Every finding on record at Maplewood Health Care Center

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when staff failed to use Personal Protective Equipment (PPE) during dining and medication administration for 3 of 8 (Resident #7, #47, and #114) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, Transmission-Based (Isolation) Precautions [TBP], revealed .Contact precautions.refer to measures.to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.Droplet precautions.actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.will don [put on] appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions.Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.Droplet Precautions.Healthcare personnel will wear a facemask for close contact with an infectious resident.Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. Review of the undated facility policy titled, Standard Precautions Infection Control Protocol, revealed Hand Hygiene .After touching blood, body fluids, secretions, excretions, contaminated items; before & after removing PPE; between resident contacts; before meals and after using the restroom .Gloves.For touching blood, body fluids, secretions, excretions, contaminated items.non-intact and intact resident skin .Gown.During procedures and resident-care activities when contact of clothing/exposed skin with bloody/body fluids, secretions, and excretions is anticipated . Review of the facility policy titled, Enhanced Barrier Precautions, dated March 20, 2024, revealed .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .High-contact resident care activities include.Device care or use: central lines, urinary catheters, feeding tubes. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Extended Spectrum Beta Lactamase (ESBL) Resistance (Multidrug Resistance Infection), and Influenza. Review of the Physician Order dated 3/18/2026, revealed .Contact Isolation r/t [related to] ESBL IN URINE every shift.Droplet Precautions r/t: FLU [Influenza]. every shift. During an observation on 3/23/2026 at 11:58 AM, Certified Nursing Assistant (CNA) B entered Resident #7's room carrying a dining tray. Resident #7's door had 2 posted signs which declared Resident #7 was in Droplet and Contact Precautions. CNA B sat the dining tray on the over bed table and encouraged Resident #7 to wake up and eat. CNA B removed the cover of the lunch plate and placed the over bed table over Resident #7. CNA B left the room when the resident began to eat. CNA B failed to don PPE while in a Droplet/Contact Isolation room. During an observation on 3/23/2026 at 2:41 PM, Licensed Practical Nurse (LPN) A donned gloves, entered Resident #7's room, and detached the tubing of the completed antibiotic from the Peripherally Inserted Central Catheter (PICC) in the left arm of Resident #7. LPN A then went to the other side of the bed and turned Resident #7 onto her left side and straightened the bed covers before exiting the room. LPN A failed to don the appropriate PPE in an TBP room. During an interview on 3/25/2026 at 10:41AM, the Infection Control Preventionist (ICP) was asked what the protocol was when entering a resident's room that was in Transmission Based Precautions. The ICP stated, .will need to dress out with all PPE . gown, gloves, and mask.Yes.should dress out when delivering trays. The (ICP) was asked if staff should dress out when handling a PICC line or when turning a resident in the bed. The ICP stated, Yes.any close contact with a resident that is in isolation. 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Dysphagia (difficulty swallowing), Diabetes, and Gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food.) Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 6 on the BIMS assessment, which indicated she was severely cognitively impaired. Review of the of the Order Review History Report dated March 25, 2026 revealed orders for the following medications to be administered by G-Tube (Gastrostomy): Asprin (an anti-inflammatory medication) 81 mg (milligrams) daily Carvedilol (a blood pressure medication) 6.25 mg twice daily Folic Acid (a supplement) 1 mg every day Duloxetine (an antidepressant) 20 mg Delayed Release 2 capsules every day Jardiance (a medication to treat Diabetes) 10 mg every day Multivitamin liquid 5 ml (milliliters) every day Mirilax (a laxative)17 Grams every day Vitamin B-1 (a supplement) 100 mg every day Vitamin D-3 (a supplement )125 mcg every day Vitamin C (a supplement) 500 mg every day Vitamin E (a supplement) 400 units every day Zinc Citrate (a supplement) 50 mg every day Gabapentin (used to treat Neuropathy and Seizure Disorder) 300 mg two times a day Observation during medication administration on 3/25/2026 at 7:21AM, revealed LPN C prepared medications (meds) for administration through Resident #47's G-Tube. LPN C crushed the following meds and put them in a plastic cup: Aspirin, Folic Acid, Carvedilol, Duloxetine, Jardiance, Miralax, Vitamin B-1, Vitamin C, Vitamin D-3, Zinc, Gabapentin. LPN C put the liquid Multivitamins and Vitamin E in a second cup. LPN C entered Resident #47's room, without donning PPE, with both cups of meds and a third cup containing water, performed hand hygiene, donned gloves, checked placement of the G-tube, and checked for residual (measurement of remaining stomach contents.) LPN C flushed the G-Tube with 30 mls (milliliters) of water, administered the medications through the G-tube as ordered and flushed the G-Tube with another 30 mls of water. LPN C failed to wear PPE (gown) while administering medications in an EBP room. During an interview on 3/25/2026 at 7:45 AM, LPN C was asked if he should have worn a gown while in a room with EBP. LPN C stated .not with med administration just with care. During an interview on 3/25/2026 at 7:50 AM, the Director of Nursing (DON) was asked if a gown should be worn when administering medications through a Gastrostomy Tube. The DON stated, No, I don't think so, it's my understanding that only when providing care. Really, I don't know, I'm just going to be honest . 4. Review of the medical record revealed Resident #114 was admitted to the facility on [DATE], with diagnoses including Diabetes, Atrial Fibrillation, Anemia and Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #114 scored a 11 on the BIMS assessment, which indicated he was moderately cognitively impaired. Review of Physician's Orders dated 3/11/2026, revealed .Repatha [a cholesterol lowering medication].140 MG/ML [MILLIGRAM/MILLILITER] Solution prefilled syringe. Inject 1ML Subcutaneously (SQ) to right low quadrant of the abdomen.every 2 weeks . Observation during medication administration on 3/25/2026 at 9:15 AM, revealed LPN D obtained a prefilled syringe of Repatha for administration to Resident #114. LPN D knocked on Resident #114's door, took the medication into the residents' room, explained the procedure, sanitized her hands, cleaned the right lower quadrant of Resident #114's abdomen with an alcohol prep and administered the Repatha injection subcutaneously. LPN D failed to don gloves before administering the injection to Resident #114. During an interview on 3/25/2026 at 9:18 AM, LPN D was asked if she should have worn gloves while giving an injection. LPN D stated, .I guess, I thought somewhere along the way you didn't have to. During an interview on 3/25/2026 at 9:21 AM, the DON was asked if gloves should be worn when administering an injection. The DON stated, Yes ma'am .

