An updated care plan was done on Resident #22 and Resident #25 completed on 10/29/15. Staff was being in-serviced on sexual abuse and neglect. Residents will be checked on abuse registry to see if anyone else is on the registry. The Admissions Team will be educated on the admission process to include reviewing the abuse registry. This will be monitored by the Administrator. In-service will be done on how to report and investigate allegations of abuse. All in-services will be done by Nursing Administration. Allegations of abuse (including sexual) will be reviewed daily in the morning meeting to the Administrator and Director of Nursing (DON) or designee. Administrator / Director of Nursing will monitor to see if incidents are reported and investigated properly. Incidents will be reported to Quality Assurance Committee (QA) monthly by the Director of Nursing. The Quality Assurance Performance Improvement (QAPI) Committee will track and trend incidents. The surveyors verified the AOC by completing record reviews and interviews. The Immediate Jeopardy was removed on 10/29/15 at 10:00 PM. The facility provided an acceptable Allegation of compliance (ACO) on 10/29/15. It was determined on 10/29/15 the corrective actions implemented on 10/29/15, removed the IJ. The IJ existed from 8/13/15 through 10/28/15. The IJ was removed on 10/29/15. 3. The QA committee failed to ensure care was provided in a dignified manner when staff called a resident baby and referred to incontinent briefs as diapers for 1 of 26 (Resident #3) sampled residents. Refer to F 241. 4. The QA committee failed to ensure the assessment was accurate for food and liquid consumption and swallowing difficulty for 1 of 26 (Resident #3) sampled residents. Refer to F278. 5. The QA committee failed to ensure the facility developed a comprehensive and individualized care plan for 2 of 26 (Residents #3 and 4) sampled residents. Refer to F279. 6. The QA committee failed to ensure the care plan was reviewed and/or revised for behaviors for 1 of 26 (Resident #14) sampled residents Refer to F280. 7. The QA committee failed to ensure care was provided according to the residents care plans for a splint, a dycem mat, floor mats, bed alarm and/or personal hygiene care for 4 of 26 (Residents #5, 7, 10 and 23) sampled residents. Refer to F282. 8. The QA committee failed ensure staff followed physician orders [REDACTED]. Refer to F309. 9. The QA committee failed to ensure assistance was provided for activities of daily living (ADLs) to maintain good grooming for 6 of 26 (Residents #2, 5, 7, 8, 10 and 23) sampled residents. Refer to F312. 10. The QA committee failed to ensure incontinence care was provided for 2 of 8 (Residents #3 and 10) sampled residents who are incontinent. Refer to F315. 11. The QA committee failed to ensure a causative factor was documented for the use of a gastrostomy tube ([DEVICE]) and failed to ensure the correct feeding formula was infusing for 1 of 3 (Resident #3) sampled residents with a [DEVICE]. Refer to F322. 12. The QA committee failed to ensure fall interventions were in place for 2 of 26 (Residents #7 and 10) sampled residents. Refer to F323. 13. The QA committee failed to ensure narcotic medications were reconciled in an accurate manner for 7 of 14 (1 west floor split medication cart, 1 east floor split medication cart, 1 east floor medication cart, 1 west floor medication cart, 2nd east floor medication cart, 2nd split floor medication cart, and 2nd west floor medication cart) medication storage areas. Refer to F431. 14. The QA committee failed to ensure incontinence care was provided to prevent the potential spread of infections and failed to change gloves during a dressing change to prevent the potential spread of infection for 2 of 26 (Residents #3 and 9) sampled residents. Refer to F441. 15. The QA committee failed to ensure the clinical record was complete for 4 of 26 (Residents #2, 5, 7, and 23) sampled residents. Refer to F514. The facility failed to have a QA committee that addressed identified concerns.