Based on policy review, facility daily staffing review, medical record review, hospital record review, and interview, the facility failed to ensure residents were free of neglect as evidenced by the facility's failure to provide sufficient licensed nursing staff to perform assessments and administer morning medications as ordered for 6 of 6 (Resident #1,#2, #3, #4, #5, and #6) sampled residents reviewed. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 experienced a change of condition, and a nurse was not available on the 100 Hall to assess Resident #1. Resident #1's spouse called 911. Resident #1 was evaluated in the Emergency Department (ED) and admitted to the hospital. Resident #2 did not receive the morning blood glucose check, scheduled Insulin or Metformin, as ordered by the physician on 2/23/2025, and at 7:46 PM, Resident #2's blood glucose level reached 402 milligrams per deciliter (mg/dl). Immediate Jeopardy (IJ) is a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A partial-extended survey was conducted 2/28/2025 through 3/3/2025. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-600 on 2/24/2025 at 6:30 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J which is substandard quality of care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F600 was received on 2/28/2025, and the Removal Plan was validated onsite by the surveyor on 3/3/2025 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 2/23/2025 through 2/26/2025 for F-600, the IJ was removed on 2/27/2025. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures to prohibit and prevent .neglect .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses .as ordered by the physician . Review of the facility's undated policy titled, Blood Glucose Monitoring, revealed .The facility will perform blood glucose monitoring as per physician's orders . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Type 1 Diabetes, Heart Failure, and Acquired absence of left leg. Resident #1 was admitted to the facility from an acute care hospital after a left leg amputation. Review of the physician's orders dated 2/22/2025, included Apixaban (anticoagulation medication used to thin the blood to prevent blood clots and stroke) 2 milligrams (mg) by mouth 2 times a day. Review of the Order Summary Report for February 2025, revealed .2/22/2025 .Apixaban .5mg by mouth two times a day for blood . Review of the Medication Administration Record (MAR) dated 2/23/2025, revealed Resident #1 did not receive the 8:00 AM Apixaban medication as scheduled. Review of the progress notes dated 2/23/2025, revealed there was no documentation Resident #1 was transferred to the hospital by Emergency Medical Services (EMS). Review of the hospital medical record dated 2/23/2025, revealed .2/23/2025 at 14:23 [2:23 PM] .[Resident #1] presented to the Emergency Department [ED]. Patient was brought here from [Named Nursing Home] .he was not getting his medications .there was no nurse available to give them to him .review of systems .positive for fatigue .weakness .Blood Pressure 115/49 Review of the hospital lab results dated 2/23/2025 revealed blood glucose [blood sugar] level 276 mg/dl .2/23/2025 at 1841 [6:41 PM] CM [Case Management] Director received a message asking if an APS [Adult Protective Services] or Ombudsman referral needed to be made on the patient due to neglect at [Named Nursing Home] due to patient not receiving his morning meds [medications] and they didn't have a nurse .CM Director called [Named Nursing Home] Administrator to find out what was going on .[Named Administrator] stated they had a nurse call in .Final [ED] Diagnosis: Generalized Weakness, Coronary Artery Disease, Chronic Kidney Disease, and Type 2 Diabetes . During an interview on 2/24/2025 at 11:05 AM, the Administrator confirmed Resident #1 was transferred to the hospital on 2/23/2025 at approximately 1:30 PM, Resident #1 did not receive his morning medications and there was not a nurse on the 100 Hall to assess Resident #1 for a change in condition prior to being transferred to the hospital. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes, Dementia, and Polyneuropathy. Review of the physician's orders dated 2/21/2025, revealed Glargine (long-acting insulin used to lower blood glucose level in diabetic patients) 25 units subcutaneously (beneath the skin) 2 times a day and Metformin 500 mg 2 times a day. Review of the MAR dated 2/23/2025, revealed .Glargine 25 units subcutaneously two times a day for Diabetes .0800 [8:00 AM] .Metformin .500mg .by mouth two times a day [at] 0800 [8:00 AM] and 1600 [4:00 PM] . Review of the Medication Audit Report dated 2/23/2025, revealed Metformin 500 mg was scheduled to be administered at 8:00 AM. The Metformin was administered at 2:44 PM. Novolin R (Regular-short acting) sliding scale Insulin was scheduled to be administered at 11:00 AM. The Novolin R insulin was administered at 2:47 PM. There was no documentation Resident #2 received a blood glucose check, and the scheduled Glargine insulin or Metformin on 2/23/205 at 8:00 AM as ordered by the physician. Review of the Blood Sugar Summary for Resident #2 revealed the following: On 2/23/2025 at 8:00 AM, there was no blood sugar documented. On 2/23/2025 at 11:00 AM, there was no blood sugar documented. On 2/23/2025 at 2:47 PM, Resident #2's blood sugar was 313 mg/dl and 8 units of Novolin R insulin was administered. On 2/23/2025 at 5:32 PM, Resident #2's blood sugar was 332mg/dl and 8 units of Novolin R insulin was administered. On 2/23/2025 at 7:46 PM, Resident #2 blood sugar was 402 mg/dl. During interview on 2/24/2025 at 3:32 PM, the DON confirmed Resident #2 did not receive morning blood glucose checks, insulin or Metformin as scheduled on 2/23/2025. The DON confirmed Resident #2 experienced elevated blood glucose levels in the afternoon, and it continued to rise to 402 mg/dl. The DON confirmed elevated blood glucose levels could lead to serious complications for diabetic residents. 4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Abscess of buttock, Methicillin Resistant Staphylococcus Aureus Infection, Type 2 Diabetes, and Seizure disorder. Review of the admission physician orders for Resident #3 revealed the following dated orders: 1/28/2025 Keppra (seizure medication) 500mg 1 tablet two times a day for seizures. 1/29/2025 Insulin Lispro (fast acting insulin to treat diabetes) sliding scale for blood glucose: 201-250 = administer 2 units sc. 251-300= administer 4 units sc. 301- 350= administer 8 units sc. 401-500= administer 10 units sc. 2/22/2025 Clindamycin (antibiotic) 300 mg three times a day by mouth for infection control. 2/22/2025 Mupirocin external ointment 2% (treatment/prevention of skin infections) apply two times a day for infection control. Review of the Medication Administration Audit Report dated 2/23/2025 revealed Resident #3 did not receive the following medications as scheduled: Keppra 500 mg scheduled for 8:00 AM was not administered until 3:33 PM. Clindamycin scheduled for 8:00 AM, 12:00 PM, and 8:00 PM, was not administered until 4:05 PM. Mupirocin ointment scheduled for 8:00 AM was not administered until 2:01 PM. Insulin Lispro sliding scale scheduled for 11:00 AM was not administered until 2:00 PM. 5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes, Chronic Kidney Disease, Chronic Heart Failure, and Atrial Fibrillation (irregular heart rhythm). Review of the physician orders for Resident #4 revealed the following dated orders: 1/30/2025 Amiodarone HCL (medication used to treat life-threatening heart rhythm problem) 200mg by mouth one time a day. 1/30/2025 Insulin Lispro sliding scale insulin sc before meals and at bedtime. 1/29/2025 Midodrine 10 mg by mouth three times a day for blood pressure. Review of the Medication Administration Audit Report dated 2/23/2025 revealed Resident #4 did not receive the following medications as scheduled: Amiodarone 200 mg scheduled for 8:00 AM, was not administered until 2:55 PM. Insulin Lispro sliding scheduled for 11:30 AM was not administered. Midodrine 10 mg scheduled for 8:00 AM and 12:00 PM, the documentation revealed both scheduled doses were administered at 3:58 PM. 6. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of Infection following a procedure, open wound right foot subsequent encounter, Type 2 Diabetes, Hypertensive Heart disease with Heart Failure. Review of the physician orders for Resident #5 revealed the following dated orders: 2/22/2025 Insulin Lispro sliding scale administer sc before meals and at bedtime. Review of the Medication Administration Audit Report dated 2/23/2025 revealed: The Insulin Lispro sliding scale insulin scheduled before lunch at 11:30 AM was not administered until 2:00 PM. 7. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Aftercare following surgical amputation, Type 2 Diabetes, and Chronic Kidney Disease. Review of the physician orders for Resident #6 revealed the following dated orders: 2/23/2025 Glipizide (diabetes medication) 2.5 mg extended release by mouth one time a day. 2/18/2025 Metoprolol Tartrate (medication used to treat high blood pressure) 50 mg by mouth two times a day. Review of the Medication Administration Audit Report dated 2/23/2025 revealed: The Glipizide 2.5mg extended release scheduled for 8:00 AM was not administered until 2:19 PM. The Metoprolol Tartrate 50 mg scheduled for 8:00 AM was not administered until 2:34 PM. 8. Review of the daily staffing schedule dated Sunday, 2/23/2025, revealed Licensed Practical Nurse (LPN) A did not report to work for the 7:00 AM - 7:00 PM shift as scheduled on the 100 hall. LPN C was assigned to work the 300 Hall from 7:00 AM- 7:00 PM and the 100 Hall from 7:30 AM- 2:00 PM. LPN B reported to work at 1:50 PM to work on the 100 Hall. LPN C was unable to provide care for the residents on the 100 Hall due to the workload on the 300 Hall. 9. During an interview on 2/24/2025 at 8:25 AM, the Administrator stated, .the 7:00 AM nurse assigned to the 100 Hall [LPN A] did not show up for work . The Administrator stated LPN C was assigned to the 300 hall and the 100 hall was added to (LPN C)'s assignment when (LPN A) didn't show up for work. (LPN C) had a hospice resident on the 300 hall that was transitioning (a term used for a hospice patient in the process of dying) so (LPN C) was busy caring for the hospice resident. The Administrator confirmed on 2/23/2025 there were 25 residents on the 100 hall and 24 residents on the 300 hall and the residents on 100 hall did not receive scheduled morning medications as ordered. During an interview on 2/24/2025 at 9:23 AM, EMS Paramedic E stated, . I received the 911 call around 1:30 PM to go out to [Named facility]. [Named Resident #1]'s wife stated he had not received any meds today because there was not a nurse working on the 100 Hall. EMS Paramedic E stated, .[Resident #1]'s spouse was concerned because the resident was sweating and seemed sick .[Resident #1]'s spouse couldn't find a nurse on the hall to assess [Resident #1]. The resident's spouse called 911. When we got there [at the facility] there wasn't a nurse [on the 100 hall] to get report from . EMS Paramedic E stated Resident #1 was transported by EMS to the Emergency Department and admitted to the hospital. During an interview on 2/24/2025 at 9:55 AM, LPN B stated she was on-call for the facility on 2/23/2025. LPN B was asked to explain what being on-call meant. LPN B stated, The on-call nurse is responsible for coming to work if a scheduled nurse can't work. LPN B was asked what time she was contacted by the facility to report to work to replace the 100 hall nurse (LPN A). LPN B stated, .I got a phone call around 12:30 [PM] from the Staffing Coordinator. I was grocery shopping at the time, so I went home, changed clothes and came to work. LPN B was asked what time she arrived to work on the 100 hall. LPN B stated, .I got here [at the facility] around 1:45 PM .[Named LPN C] and [Named LPN F] were just beginning to check vital signs and start passing meds on the 100 hall . LPN B arrived 6.75 hours after the day shift began, to replace LPN A, and was assigned to the 100 hall. During an interview on 2/24/2025 at 10:08 AM, LPN C stated, I came in [to work] at 7:00 AM, I was told by [Named LPN D] there wasn't a nurse on the 100 hall, the nurse [LPN A] scheduled to work didn't show up, but that [Named LPN B] would be coming in soon. So I took the med [medication] cart keys (to the 100 hall med cart) and went back to my hall [300 hall]. I had a resident [on the 300 hall] that was transitioning [dying] so I was busy with that resident. Around 11:30 AM, I sent a text message to the DON [Director of Nursing] and told her the nurse scheduled to work on the 100 hall didn't show up today and the DON told me we needed to tag team the 100 hall to give medications to the residents. LPN C was asked what time he went to the 100 hall to administer medications. LPN C stated, It was around 1:30 PM. [Named LPN F] helped me, we started checking vital signs and giving medicines to the residents on the 100 hall . LPN C and LPN F began administering medications and checking vital signs on the 100 hall at 1:30 PM (6.5 hours after the 7:00 AM- 7:00 PM shift began). During an interview on 2/24/2025 at 10:30 AM, LPN D stated she worked the night shift (7:00 PM-7:00 AM) on 2/22/2025 on the 200 Hall. LPN D stated, .The nurse [LPN A] scheduled to work [2/23/2025 on the 7:00 AM- 7:00 PM shift] the 100 hall, didn't show up for work. I tried to call [named Staffing Coordinator]. I text the DON around 7:20 AM and told her the day [100 hall] nurse did not show up. I never spoke with [LPN B], the nurse on-call . During an interview on 2/24/2025 at 10:47 AM, the DON was asked if she was told the 100 hall nurse did not show up to work on 2/23/2025 for the 7:00 AM shift. The DON confirmed (LPN D) contacted her on 2/23/2025 around 7:20 AM and reported the 100 hall nurse [LPN A] had not reported to work. The DON was asked what was done to replace the 100 hall nurse. The DON stated, .I told [named LPN D] to reach out to the [named Staffing Coordinator]. The DON confirmed she did not follow up with the staffing coordinator or the on-call nurse (LPN B) to ensure the 100 hall had nursing coverage. During an interview on 2/24/2025 at 10: 49 AM, the Staffing Coordinator stated [named Registered Nurse F] called me at 12:34 PM, and said the day nurse [100 hall] didn't show up, I reached out to [named LPN B] to come in. [LPN B] said she was at the grocery store and would come in. The Staffing Coordinator was asked if anyone tried to reach her at shift change. The staffing coordinator stated, No, the first time I was called was at 12:34 PM, and I called [LPN B] right away . During an interview on 2/25/2025 at 4:18 PM, Resident #1's spouse stated, .On Sunday [2/23/2025] around 11:30 [AM] I went to see him [Resident #1], he was really sweaty and didn't look good. I thought he might have a fever or a low blood sugar. I asked the girl [unknown name] at the nurse's station if the nurse could check on him. The girl sitting at the desk said, 'He don't [doesn't] have a nurse.' I said, 'What do you mean he doesn't have a nurse.' I just called the ambulance .[Resident #1] is still in the hospital today [2/25/2025] . An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F600 was received on 2/28/2025, and the Removal Plan was validated onsite by the surveyor on 3/3/2025 through policy review, medical record review, observation, review of education records, and staff interviews. The 300 hall Charge Nurse verified the 100 hall medication count and keys at 7:28 AM on 2/23/2025 from the 7:00 PM - 7:00 AM 100 hall charge nurse after being informed that assigned nurse would be arriving soon. This 300 Hall Charge Nurse then returned to 300 hall to continue medication administration on hall 300. From approximately 8:15 AM to 10:15 AM on 2/23/2025, the treatment nurse was noted providing treatments on the 100 hall for various residents, to include Resident #2. Following completion of care for other unforeseen acute resident conditions and 300 hall medication administration, the 300 hall Charge Nurse alerted the Director of Nursing that the scheduled nurse that was believed to be arriving late for the 100 hall, had not arrived. The Registered Nurse charge nurse from hall 200 attempted to notify the staffing coordinator/scheduler at approximately 12:12 PM on 2/23/2025. The 300 Hall Charge Nurse began medication administration for the 100 hall until the Nurse Manager on call arrived at 1:49 PM on 2/23/2025. On 2/23/2025 at approximately 12:40 PM, the Nursing Home Administrator was made aware that the scheduled 100 hall 7:00 AM -7:00 PM shift charge nurse had not arrived to scheduled shift. The Director of Nursing notified the Regional Director of Clinical Services at approximately 1:40 PM. At approximately 2:00 PM and 3:40 PM on 2/23/2025, a governing body meeting was held with attendance including the Director of Nursing, Administrator, Regional Director of Clinical Services (RDCS), Chief Operating Officer, and [NAME] President (VP) of Clinical Services to discuss findings, root cause, plan of correction, education, and development and implementation of a Performance and Improvement Plan. The Root Cause was determined to be the Charge Nurse failure to report to duty, gap in employee communication, and unforeseen patient acuity that coincided with the 300 Hall nurse's medication pass leading to the delay. Education was provided on 2/23/2025 to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures, which included but were not limited to the specific details of rotating the Administrator, Director of Nursing, or Assistant Director of Nursing as designated, verifying the facility following each 7:00 AM to 7:00 PM shift change to ensure adequate and appropriate staff to administer resident medications and to monitor/assess residents needs and conditions, Communication, Procedure for delayed/missed medication, Assessments and Notifications, Reinstructed regarding Abuse Prohibition and Neglect, Staffing Procedures and adjustments which included but were not limited to specific details of shift relief has not arrived by their scheduled shift time, the off going nurse will promptly contact the Nurse Manager on call. The Nurse Manager on call will coordinate charge nurse coverage with the staffing scheduler. The off going nurse will remain at the facility to complete medication administration and to ensure resident care is continued until the Nurse Manager on call or oncoming nurse has arrived to relieve the off going charge nurse, and procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration, and ongoing monitoring plan to prevent recurrence. On 2/23/2025 at 2:47 PM, Resident #2's blood glucose level was assessed at 313 mg/dl by the 300 Hall Charge Nurse with 8 units of Novolin R per sliding scale administered per physician order; at 5:32 PM, Resident #2's blood glucose level was assessed by the on call Nurse Manager at 332 mg/dl with 8 units of Novolin R administered per sliding scale Resident #2 noted with physician order stating metFORMIN HCL [hydrochloride] ER [extended release] Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCL) Give 500 mg by mouth two times a day for DM. On 2/23/2025, the 300 hall Charge Nurse administered the Metformin 500 mg dose to Resident #2 at 2:44 PM. Metformin 500 mg was also administered to Resident #2 by on call Nurse Manager for next scheduled dose following Physician notification of delayed and missed morning medication administrations at 5:28 PM. The Charge Nurse administered 25 units of Insulin Glargine as ordered at 7:46 PM on 2/23/2025 with a blood glucose of 402 mg/dl. All 100 hall residents, to include Resident #2, were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse. All applicable Residents blood glucose levels, to include Resident #2, were assessed per accucheck on 2/23/2025 upon arrival of Director of Nursing to facility between 2:00 PM and 3:00 PM with physician notification completed. The Medical Director was notified by the DON on 2/23/2025, for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained. The Physician was notified of all medications showing missed administration with verbal agreement provided to administer all medications at this time; notified of all missed accuchecks and insulin administrations with current blood glucose levels with no further orders. The Medical Director was included in adhoc [for this situation] Quality Assurance and Performance Improvement (QAPI) meeting on 2/23/25 with attendance including Administrator, Director of Nursing, and Regional Director of Clinical Services for discussion of notification of resident assessment findings, to include Resident #2, reviewed and approved Performance Plan developed. 2/23/2025 All on duty Licensed Nurses were educated by the Director of Nursing and Regional Director of Clinical Services regarding On-call procedures, communication, timely medication administration, reinstructed regarding abuse prohibition and neglect, and staffing procedures which details included but not limited to the facility procedure/protocol of notifying the Nurse Manager on call if a clinical staff member does not report to their scheduled shift in order for coverage to be coordinated. All off duty, to include PRN (as needed) or Agency, licensed nurses will receive this education prior to the beginning of their next shift. The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents on 2/23/2025. On 2/24/2025 at 7:15 pm, a Governing Body meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and VP of Clinical Services to discuss the notification of immediate jeopardy. Reviewed all findings from 2/23/2025 and developed Performance Improvement with agreement to continue with action and plan developed. Adhoc QAPI meeting held on 2/26/2025 with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place effective 2/23/2025. The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition. Monitoring will occur twice daily x (times) 7 days, then twice daily during business days x 3 weeks, then weekly thereafter during morning clinical meeting. If substantial compliance is not met, re-education will be initiated, and audits will be reinitiated. The Director of Nursing will report the findings to the monthly QAPI Committee meeting. Removal plan was discussed and approved by Medical Director 2/25/25, 2/26/25, and 2/28/25. The Administrator will ensure the removal plan is completed.

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to implement fall interventions for 1 of 4 (Resident #56) sampled residents reviewed for falls. The facility failed to follow the fall prevention intervention of 2 person bed mobility assistance, when on 11/17/2024, Resident #56 fell out of the bed and sustained a fractured hip, resulting in Actual HARM to Resident #56. The findings include: 1. Review of the facility's undated policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .The nurse will indicate the resident's fall risk . and initiate interventions on the resident's baseline care plan .with the resident's level of risk . Review of the facility's undated policy titled, Comprehensive Care Plan Policy, revealed .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . 2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Left Hemiplegia, Parkinsons, Dementia, Fracture of Left Femur, Diabetes, Depression, Anxiety, Testicular Hypofunction, and Impulse Disorder. Review of the Fall Risk Assessment for Resident #56 dated 12/28/2023, revealed .High Risk for Falling . Review of the Nurse Progress Note for Resident #56 dated 12/28/2023 at 12:34 PM, revealed .Resident was laying on his stomach on the floor next to [the] bed .Laceration noted on right forearm .bruise forming on right knee. Blood noted in nostrils .Two staff members are to be used while providing care . Review of the Nurse Progress Note for Resident #56 dated 12/28/2023 at 7:15 PM, revealed .Vital Signs .Blood Pressure: 165/96; Heart Rate: 96 .also observed prominent swelling to the left knee, redness / bruising to the nasal region, and abrasions located throughout various [regions] of the body that were sustained from the fall .resident voiced excruciating pain .MD [Medical Director] .order to send the resident out to the .ER [emergency room ] for evaluation . Review of the Facility Investigation Incident Report for Resident #56 dated 12/28/2023, revealed .Resident was laying on his stomach on the floor .Immediate Action Taken .Two staff members are to be used while providing care . Review of the care plan for Resident #56 dated 12/29/2023, revealed .two persons assist with bed mobility . Multiple attempts were made to contact the Nurse and CNA that were present for the fall on 12/28/2023, with no success. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #56 was cognitively intact and required moderate assist with ADLs (Activities of Daily Living). Review of the annual MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #56 had no cognitive impairment, required extensive assist with ADLs, and 2 person assist with turns and repositions. Review of the Care Plan dated 11/17/2024, revealed Resident #56 required 2 person assist with bed mobility. Review of the Facility Investigation Incident Report for Resident #56 dated 11/17/2024 at 9:00 PM, revealed .resident found in floor laying on back between the bed and the window on left side .while CNA was administering ADL/incontinent care, cna [CNA] was rolling resident over from the right side of bed to clean and he [Resident #56] had grabbed to night stand draw [drawer] .continues to fall into floor .Immediate Action Taken .head to toe assessment .neuro checks started .EMS [Emergency Medical Services] contacted for transfer to ER . Review of the Nurse Progress Note for Resident #56 dated 11/17/2024 at 10:43 PM, revealed .EMS here to transport to ER .Resident refusing to go to ER . Review of the Fall Risk Assessment for Resident #56 dated 11/17/2024, revealed .Moderate Risk for Falling . Review of the Nurse Progress Note for Resident #56 dated 11/18/2024 at 6:45 AM, revealed .Resident complaining of L [Left] hip pain and being unable to lift LLE [Left Lower Extremity] MD contacted and ordered resident be transferred to ED [Emergency Department] for evaluation and imaging . Review of the Hospital Record for Resident #56 dated 11/18/2024, revealed .male brought in .after having fallen on his left hip when being turned in the bed .complains of left .thigh pain .CT [Computed Tomography] Scan [medical imaging used to obtain detailed internal images of the body] imaging showed minimally displaced/impacted .femoral neck [specific type of hip fracture] fracture . Review of the Nurse Progress Note for Resident #56 dated 11/18/2024 at 9:12 PM, revealed .Resident admitted to [the] hospital due to fractured left hip . Resident #56 was admitted to the hospital on 11/18/2024 - 11/20/2024. Review of the Nurse Progress Note for Resident #56 dated 11/20/2024 at 5:17 PM, revealed .Admission Summary .Resident arrived to fscility [facility] via [by way of] EMS per stretcher x [times] 2 attendants. admitted S/p [status post-a shorthand notation to indicate a specific event or procedure for a past medical event] hospitalization for fx [fracture] to hip from fall . Review of the Physician's Order for Resident #56 dated 11/20/2024, revealed .non weight bearing to LLE every shift for Left hip fx .Ensure surgical site clean dray [dry] and intact . Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #56 was cognitively intact. Resident #56 was dependent on staff for bed mobility and experienced a fall with a major injury requiring surgery. During an interview on 1/14/2025 at 2:48 PM, Registered Nurse (RN) C stated .I was in another room and the CNA [CNA D] came out and hollered for help .I went in and said let me get help .got staff and used the hoyer [mechanical lift] to get him back on the bed .he [Resident #56] said she [CNA D] rolled me out of the bed .she was changing him. She said he grabbed the side table and kept on rolling .I called EMS, and when they got there he refused to go .They [EMS] asked him appropriate questions and they said he was okay .when I came back the next morning he was gone .I turned in CNA [D] witness statement [a document that records facts and details] to DON [Director of Nursing] CNA [D] was [the] only one in the room .He's supposed to be 2 person assist . During an interview on 1/14/2025 at 3:16 PM, CNA D stated .When I rolled him [Resident #56] over he was holding onto the nightstand .started falling out of the bed .I didn't find out until after that he [Resident #56] was a 2 person assist .I had just started working on that side .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury and failed to provide treatments for 2 of 4 (Residents #72, and #85) sampled residents reviewed for pressure ulcers/injuries. Resident #72, who was at risk of developing pressure ulcers/injuries due to contractures [a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that limits movement of a joint or body part] of the extremities and was dependent on staff for preventative interventions, developed a pressure ulcer/injury to the palm of her left hand from having long fingernails embedded into the skin, resulting in actual Harm to Resident #72. The findings include: 1. Review of the facility's undated policy titled, Activities of Daily Living (ADLs), revealed A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming .personal .hygiene .The facility will maintain individual objectives of the care plan and periodic review and evaluation . Review of the facility's undated policy titled, Pressure Injury Prevention and Management, revealed .This facility is committed to the prevention of avoidable pressure injuries .facility shall establish and utilize a systemic approach for pressure injury prevention .Licensed nurses will conduct a full body skin assessment .weekly .Nursing assistants will inspect skin during bath and report any concerns .Interventions will be based on specific factors identified in the risk .skin assessment .moisture management, impaired mobility . 2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Left Knee Contracture, and Right Knee Contracture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #72 was cognitively intact. Resident #72 required substantial assistance with most Activities of Daily Living (ADLs) and was dependent for bathing and dressing. The resident had upper and lower extremity impairment on 1 side. Review of the Weekly Skin Check, for Resident #72 dated 12/12/2024, revealed .no new or abnormal skin issues this weekly assessment . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14 which indicated Resident #72 was cognitively intact. Resident #72 required substantial assistance with most ADLs and was dependent for bathing and dressing. The resident had upper and lower extremity impairment on 1 side. Review of the Nurses Note for Resident #72 dated 12/18/2024, revealed .Summoned to resident's room per staff, noted a trauma wound to plam [palm] of left hand r/t [related to] contratcure [contracture] and fingernails digging into skin. Daughter persent [present] at bedside et [and] is aware. [Named physician] is aware with new orders to cleanse left hand with dwc [dermal wound cleanser]/ns [normal saline], pat dry, silde [slide] silver alginate between fingers and palm of hand. Change Qd [every day] et PRN [as needed] . Review of the Physician's Order for Resident #72 dated 12/18/2024, revealed .Cleanse left hand with dwc/ns, pat dry, place silver alginate between fingers and palm of hand. Every day shift AND every 1 hours as needed . Review of the .Follow Up Question Report ., for Resident #72 dated 12/1/2024-12/31/2024, revealed no issues during skin observations for 12/7/2024-12/19/2024. Review of the .Weekly Wound Progress ., for Resident #72 dated 12/19/2024, revealed .Left hand [palm] .trauma .2.0 [centimeters (cm) length] 1.35 [width] 0.1 [depth] . Review of the Weekly Skin Check, for Resident #72 dated 12/20/2024, revealed .no new skin issues noted at this time . Review of the care plan for Resident #72 dated 9/29/2023, with a revision date of 12/20/2024, revealed .Trauma from nails to palm of left hand, Nails trimmed . There were no interventions implemented to prevent further pressure injury to the resident's left palm. Review of the Nurses Note for Resident #72 dated 12/20/2024, revealed .Wound Trauma- Cleanse left hand with dwc/ns, pat dry, place silver alginate between fingers and palm of hand. every day shift, pt [patient] refused to have dressing changed, asked to wait till [until] saturday [Saturday] 12/21 [12/21/2024]. Review of the Treatment Administration Record (TAR) dated December 2024, revealed the facility failed to document the treatment for the pressure injury to the left palm on December 21, 2024. Review of the .Weekly Wound Progress ., dated 12/23/2024, revealed .Left hand (palm) .1.5 [length] 1.2 [width] 0.1 [depth] . Review of the .Weekly Skin Check, dated 12/28/2024, revealed .no new skin issues noted . Review of the .Weekly Wound Progress ., dated 12/30/2024, revealed .Left hand (palm) .1.08 [length] 0.7 [width] 0.1 [depth] . Review of the .Weekly Skin Check, dated 1/4/2025, revealed .no new skin issues noted . Review of the TAR dated January 2025, revealed the facility failed to document the treatment for the pressure injury on January 4, 2025. During an interview on 1/13/2025 at 11:10 AM, the Treatment Nurse confirmed the wound to Resident #72's hand was a preventable pressure ulcer/injury and should have been noticed during the Certified Nursing Assistants (CNA) skin assessments. During an observation and interview on 1/13/2025 at 11:30 AM, the Treatment Nurse was asked if this surveyor could see the area of the pressure injury to Resident #72's hand. The Treatment Nurse tried to open the resident's left hand and was able to open the resident's hand enough to see that the wound had healed. Further observations revealed Resident #72's nails were long and needed to be trimmed. The Treatment Nurse stated she was going to trim the resident's nails when the daughter arrived. The Treatment Nurse stated that the resident usually keeps a washcloth in her hand to prevent any further pressure injuries since she refused anything else to be in her hand to prevent pressure injuries. Observations revealed Resident #72 did not have a washcloth in her left hand as a measure to prevent further pressure injuries to the palm of her contracted left hand. During an interview on 1/13/2025 at 12:53 PM, the Director of Nursing (DON) confirmed that trimming nails and nail care should be done during residents' personal care and Resident #72's hand was a preventable pressure ulcer/injury. The DON confirmed the weekly skin assessment should have had documentation of skin issues prior to when the trauma to the palm of the hand occurred. 3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnosis of Metabolic Encephalopathy, Sepsis, Pressure Ulcer Sacral Area Stage 4, Osteomyelitis, Atrial Fibrillation, Acute Kidney Failure, Anxiety, Paraplegia, and Bladder Neck Obstruction. Review of the quarterly MDS dated [DATE], revealed Resident #85 had a BIMS score of 6, indicating Resident #85 had severe cognitive impairment. The resident was dependent on staff for all ADL's. Resident #85 had a Stage 4 pressure ulcer. Review of the Physician Orders dated 10/24/2024, revealed Wound Pressure-Cleanse sacrum with .ns .collagen powder, dakins [cleaning solution] soaked gauze and secure with cover dressing. Review of the November 2024 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 11/4/2024, 11/5/2024, and 11/26/2024. Review of the December 2024 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 12/8/2024, 12/21/2024 and 12/22/2024. Review of the January 2025 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 1/4/2025 and 1/5/2025. During an interview on 1/14/2025 at 3:00 PM, the Interim DON was shown the TARS with the missing treatments. The Interim DON was asked should there be missing treatments related to pressure ulcer care. The Interim DON stated, No. 4. During an interview on 1/13/2025 at 12:53 PM, the Interim DON was asked if staff should be missing treatments. The Interim DON stated, No, if they are missed, a reason should be documented. 50408