Based on policy review, medical record review, observation, and interview, it was determined the facility failed to assess, implement interventions, and follow physician orders [REDACTED]. Failure of the facility to assess and implement timely interventions and provide treatments as ordered resulted in actual harm when Resident #7 developed an avoidable pressure sore. The findings included: 1. Review of the facility's "Skin Management" policy documented, "...The purpose is the prevention and management of wounds and to provide consistent care of the integumentary system... The timely identification of potential risks, implementation of preventive measures, consistent wound care and tracking of the progress of all wounds until healed are essential components of the policy... 5.a. All residents will be assessed for risk of skin breakdown on admission, readmission, quarterly, and with change of condition... b Routine preventive interventions include, but are not limited to, the following: (1) Pressure redistribution mattress... will be provided for all residents with a score of 8 or above on the Pressure Sore Risk Assessment... Surfaces 1. Once a resident is identified as having a skin ulceration, they will be placed on an appropriate surface as follows: STAGE 1 or STAGE 11 will be placed on an appropriate support surface... An individualized repositioning program will be determined, care planned, and implemented... 7. A repositioning schedule will be established and implemented..." 2. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A nurses note dated 6/29/11 at 12:20 PM documented, "...PROBLEM / CARE:Has 1+ (plus) foot problem... hammer toe, overlapping toe, pain, structural problem..." A nurses note dated 9/16/11 at 5:06 PM documented, "...Weekly Skin Assessment: Note: Has no skin problems or [MEDICAL CONDITION] present... all skin intact." A nurses note dated 10/19/11 at 4:23 PM documented, "...DATE OF DISCOVERY: 10/19/11... pressure ulcer secondary to 2+ pedal [MEDICAL CONDITION], hammer toe, no socks, and tight, plastic clogs... on right 2nd toe SIZE: 0.5 cm (centimeters) x (by) 1.0 cm Depth: 0.3 cm... Pressure Reducing Devices: pressure reducing mattress to bed and chair/ larger shoes... TEACHING DONE: skin care/ precautions/ eliminate too small shoes/ wide toe box shoes only with clean socks daily." A nurses note dated 12/7/11 at 11:00 AM documented, "...Stage 3-now appears as Stage 2... length 0.2 width 0.6 depth 0.1." A physician's orders [REDACTED]. Apply TAO (topical antibiotic ointment) and dry drsg.(dressing) daily AM until healed." A review of the October 2011 Treatment Administration Record revealed no documentation of the wound being treated on 2 of 13 days in October 2011. Observations in Resident #7's room on 12/15/11 at 8:40 AM, Nurse #10 removed Resident #7's shoe and sock and dressing and the surveyor confirmed the presence of an open dark wound on the right 2nd toe area. Resident #7 complained that the area was "sore". During an interview at the 300 hall nurses station on 12/13/11 at 8:45 AM, Nurse #4 stated, "she (Resident #7) has a hammer toe, had a pair of clogs put on without socks and were too tight and got a breakdown, looked like a stage 3... we got rid of tight clogs and no shoes put on her without socks also on her." During an interview in the conference room on 12/15/11 at 1:40 PM, the Director of Nursing (DON) stated, "her (Resident #7) shoes were too tight, CNA's (certified nursing assistants) should report to nurse and not put them on if it is swelled, would expect CNA's to report to nurse and hope they would not put them (shoes) on her." The facility failed to accurately and timely assess, implement interventions and provide treatments as ordered which resulted in actual harm when Resident #7 developed an avoidable pressure ulcer. 3. Medical record review for Resident #4 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]." Review of the "PRESSURE SORE RISK ASSESSMENT" dated 11/27/11 documented, "...TOTAL SCORE: 11... RISK CATEGORY: Pressure sore, HIGH RISK, 8 and Above..." Observations in Resident #4's room on 12/12/11 at 10:30 AM and 3:50 PM, on 12/13/11 at 8:15 AM and at 4:55 PM and on 12/14/11 at 6:05 AM and at 8:18 AM, revealed Resident #4 lying in bed without heel protectors or without a pressure relieving device for the bed. Observations in Resident #4's room on 12/14/11 at 6:05 AM, 8:18 AM and 9:23 AM, revealed Resident #4 lying in bed on her back. During an interview in Resident #4's room on 12/14/11, the Director of Nursing (DON) was asked about the interventions documented to help prevent skin breakdown for Resident #4. The DON confirmed the heel protectors were not in place and stated, "...I expect to see them(heel protectors) on both feet... the nurse is responsible to make sure the CNAs are putting them (heel protectors) on... the treatment nurse checks on them daily..." The DON was asked about the pressure relieving device. The DON confirmed that there was no pressure relieving device was on Resident #4's bed. 4. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observations in Resident #5's room on 12/12/11 at 10:30 AM, on 12/15/11 at 8:30 AM and 10:30 AM, revealed Resident #5 in bed with no heel protectors on. The facility failed to ensure the heel protectors were applied as ordered by the physician.