Based on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. The kitchen floor was dirty, the cook ware had sticky black carbon build-up, the convection oven had dried food particles inside with thick black sticky substance buildup. The meal and miscellaneous carts were dirty with dry food particles inside the carts. The facility failed to complete the food temperature log, freezer log, and cooler log. The facility failed to check the dish washer temperatures and sanitizing solution level three times a day. The facility had a census of 103 with 101 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility undated policy titled, Sanitation Inspection, revealed .It is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary and in compliance with .state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter .Daily: Food service staff shall inspect refrigerators/coolers, freezer, storage area temperatures, and dishwasher temperatures daily .the dietary manager shall inspect all food services areas weekly to ensure . Review of the facility undated policy titled, Monitoring of Cooler and Freezer Temperatures, revealed .It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety .Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit .Temperatures will be checked and logged at least twice per day by designated personnel . Review of the facility undated policy titled, Record of Food Temperatures, revealed .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Food temperatures will be checked on all items prepared in the dietary department .Measure and record the temperatures for each food product and milk at all meals. Record temperature on the temperature log . Review of the facility undated policy titled, Food Safety Requirements, revealed .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .For low temperature dishwasher .the wash temperature shall be 120 .F [Fahrenheit] .The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse .Chemical solutions shall be maintained at the correct concentration .at least once per shift .Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes . 2. Observation in the kitchen on 1/7/2024 at 1:16 PM, revealed the following. The Kitchen floor was dirty with dried food crumbs, and pieces of paper on the kitchen floor. The dish washer temperatures and test the sanitizing solution level of the low temperature dishwasher had not been completed. 3. Observation in the kitchen on 1/8/2024 at 11:16 AM, revealed the following. The Kitchen floor was dirty with dried food crumbs, and pieces of paper on the kitchen floor. The convection oven had dried food particles and had a thick black sticky substance buildup inside. One meal cart was dirty with dry food particles on the bottom of the cart. One metal cart that the plates lids were stored on, was dirty. One miscellaneous silver cart that contained peanut butter, jelly, bread, and hotdog buns was dirty and contained food particles. The freezer log, cooler log and the dish washer temperatures and test the sanitizing solution logs had not been completed. 4. Observation in the kitchen on 1/9/2024 at 7:44 AM, revealed the following. The Kitchen floor was dirty with dried food crumbs and had a plastic lid lying on the kitchen floor. The convection oven had dried food particles and a thick black sticky substance buildup inside. One meal cart was dirty with dry food particles on the bottom of the cart. One miscellaneous silver cart that contained peanut butter, jelly, bread, and hotdog buns was dirty and contained food particles. 5. Review of the Time/Temperature Food Preparation Log . dated November 2024 failed to reflect the completion of the food temperature checks for all three meals on 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024. Review of the Time/Temperature Food Preparation Log . dated December 2024 failed to reflect the completion of the food temperature checks for all three meals on 12/1/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024 and 12/31/2024. Review of the Time/Temperature Food Preparation Log . dated January 2025 failed to reflect the completion of the food temperature checks for all three meals on 1/1/2025, 1/2/2025, 1/3/2025, 1/4/2025, 1/5/2025, 1/6/2025, and 1/7/2025. 6. Review of the TEMP [Temperature] LOG - FREEZER . Temperature logs dated November 2024, revealed the freezer temperature should be checked twice a day in the AM and PM, and initialed. Review of the freezer temperature logs failed to reflect the completion of the AM and PM checks on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024. Review of the TEMP [Temperature] LOG - FREEZER . Temperature logs dated December 2024, revealed freezer temperature was to be checked twice a day in the AM and PM, and initialed. Review of the freezer temperature logs failed to reflect the completion of the AM and PM checks on 12/3/2024, 12/4/2024, 12/9/2024, 12/10/2024, 12/15/2024, 12/16/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024. 7. Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated November 2024, revealed the cooler temperature was to be checked twice a day in the AM and PM, and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 11/1/2024, 11/2/2024, 11/3/2024, 11/11/2024, 11/12/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024. Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated December 2024, revealed the cooler temperature was to be checked twice a day in the AM and PM and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 12/3/2024, 12/4/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024. Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated January 2025, revealed the cooler temperature was to be checked twice a day in the AM and PM and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 1/1/2025, and 1/2/2025. 8. Review of the DISH MACHINE LOG . sanitation logs dated November 2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper, and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024. Review of the DISH MACHINE LOG . sanitation logs dated December 2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials on 12/1/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024. During a telephone interview on 1/14/2025 at 8:17 AM, Registered Dietician (RD) confirmed the kitchen should be cleaned, meal temperatures should be checked on the line before it's served and documented, and the dishware temperatures with sanitizer should be checked and documented. During an interview 1/14/2025 at 2:03 PM, the Certified Dietary Manager (CDM) confirmed the kitchen and the equipment should be clean and stated, .it was dirty I can't lie about it . I have never run a dirty kitchen .that's going to change .one of the best things happened the other day .sprinkler popped .when they [kitchen staff] seen the dirt come off the floor .said that's what is in our floor, it's dirty .I didn't hold them accountable for what they did in 24 [referring to 2024] .then you guys come .I've told them for the whole year .I showed them what was supposed to be done .I know I haven't done my job due diligent .moving forward it's going to be by the book .bent the rule not putting my foot down . The CDM confirmed the staff should document the meal temperatures with every meal, check the dish washer temperatures and the sanitizer three times a day, check the temperatures and document the freezer and cooler temperatures twice a day and stated, .I tell them it's not me it's what the state looks for .the whole nine yard and I have preached that to them for the whole year .and it takes you to come in to validate .25 [referring to 2025] is a different year .they aren't going to like me .I told my staff we are going to get a tag of some sort .I was expecting it because I know what I gave you wasn't sufficient . During an interview on 1/14/2025 at 4:01 PM, the Administrator confirmed the kitchen should be clean, the staff should document the meal temperatures with every meal, check the dish washer temperatures and the sanitizer three times a day, check the temperatures and document the freezer and cooler temperatures twice a day.

Based on facility policy review, observation, and interview the facility failed to ensure that medication records were in order and an account of the controlled medications were maintained and reconciled for 1 of 5 Registered Nurse (RN) J observed for Medication Administration. The findings include: 1. Review of the facility's undated policy titled Medication Administration, revealed .Observe resident consumption of medication .if medication is a controlled substance, sign narcotic book . 2. Observation at the 300 hall Medication (Med) Cart beginning on 1/13/2025 at 1:31 PM revealed the following: a. LPN J was asked to review Resident #1's narcotic reconciliation. Review of the Controlled Drug Record for Resident #1 revealed .GABAPENTIN (used to treat seizures and nerve pain) .300 MG (Milligram) CAPSULE .Amount Remaining 10 . Review of Resident #1's narcotic card revealed a count of 8 capsules remaining. LPN J was asked about the difference in the number and stated, .I gave him a dose at 8 and another at noon .That's how busy I have been .There are 8 in the package, not 10 . b. LPN J was asked to review Resident #20's narcotic reconciliation. Review of the Controlled Drug Record for Resident #20 revealed .ALPRAZOLAM (used to treat anxiety) 1 MG TABS .Amount Remaining .18 . Review of Resident #20's narcotic card revealed a count of 16 tablets remaining. LPN J was asked about the difference in the number and stated, .I gave her a dose at 8 and another at noon .I signed them off in the computer but haven't signed them off in the book yet . c. LPN J was asked to review Resident #48's narcotic reconciliation. Review of the Controlled Drug Record for Resident #48 revealed .HYDROcodone/ACET (Acetaminophen used to control pain) 5-325MG TAB .Amount Remaining .11 . Review of Resident #48's's narcotic card revealed a count of 10 tablets remaining. LPN J was asked about the difference in the number and stated, .I gave her a dose at 8 .I haven't written it in the book yet . During an interview on 1/13/25 at 2:25 PM, the Interim Director of Nursing (DON) confirmed that narcotics should be signed out in the Narcotics Book after they are administered.

Based on policy review, medical record review, and interview, the facility failed to develop a care plan for 1 of 32 (Resident #72) residents reviewed for care plans. The findings include: 1. Review of the facility's undated policy titled, Pressure Ulcer Prevention and Management, revealed This facility is committed to the prevention of avoidable pressure injuries .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse timely .Interventions will be based on specific factors .skin assessment .moisture management, impaired mobility .Interventions will be documented in the care plan and communicated to all relevant staff . 2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Epilepsy, Left Knee Contracture, and Right Knee Contracture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #72 was cognitively intact. Resident was at risk for pressure injuries and had upper and lower extremity impairment on 1 side, and substantial assistance to totally dependent with ADLs. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated Resident #72 was cognitively intact. Resident was at risk for pressure injuries and had upper and lower extremity impairment on 1 side, and substantial assistance to totally dependent with ADLs. Review of the care plan with a revision date of 12/20/2024 revealed .trauma from nails to palm of left hand, nails trimmed . There were no interventions in place. During an interview on 1/13/2025 at 12:53 PM, the Minimum Data Set (MDS) Coordinator confirmed there should be an intervention on the care plan for trauma from nails to the palm of the left hand. The facility failed to develop a care plan for Resident #72 to include interventions for wound care to palm of the left hand.

Based on policy review, medical record review, and interview, the facility failed to conduct a quarterly care plan conference meetings with resident/family representative for 1 of 32 (Resident #68) sampled residents reviewed for care plan meetings. The findings include: 1. Review of the undated facility policy titled, Comprehensive Care Plans revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .The care planning process will include an assessment of the resident's personal and cultural preferences in developing goals of care .The comprehensive care plan will be prepared by an interdisciplinary team, that includes .Family members, surrogate, or others desired by the resident .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set [MDS] assessment . 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including Lack of Coordination, Severe Protein Calorie Malnutrition, Diabetes, Heart Disease, Anxiety and Depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 is rarely/never understood and is dependent on staff for Activity of Daily Living. 3. The facility was unable to provide documentation that a quarterly Care Conference was conducted with the Resident or Responsible Party regarding the quarterly 1/15/2024 comprehensive assessment. 4. During an interview on 1/13/2025 at 9:21 AM, the Social Service Director confirmed the family representative was not invited to the care plan meeting for the comprehensive MDS for January. During an interview on 1/13/2025 at 10:50 AM, the Regional Director of Clinical Services confirmed a care plan conference meeting with family should be quarterly with the MDS assessment completion.

Based on policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident abuse for (Resident #76 and #307) and an injury of unknown origin (Resident #81) for 3 of 10 sampled residents reviewed for Abuse. The finding include: 1. Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed, .Abuse .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .verbal abuse .includes disparaging and derogatory terms to residents .physical .hitting, slapping .includes controlling behavior through corporal punishment .designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse . to the state survey agency and other officials in accordance with state law .Possible indicators of abuse include .Resident, staff, or family report of abuse .physical marks such as bruises .physical injury of a resident, of a unknown source .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .Immediately, but no later than 2 hours after the allegation is made .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . 2. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Paraplegia, Seizures, Bipolar 2 Disorder, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #76 was cognitively intact. During an interview on 1/6/2025 at 4:09 PM, Resident #76 reported to the surveyor an allegation of verbal abuse. Resident #76 stated a [named employee] called him a derogatory name. The Surveyor finished the interview and reported the allegation of verbal abuse to the Administrator in his office. The allegation of verbal abuse was not reported to the state agency until 1/15/2025 (9 days after the allegation was made). During an interview on 1/15/2025 at 2:20 PM, the Administrator was asked the types of abuse do you report to the state agency. The Administrator stated, Any type of abuse, physical, verbal, sexual, misappropriation . The Administrator confirmed he did not report to the state agency, Resident #76's allegation of verbal abuse. The Administrator was asked should you have reported this allegation of verbal abuse. The Administrator stated, Yes. 3. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including Fracture of Part of Neck of Right Femur, Dementia, Alzheimer's Disease, Muscle Weakness, History of Falling, and Unsteadiness on Feet. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 00, which indicated Resident #81 was severely cognitively impaired. Review of Resident #81's Progress Note dated 12/25/2024 at 5:10 AM, revealed .resident noted with discoloration to left forehead no s[signs]/[or]sx [symptoms] of pain noted will continue to monitor. Review of (Named Company) Weekly Skin Checks revealed .12/26/2024 .Any bruising or redness .no .1/2/2025 .Any bruising or redness .no, No new skin issues . Review of the (Named Hospital) report dated 12/31/2024, revealed .77 yr [year] female brought in from [Named facility] nursing home after 2 reported episodes of coffee ground emesis. Pt [patient] is . nonverbal .Yellow bruise noted to forehead . During a phone interview on 1/6/2025 at 2:40 PM, Resident #81's daughter stated .She was sent out about a week ago and they did not call me, the hospital did. When I got to hospital, she had a bruise on her forehead . During an observation on 1/8/2025 at 8:11 AM, Resident #81 was sitting in a wheelchair in the dining room with a yellow fading bruise to the left center of her forehead. During an interview on 1/8/2025 at 4:04 PM, LPN E was asked, Do you know when or where the yellow bruise on the resident's forehead came from? LPN E stated, She had a previous fall sometime in the beginning of December. During an interview on 1/8/2025 at 4:08 PM, Resident #81's daughter was asked when she noticed the bruise on her forehead. She replied, It wasn't there when I went out of town the Saturday before Christmas [December 21, 2024.] I saw it on 1/1/2025 when I saw her in the hospital when she was sent out. Resident's daughter was asked if she asked anyone from the facility where the bruise came from. Resident #81's daughter stated, They [facility staff] said that the bruise was from a previous fall from December twenty-something . During an interview on 1/13/2025 at 10:31 AM, LPN F was asked to describe Resident #81's bruise. LPN F stated, It was on the left side of her forehead .I saw a purplish area to her left forehead. The LPN F was asked if she did an investigation or completed an incident report. The LPN F replied, I put a pillow for positioning, no I didn't know what happened, so I didn't know what to put on a report . During an interview on 1/14/2025 at 2:23 PM, the Administrator stated, .We are acknowledging Resident #81 had a fall .we are still investigating .I have reported to the state as injury of unknown origin, there is no suspicion of abuse .the bruise should have been documented and investigated . During an interview on 1/14/2025 at 4:15 PM, the DON confirmed LPN F should have documented and reported an occurrence of Resident #81's bruise to the forehead, and the facility should have investigated the bruise . 3. Review of the medical record revealed Resident #307 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Paraplegia, Chronic Obstructive Pulmonary Disease, Urinary Retention, and Depression. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated Resident #307 was cognitively intact without physical behaviors directed towards others. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident #307 was cognitively intact without physical behaviors directed towards others. During an interview on 1/6/2025 at 11:10 AM Resident #307 stated .the nurse on hall 5 .tried to take my phone away from me and I swung and she grabbed my hand and held it down .I was cussing her and she said something about my mama and I said something about her and then I spit at her and she grabbed a towel and put it over my face and almost smothered me and I said I was calling the police .I called 911 again and the police officer came, and I told them I wanted to press charges. Then the ambulance got here, and they took me to the hospital. [Named Social worker] came and talked to me about it when I got back on Friday [1/3/2025] . The Administrator was notified of the allegation of abuse on 1/6/2025. During an interview on 1/13/2025 at 9:26 AM the Assistant Director of Nursing (ADON) A stated it was bought up to the Social Worker during the 48-hour care plan meeting. During an interview on 1/13/2025 at 9:31 AM the Administrator stated .it was discovered in care plan meeting on 1/3/2025 .the way it was reported it was not an allegation .it was a complaint .it was reported as a complaint, not as an allegation .different types of grabbing .if [Resident #307] felt he was abused he would voice it and he did not voice it in that manner from what I understand. If he felt abused or was voiced as abuse he would tell me. He did not tell me that. Based on what he said and how it was reported to me it was not abuse . The surveyor asked, When I reported this to you last week did you talk to [Resident #307] The Administrator stated, I can't remember if I talked to him about this or not .He did not say the word abuse. He voiced it as a complaint, not abuse .This is not abuse so it wasn't reported . During an interview on 1/13/2025 at 10:02 AM the Social Service Director (SSD) was asked what Resident #307 told her. The SSD stated, .she [LPN F] held my arm down and put a rag over my face .he said he felt safe in the building .the way I perceived it, if he didn't feel safe, he would not have wanted to go back to the room .He is the first one that would tell if something was wrong. If he was genuinely upset, he would have said that and not have us prompt the question .I would not perceive that as abuse . During an interview on 1/15/2025 at 2:25 PM, the Administrator stated I still feel it's not abuse .so it doesn't need to be reported . The allegation of staff to resident abuse was not reported to the state agency until 1/15/2025. 50408 51365

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 4 of 86 resident rooms (Residents #3, #28, #34, #61, #82, #84, and #94) The findings include: 1. Review of the undated facility policy Resident Rights, revealed .The resident has a right to a safe, clean, comfortable and homelike environment . Review of the facility's CLEANING SCHEDULE, dated 10/11/2023, revealed .Monday .Wednesday .Friday .Sunday .Clean commode top to base of commode .Wednesday .Friday .clean .IV poles .Monday .Clean walls, light, everything on the wall, wash window and window seal .Daily dust mop and mop room . Review of the facility's Deep Cleaning List, revealed .Dust and polish all furniture .Dry mop and wet mop entire floor-move all furniture .clean windows, screens, ledges, blinds .Dust high areas .curtain -window and cubicle .Clean Feeding Tube Poles .Clean and disinfect toilet bowl . 2. Multiple observations in Resident #3's room on 1/6/2025 at 9:50 AM, 1/7/2024 at 8:18 AM, and on 1/8/2025 at 8:27 AM, revealed dirty baseboards by the air conditioner and the window blinds had yellowish-brown splatter marks. The commode had a dirty grayish black ring around the water line and a dark brown smear above the water line on the left side. 3. Multiple observations in Resident #82 and Resident #94's shared bathroom on 1/6/2025 at 10:23 AM and on 1/8/2025 at 8:13 AM, revealed a strong odor of urine and the floor was sticky with visible footprints. The floor entering the room was sticky and revealed footprints and wheelchair marks. Dirt and crumbs were observed on the floor. Dark streaks and splatter were observed on the wall beneath the sink. The floor between Resident #94's bed and the wall had several grayish spots and splatters. 4. Multiple observations in Resident #34 and #61's room on 1/6/2025 at 10:32 AM and on 1/09/25 at 9:04 AM, revealed the window valance by the bed had large spots of thick gray dusty build up showing in the folds of the material. 5. Multiple observations in Resident #28 and 84's room on 1/6/2025 at 10:32 AM, 1/07/25 at 8:31 AM, and on 1/8/2025 at 8:19 AM, the base of the enteral feeding tube pole had a yellowish tan hardened substance on and around the base of the pole, and crumbs and dirt on the floor between the two beds. During an interview on 1/09/25 at 9:04 AM, the Administrator confirmed toilets should be cleaned, resident rooms and bathrooms should be clean without odors, the resident's floors should be clean, and the curtains should not be showing a thick layer of dust. During an interview on 1/13/2025 at 10:55 AM, the Head of Housekeeping confirmed the resident rooms should be kept clean and odor free.

Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate alleged allegations of abuse that included an injury of unknown origin (Resident #81) and staff to resident abuse (Resident #307) for 2 of 11 sampled residents reviewed for abuse. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed . An immediate investigation is warranted .B. Written procedures for investigation include .Identifying staff responsible for the investigation . Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .others who might have knowledge of the allegations .Focusing the investigation on determining if abuse . and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . Review of the facility's undated policy titled, .Incidents and Accidents, revealed It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents .The following incidents require an incident report .Falls .Unobserved injuries .The supervisor or other designee will be notified of the incident .The nurse will contact the resident's practitioner .In the event of an unwitnessed fall or blow to the head, the nurse will initiate neurological checks .The resident's family or representative will be notified of the incident .The nurse will enter the incident information into the appropriate form/system within 24 hours of occurrence .Meeting regulatory requirements .Documentation should include .nature of the incident .initial findings .date, time .notifications .The nurse will examine any first aid to any visitor or employee involved in an incident .If an incident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator . 2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Fracture of Part of Neck of Right Femur, Dementia, Alzheimer's Disease, Muscle Weakness, History of Falling, and Unsteadiness on Feet. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 00, which indicated Resident #81 was severely cognitively impaired. Review of Resident #81's Progress Note dated 12/25/2024 at 5:10 AM, revealed .resident noted with discoloration to left forehead no s [signs]/[or] sx [symptoms] of pain noted will continue to monitor. Review of (Named Company) Weekly Skin Checks revealed .12/26/2024 .Any bruising or redness .no .1/2/2025 .Any bruising or redness .no, No new skin issues . Review of the (Named Hospital) report dated 12/31/2024, revealed .77 yr [year] female brought in from [Named facility] nursing home after 2 reported episodes of coffee ground emesis. Pt [patient] is . nonverbal .Yellow bruise noted to forehead . During a phone interview on 1/6/2025 at 2:40 PM, Resident #81's Daughter stated .She was sent out about a week ago and they did not call me, the hospital did. When I got to hospital, she had a bruise on her forehead . During an observation on 1/8/2025 at 8:11 AM, Resident #81 was sitting in a wheelchair in the dining room with a yellow fading bruise to the left center of her forehead. During an interview on 1/8/2025 at 4:04 PM, LPN E was asked, Do you know when or where the yellow bruise on the resident's forehead came from? LPN E stated, She had a previous fall sometime in the beginning of December. During an interview on 1/8/2025 at 4:08 PM, the Resident #81's daughter was asked, when she noticed the bruise on her forehead. She replied, It wasn't there when I went out of town the Saturday before Christmas. I saw it on 1/1/2025 when I saw her in the hospital when she was sent out. Resident's daughter was asked if she asked anyone from the facility where the bruise came from. Resident #81's daughter stated, [Facility staff] said that the bruise was from a previous fall from December twenty-something . During an interview on 1/13/2025 at 10:31 AM, LPN F was asked to describe Resident #81's bruise. LPN F stated, It was on the left side of her forehead .I saw a purplish area to her left forehead. The LPN F was asked if she did an investigation or complete an incident report. The LPN F replied, I put a pillow for positioning, no I didn't know what happened, so I didn't know what to put on a report . During an interview on 1/14/2025 at 4:15 PM, the Interim DON confirmed LPN F should have documented and reported an occurrence of Resident #81's bruise to the forehead, and the facility should have reported and investigated the bruise immediately . During an interview on 1/14/2025 at 2:23 PM, the Administrator stated, .We are acknowledging Resident #81 had a fall .we are still investigating .I have reported to the state as injury of unknown origin, there is no suspicion of abuse .the bruise should have been documented and investigated . All three individuals are suspended pending investigation . 3. Review of the medical record revealed Resident #307 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Paraplegia, Chronic Obstructive Pulmonary Disease, Urinary Retention, and Depression. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated Resident #307 was cognitively intact without physical behaviors directed towards others. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident # 307 was cognitively intact without physical behaviors directed towards others. Review of the progress notes dated 12/27/2024, revealed .Behavior Note . Resident called 911 complaining of pain from suprapubic cath [catheter] upon arriving to room this writer asked resident what was going on, he preceded to say, the ambulance was on the way this writer asked resident again what was going on and why did he call them? Resident began to get loud and .this writer stated to him that that is not the correct way to speak to someone trying to help him resident then attempted to run me over with his chair as he told me to get .out of his room. During an interview on 1/6/2025 at 11:10 AM Resident #307 stated .the nurse on hall 5 .tried to take my phone away from me and I swung and she grabbed my hand and held it down .I was cussing her and she said something about my mama and I said something about her and then I spit at her and she grabbed a towel and put it over my face an almost smothered me and I said I was calling the police .I called 911 again and the police officer came, and I told them I wanted to press charges. Then the ambulance got here, and they took me to the hospital. [Named Social worker] came and talked to me about it when I got back on Friday [1/3/2025] . The Administrator was notified of the allegation of abuse on 1/6/2025. During an interview on 1/13/2025 at 9:26 AM, the Assistant Director of Nursing (ADON) A stated it was brought up to the Social Worker during the 48-hour care plan meeting. During an interview on 1/13/2025 at 9:31 AM, the Administrator stated .it was discovered in care plan meeting on 1/3/2025 .the way it was reported it was not an allegation .it was a complaint .it was reported as a complaint, not as an allegation .different types of grabbing .if he [Resident #307] felt he was abused he would voice it and he did not voice it in that manner from what I understand. If he felt abused or was voiced as abuse he would tell me. He did not tell me that. Based on what he said and how it was reported to me it was not abuse . The surveyor asked, When I reported this to you last week did you talk to him The Administrator stated, I can't remember if I talked to him about this or not .He did not say the word abuse. He voiced it as a complaint, not abuse .This is not abuse so it wasn't reported . During an interview on 1/13/2025 at 10:02 AM the Social Service Director (SSD) was asked what Resident #307 told her. The SW stated, .she [LPN F] held my arm down and put a rag over my face .he said he felt safe in the building .the way I perceived it, if he didn't feel safe, he would not have wanted to go back to the room .He is the first one that would tell if something was wrong. If he was genuinely upset, he would have said that and not have us prompt the question .I would not perceive that as abuse . During an interview on 1/15/2025 at 2:25 PM, the Administrator stated I still feel it's not abuse . Review of the undated Summary provided revealed .nurse tried to grab his arm and place a rag on his face . 51365

Based on policy review, medical record review and interview, the facility failed to notify the resident's legal representative of a transfer of the resident from the facility for 1 of 1 (Resident #81) sampled resident reviewed for notification of change. The findings include: 1. Review of the undated facility policy titled, Notification of Changes, revealed .The facility must inform .or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .A transfer or discharge of the resident from the facility . Review of the undated facility policy titled, Transfer and Discharge (including AMA), revealed .Emergency Transfers/ Discharges- initiated by the facility for medical reasons .Notify resident and/or resident representatives . 2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating Resident #81 had severely impaired cognition. Review of Progress Note dated 12/31/2024 at 6:22 PM, Revealed .Resident [#81] had two episodes of vomiting coffee ground emesis, on call md [Medical Doctor] made aware with order to send resident to [Named Hospital] ED [Emergency Department] for eval. [evaluation] RP [Responsible Party] aware of transfer. Resident transferred to [Named Hospital] . This progress note was written after Resident #81 had been sent out to the hospital, the hospital notified the daughter, and then daughter called the facility to confirm the resident had been sent out. During a phone interview on 1/6/2025 at 3:05 PM, Resident #81's RP stated .They did not call New Years Eve when they sent her out. The hospital notified me she was there .I called [the facility] and asked them what was going on . During an interview on 1/14/2025 at 4:18 PM, the Interim Director of Nursing (DON) was asked, What would you consider a reasonable amount of time to notify the RP if a resident is transferred to the hospital? The Interim DON stated, Within an hour. We may not call immediately if it's an emergency, but as soon as we get them out of the building they should call. The facility failed to notify the resident's RP of the transfer from the facility to the hospital.

Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed. The findings include: 1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings . 2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. 3. During an interview on 1/9/2025 at 10:54 AM, the Activity Director was asked if a private place should be provided for uninterrupted resident council meetings. The Activity Director stated, Yes. During an interview on 1/9/2025 at 11:25 AM, the Director of Nursing (DON) was asked if a private place should be provided for uninterrupted resident council meetings. The DON stated, Yes.

Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed. The findings include: 1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings . 2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. 3. During an interview on 1/9/2025 at 10:54 AM, the Activity Director was asked if a private place should be provided for uninterrupted resident council meetings. The Activity Director stated, Yes. During an interview on 1/9/2025 at 11:25 AM, the Director of Nursing (DON) was asked if a private place should be provided for uninterrupted resident council meetings. The DON stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infections for 1 of 1 (Licensed Practical Nurse (LPN) E) staff members that failed to use hand hygiene during ostomy care. The findings include: 1. The facility's undated policy titled, Hand Hygiene, revealed .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Before and after handling clean or soiled dressings . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Quadriplegia, Diabetes, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #6's Brief Interview for Mental Status (BIMS) of 9, indicating severe cognitive impairment, and functional limitation for range of motion (ROM) to lower extremity with impairment on one side. Resident #6 requires total assistance for all activities of daily living (ADL's), and Ileostomy was coded during this review. Review of Resident #6's physician orders dated 6/11/2024, revealed .Change ostomy bag every 3 days and as needed one time a day, every 3 day(s) for ostomy care . Observation in resident's room on 1/13/2025 at 11:09 AM, revealed Resident #6 lying in the bed wearing a hospital gown. LPN E entered Resident #6's room to perform ostomy care. LPN E washed his hands, donned a pair of gloves, removed the partially filled ostomy bag, cleaned around the stoma with a wet wipe, measured the stoma site, picked up a pair of scissors and cut around the ostomy bag and then placed the bag over the stoma. LPN E then placed on the dirty supplies in a plastic bag and tied the bag up. LPN E removed his gloves, washed his hands, then placed the plastic bag in trash barrel in the hallway. During an interview on 1/14/2025 at 3:00 PM, LPN E confirmed he should have changed gloves, washed his hands and donned on a new pair of gloves after he had cleaned the stoma area and then applied the new pouch. During an interview on 1/14/25 at 01:35 PM, the Assistant Director of Nursing (ADON) stated, .after removal pouch wash hands after cleaning stoma, measure and then apply ostomy bag, wash hands and confirmed turn the water off with a new paper towel. During an interview on 1/15/2025 at 2:47 PM, The Director of Nursing confirmed the Licensed Nurse should change gloves, wash hands and don a new pair of gloves after cleansing the ostomy stoma, to apply the new pouch.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and labeled when expired medications were observed in 1 of 1 (Med Storage Room) medication storage areas, and when an over-the-counter medication was observed in a shared bathroom. The findings include: 1. Review of the facility's undated policy titled Medication Storage revealed .All drugs and biologicals will be stored in locked compartments .The pharmacy and all medication rooms are routinely inspected .for discontinued, outdated .medications . 2. Observation in the Medication Room on 1/15/2025 at 1:51 PM, revealed 8 expired Humalog Solution 100 UNIT/ML Pens with the use by date of 12/19/24. During an interview on 1/15/2025 at 2:28 PM, the Assistant Director of Nursing A confirmed that there should be no expired medications in the med room. 3. Observation in the shared bathroom for Resident # 36 and #79 on 1/6/2025 at 9:43 AM, and 5:31 PM, revealed a 7.1-ounce pump can of over-the-counter medication for muscle cramps. During an interview on 1/14/2025 at 3:07 PM, the Interim Director of Nursing (DON) was asked should there be over the counter medication in the bathroom. The Interim DON stated, No.

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #42 and #99) reviewed with in-house acquired pressure ulcers. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk assessment .Periodically as indicated by the individual's degree of pressure injury risk Stage III [3]: Full thickness skin loss Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough [dead tissue] may be present .May include undermining and tunneling .Category/Stage IV [4] : Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar [a thick crust of dead tissue] may be present .Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed . Review of the facility's policy titled, .Skin Integrity Management System, dated 2/24/2021, revealed .treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .If a new pressure injury is noted, a Weekly Wound Progress .will be started. Notification of Physician and Responsible Party will be documented in the Progress Notes .Contact Physician for treatment recommendation approval . Review of the facility's undated policy titled, .Wound Treatment Management, revealed .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Characteristics of the wound .Pressure injury stage .Size .including shape, depth, and presence of tunneling and/or undermining .volume and characteristics of exudate .presence of pain .Presence of infection or need to address bacterial bioburden .condition of the tissue in the wound bed .condition of periwound skin . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse Practitioner Note dated 6/17/2022, revealed .no skin wound . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had a pressure relieving device for the bed. Review of a quarterly Braden Scale dated 6/30/2022, revealed Resident #42 was at moderate risk for developing pressure ulcers. Review of a Nurses' Progress Note dated 7/9/2022 at 5:55 PM, written by Agency Licensed Practical Nurse (LPN) #7, revealed .while completing rounds, CNA [Certified Nursing Assistant] discovered wound to right buttock. CNA noticed that bed air mattress was turned off. Notified wound care nurse . Review of a Nurses' Progress Note dated 7/9/2022 at 7:00 PM, written by Agency LPN #7, revealed .Wound is 4 cm [centimeters] in length and 4.5 cm in width . Review of a Late Entry Nurses' Progress Note, written by Wound Care Nurse #1, revealed the note was written on 7/15/2022 with an effective date of 7/9/2022 and documented, .Received report of incident that resident obtained wound to sacral region. Treatment started of Calcium Alginate with santyl [ointment that removes dead tissue from wounds] and dry protective dressing daily [the Physician was not notified of the wound and treatment was not started until 7/11/2022] . Review of the Weekly Wound Progress Notes revealed no documented assessment of Resident #42's sacral wound on 7/9/2022 by Wound Care Nurse #1. There was no documentation that the Physician or the Responsible Party (RP) were notified about the new pressure wound on 7/9/2022. Review of a Physicians' Order dated 7/11/2022, revealed .Wound Pressure .cleanse R [right] buttock wound with dwc .apply santyl, calcium alg, and secure with protective dressing .every day shift . Review of the medical record revealed there was no other order for the Right buttock wound prior to 7/11/2022. Review of a Nurses' Progress Note dated 7/11/2022, written by Wound Care Nurse #2, revealed, .Notified by ADON [Assistant Director of Nursing] of residents wound to R buttocks .MD [Medical Doctor] made aware with new orders to cleanse R buttocks with dwc [wound cleanser], apply santyl, calcium alg [alginate] [absorbs wound drainage and provides a moist environment for wound healing], and secure with protective dressing daily and PRN (as needed) .Tx [Treatment] completed per MD orders. [Named Responsible Party] contacted and voiced understanding and stated she would tell Responsible Party . Review of a Weekly Wound Progress Note written by Wound Care Nurse #2, dated 7/11/2022, revealed, .Site .R buttocks .Type .Pressure .Length .4.0 [centimeters] .Width .4.5 [centimeters] .Depth 0.1 [centimeters] .Stage .Unstageable .Necrotic tissue present .Acquired in Facility .MD notified .RP notified . The Physician and RP were not notified until 7/11/2022. This was 2 days after the wound was discovered. Review of the 7/2022 Treatment Administration Record (TAR), revealed treatments were not documented as administered on 7/16/2022, 7/17/2022, or 7/22/2022. Review of a Weekly Wound Progress Note dated 8/17/2022, revealed .Site .R buttocks .Type .Pressure .Length .2.8 [centimeters] .Width .4.2 [centimeters] .Depth 0.5 [centimeters] .Stage .IV [4] .Granulation tissue present .Slough tissue present .Necrotic tissue present . Observation in the resident's room on 8/17/2022 at 1:00 PM, revealed Wound Care Nurse #2 removed the dressing to Resident #42's right buttock to reveal a Stage 4 Pressure Ulcer approximately 3 centimeters long and 4 centimeters wide with a depth of 0.5 centimeter. During a telephone interview on 8/19/2022 at 11:48 AM, LPN #5 confirmed she had provided care for Resident #42 on 7/7/2022, and she had no skin breakdown. She stated, .I would have shown it [skin breakdown] to the nurse .when I came back on the 8th [7/8/2022] she was already gone to the COVID Unit . During an interview on 8/19/2022 at 12:01 PM, LPN #1 confirmed she had moved Resident #42 to the COVID Unit on 7/8/2022, and she had no skin breakdown. During an interview on 8/19/2022 at 2:26 PM, CNA #1 confirmed she worked the 7:00 PM to 7:00 AM shift on 7/8/2022. She confirmed she was doing 1 on 1 with a wandering resident in the COVID Unit. She stated, .the way his room was, you could sit in the doorway and watch him. I had to focus on him and was told to do one on one. I could not help with the patients. When [Named Agency LPN #8] was working 7-11 [7:00 PM to 11:00 PM] she was passing meds [medications] and checking the patients, she never stopped. At 11 [11:00 PM] [Named Agency LPN #9] came and we found out she was a nurse .so [Named Agency LPN #8] said you take one half of the hall and I'll take the other half, so [Named Agency LPN #9] ended up on the right side with [Named Resident #42]. I was able to watch from where I was sitting and could see the hallway. CNA #1 was asked if Agency LPN #9 checked on her patients through the night. She stated, She wasn't doing like she was supposed to . She stated Agency LPN #9 spent most of the night sitting in the room where the nurses chart and was not checking on her patients like she nurses were trained to do. She confirmed she could not remember the name of the CNA that relieved her, but after report they made rounds together. She stated, I went in .she [Resident #42] was slumped down in the bed .the air mattress motor was turned off. She was sunk in .the mattress had deflated down. I put my hand on the end of the bed to feel the mattress, and I felt the hard metal under the mattress where there was no air it was hard .I flipped it back on. I stayed and watched the mattress fully inflate .we turned her over and looked at her right side .where she was laying and the whole hip and leg was real red all the way down from laying so long. We positioned her and put a pillow between her legs, and it was time for shift to end, and I left . There was no documentation of the redness or that a nurse was notified of the redness in the medical record. During a telephone interview on 8/19/2022 at 3:52 PM, CNA #2 confirmed she worked in the COVID Unit on the day shift on 7/8/2022 when Resident #42 came to the unit. She confirmed she checked on the resident and changed her. She confirmed she had no breakdown, and the mattress was inflated and working. She stated, I'm certain. During a telephone interview on 8/19/2022 at 3:52 PM, Agency LPN #8 confirmed she had worked on the COVID Unit on 7/8/2022 on the 7:00 PM to 7:00 AM shift. She confirmed there were more than 20 patients on the unit that night, and she was the only staff member to provide care for all the residents. She confirmed there was a CNA, but she was doing 1 on 1 with another resident who was a wanderer, so she couldn't help her. She stated it was very difficult to administer medications, check and change residents, and don and doff personal protective equipment while providing care for over 20 residents. She stated, .another nurse came later in the shift .I took the left side, she took the right side . She was asked if the air mattress was on and inflated when she checked her. She stated, .I'm sure it was. I took her vital signs. I leaned on the bed . She stated, .I learned she had the wound the next day .I think they said her air mattress was off all night long . During a telephone interview on 8/19/2022 at 5:04 PM, Agency LPN #7 confirmed she worked 7/9/2022 on the 7:00 AM to 7:00 PM shift in the COVID Unit. She stated, .CNA came to me later in the afternoon, don't remember what time, and told me she found a wound on [Named Resident #42]. She told me they had found the bed turned off .don't know when . During a telephone interview on 8/19/2022 at 6:02 PM, Agency LPN #7 confirmed she assessed the wound and stated, It looked black, it felt like dead tissue, mushy, no drainage .I called [Named Wound Care Nurse #1]. She brought some stuff back .but didn't tell me what to do .she called me on the phone, she told me what to do, put that cream on it and covered it . She confirmed Wound Care Nurse #1 never entered the Covid unit to assess the wound on Resident #42. During an interview on 8/19/2022 at 6:18 PM, the Administrator confirmed Wound Care Nurse #1 had left before her shift was scheduled to end on 8/19/2022. He confirmed they had been trying to reach her to find out what was going on, but she would not answer her phone. He confirmed she was scheduled to work from 7:00 AM to 7:00 PM. Wound Care Nurse #1 was not available for interview in person or by telephone. During a telephone interview on 8/19/2022 at 6:20 PM, Wound Care Nurse #2 stated, .That Monday [7/11/2022], I came in, I was notified by the ADON [Assistant Director of Nursing] of [Named Resident #42]'s wound. I got the order for wound care. She was asked if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, I don't see one in there. I would have gotten the order from [Named MD]. I usually get the order from them. Every wound is different based on how it looks. She [Wound Care Nurse #1] should have come, assessed it, gotten an order, and dressed it .I don't see a wound assessment on that day . She confirmed Wound Care Nurse #1 should have started an investigation that day. During an interview on 8/19/2022 at 6:51 PM, the Director of Nursing (DON) was asked when the treatment order was obtained for Resident #42's wound that was identified on 7/9/2022. She stated, Monday, 7/11/2022. She was asked when the order should have been obtained. She stated, Immediately. She was asked if Wound Care Nurse #1 should have assessed the wound. She stated, Yes, 100 percent. I did not find out until Monday, we read it in the morning report in the notes .we saw [Named Agency LPN #7]'s notes, we started investigating. She was asked if she knew the nurse on the COVID Unit was by herself providing care for 21 patients for 4 hours on the night shift of 7/8/2022. She stated, No, if I had known that I would have been up here. She was asked when she should have been notified about the wound. She stated, Immediately .would have started the investigation. She stated, .We didn't get to the root cause of how or who turned off the bed. During an interview on 8/19/2022 at 7:38 PM, ADON #2 confirmed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #99 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #99 was cognitively intact. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound pressure .cleanse right out [outer] knee wound with dwc/ns [wound cleanser/normal saline], apply santyl, silver alg [alginate], and secure with protective dressing every 1 hour as need [needed] AND every day shift . Review of Skin/Wound Note dated 7/25/2022, revealed .Resident readmitted to [Named Facility] from [Named Hospital] Scratch marks observed to bil [bilateral] legs and upper arms, resident is [CONDITION(S)] patient . There was no documentation of a wound to the right outer ankle. Review of Weekly Wound Progress Note date 8/1/2022, revealed .right out [outer] knee .Pressure .Length 2.8 .Width 2.6 .Depth 0.2 .Stage III [3] .Observed new wound this am [morning] to residents [resident's] right outer knee .tend [tends] to lay her right knee on its outer side .[Named Wound Care Company] to evaluate on Wednesday . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound pressure .cleanse right out [outer] knee wound with dwc/ns [wound cleanser/normal saline], apply santyl, silver alg [alginate], and secure with protective dressing every 1 hour as need [needed] AND every day shift . Review of a (Named Wound Care Company) Note dated 8/3/2022, revealed the new wound to the right knee was not identified during the Wound Care Physician's visit. Review of a (Named Wound Care Company) Note dated 8/10/2022, revealed .UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT, LATERAL KNEE FULL THICKNESS .Remove Necrotic Tissue and Established Margins of Viable Tissue . During an interview on 8/19/2022 at 2:40 PM, Wound Care Nurse #1 stated it [the pressure ulcer to the right lateral knee] looked like a large bunion on the side of her leg . The Wound Care Nurse was asked if she had completed a skin assessment and documented her findings. The Wound Care Nurse stated, .No I did not document anything . Observation in the resident's room on 8/19/2022 at 3:10 PM, with the Wound Care Nurse #1, revealed an open area approximately a half dollar size to the left lateral side of the leg just below the knee with a small amount of slough in the wound bed. There was no dressing covering the wound. During an interview on 8/19/2022 at 3:29 PM, Wound Care Nurse #2 confirmed the wound was identified on 8/1/2022 as a Stage 3 pressure ulcer. Wound Care Nurse #2 confirmed during a skin assessment on 8/1/2022, she staged the wound as a stage 3 that was open with granulation tissue and slough in the wound bed. Wound Care Nurse #2 confirmed the wound was not assessed by the Wound Care Physician until 8/10/2022 and he identified the wound as unstageable on that day. During an interview on 8/19/2022 at 3:50 PM, the Wound Care Physician confirmed he did not see the wound on 8/3/2022. The Wound Care Physician confirmed when he saw the wound he could not tell the depth and staged it as an unstageable. The Wound Care Physician confirmed it was ideal to identify a wound at a stage 1 or stage 2 and stated, .you should see some indication early that something is going on . During an interview on 8/19/2022 at 6:57 PM, the Regional Nurse Consultant confirmed a wound should be identified as early as possible at a stage 1 or 2. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99.

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #42) reviewed with in-house acquired pressure ulcers. The facility's failure to notify the Wound Care Nurse of skin condition changes/redness and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough [dead tissue] may be present .May include undermining and tunneling .Category/Stage IV [4] : Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar [a thick crust of dead tissue] may be present .Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed . Review of the facility's policy titled, .Skin Integrity Management System, dated 2/24/2021, revealed .If a new pressure injury is noted .Notification of Physician and Responsible Party will be documented in the Progress Notes .Contact Physician for treatment recommendation approval . Review of the facility's undated policy titled, .Wound Treatment Management, revealed .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse Practitioner Note dated 6/17/2022, revealed .no skin wound . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had a pressure relieving device for the bed. Review of a quarterly Braden Scale dated 6/30/2022, revealed Resident #42 was at moderate risk for developing pressure ulcers. Review of a Nurses' Progress Note dated 7/9/2022 at 5:55 PM, written by Agency Licensed Practical Nurse (LPN) #7, revealed .while completing rounds, CNA [Certified Nursing Assistant] discovered wound to right buttock. CNA noticed that bed air mattress was turned off. Notified wound care nurse . Review of a Nurses' Progress Note dated 7/9/2022 at 7:00 PM, written by Agency LPN #7, revealed .Wound is 4 cm [centimeters] in length and 4.5 cm in width . There was no documentation of a description of the wound or a stage of the wound. Review of the Weekly Wound Progress notes revealed no documentation that the Physician or the Responsible Party (RP) were notified about the new pressure wound on 7/9/2022. Review of a Nurses' Progress Note dated 7/11/2022, written by Wound Care Nurse #2, revealed, .Notified by ADON [Assistant Director of Nursing] of residents wound to R [Right] buttocks .MD [Medical Doctor] made aware with new orders to cleanse R buttocks with dwc [wound cleanser], apply santyl, calcium alg [alginate] [absorbs wound drainage and provides a moist environment for wound healing], and secure with protective dressing daily and PRN (as needed) .Tx [Treatment] completed per MD orders. [Named Responsible Party] contacted and voiced understanding and stated she would tell Responsible Party . The Physician and RP were not notified until 7/11/2022. Review of a Weekly Wound Progress Note written by Wound Care Nurse #2, dated 7/11/2022, revealed, .Site .R buttocks .Type .Pressure .Length .4.0 [centimeters] .Width .4.5 [centimeters] .Depth 0.1 [centimeters] .Stage .Unstageable .Necrotic tissue present .Acquired in Facility .MD notified .RP notified . The MD (for treatment orders) and the RP were not notified until 2 days after the wound was discovered. Review of a Physicians' Order dated 7/11/2022, revealed .Wound Pressure .cleanse R buttock wound with dwc .apply santyl, calcium alg, and secure with protective dressing .every day shift . Review of the medical record revealed there was no other order for the Right buttock wound prior to 7/11/2022. Review of a Late Entry Nurses' Progress Note, written by Wound Care Nurse #1, revealed the note was written on 7/15/2022 with an effective date of 7/9/2022 and documented, .Received report of incident that resident obtained wound to sacral region. Treatment started of Calcium Alginate with santyl [ointment that removes dead tissue from wounds] and dry protective dressing daily . Review of a Weekly Wound Progress Note dated 8/17/2022, revealed .Site .R buttocks .Type .Pressure .Length .2.8 [centimeters] .Width .4.2 [centimeters] .Depth 0.5 [centimeters] .Stage .IV [4] .Granulation tissue present .Slough tissue present .Necrotic tissue present . Observation in the resident's room on 8/17/2022 at 1:00 PM, revealed Wound Care Nurse #2 removed the dressing to Resident #42's right buttock to reveal a Stage 4 Pressure Ulcer approximately 3 centimeters long and 4 centimeters wide with a depth of 0.5 centimeter. During a telephone interview on 8/19/2022 at 11:48 AM, LPN #5 confirmed she had taken care of Resident #42 on 7/7/2022, and she had no skin breakdown. She stated, .I would have shown it [skin breakdown] to the nurse .when I came back on the 8th [7/8/2022] she was already gone to the Covid Unit . During an interview on 8/19/2022 at 12:01 PM, LPN #1 confirmed she had moved Resident #42 to the Covid Unit on 7/8/2022, and she had no skin breakdown. During an interview on 8/19/2022 at 2:26 PM, CNA #1 confirmed she worked the 7:00 PM to 7:00 AM shift on 7/8/2022. She confirmed she could not remember the name of the CNA that relieved her, but after report they made rounds together. She stated, I went in .she [Resident #42] was slumped down in the bed .the air mattress motor was turned off. She was sunk in .the mattress had deflated down. I put my hand on the end of the bed to feel the mattress, and I felt the hard metal under the mattress where there was no air it was hard .I flipped it back on. I stayed and watched the mattress fully inflate .we turned her over and looked at her right side .where she was laying and the whole hip and leg was real red all the way down from laying so long. We positioned her and put a pillow between her legs, and it was time for shift to end, and I left . There was no documentation of the redness or that a nurse was notified of the redness in the medical record. During a telephone interview on 8/19/2022 at 6:02 PM, Agency LPN #7 confirmed she assessed the wound and stated, It looked black, it felt like dead tissue, mushy, no drainage . During an interview on 8/19/2022 at 6:18 PM, the Administrator confirmed Wound Care Nurse #1 had left before her shift was supposed to end on 8/19/2022 and was scheduled to work from 7:00 AM to 7:00 PM. Wound Care Nurse #1 was not available for interview in person or by telephone. During a telephone interview on 8/19/2022 at 6:20 PM, Wound Care Nurse #2 stated, .That Monday [7/11/2022], I came in, I was notified by the ADON [Assistant Director of Nursing] of [Named Resident #42]'s wound. I got the order for wound care. She was asked if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, I don't see one in there. I would have gotten the order from [Named MD]. I usually get the order from them . During an interview on 8/19/2022 at 6:51 PM, the Director of Nursing (DON) was asked when the treatment order was obtained for Resident #42's wound that was identified on 7/9/2022. She stated, Monday, 7/11/2022. She was asked when the order should have been obtained. She stated, Immediately .I did not find out until Monday [7/11/2022], we read it in the morning report in the notes .we saw [Named Agency LPN #7]'s notes, we started investigating. She was asked when she should have been notified about the wound. She stated, Immediately . During an interview on 8/19/2022 at 7:38 PM, ADON #2 confirmed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to notify the nurse of skin condition changes and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 11 of 144 staff members (Agency Licensed Practical Nurse (LPN) #2, #3, #4, #5 and #6, Certified Nursing Assistant (CNA) #1, #3, and #4, Agency CNA #1, #2, and #3) failed to complete screening for the prevention and detection of COVID-19 prior to working on 3 of 3 days (8/12/2022, 8/13/2022, and 8/14/2022) reviewed, when 2 of 5 nurses (Agency LPN #1 and LPN #2) failed to discard a lancet in the sharps container and failed to clean the inhaler mouth piece after use, and when 1 of 1 CNA (Restorative CNA #1) failed to clean the reusable equipment (resident lift) after use. This had the potential to affect the 111 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the facility's policy titled, Sign-In Kiosks, dated 2/1/2022, revealed .In an ongoing response to the current coronavirus (COVID-19) pandemic, this community has implemented the use of the Sign-in Kiosks to perform symptom screenings of staff .upon entry into the building .staff sign-in kiosk to record the body temperature of all those entering the facility and ask COVID-19 related screening questions before any person is permitted to enter the community . Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered .in a manner to prevent contamination or infection .Metered dose inhalers .follow manufacturer's product information for administration instructions . Review of the facility's undated policy titled, Administration of Injections, revealed .Dispose of sharps in puncture-resistant containers . Review of the facility's undated policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Resident-care equipment can be source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . Random observation on 8/15/2022 at 10:15 AM, revealed a sign posted at the front entrance requiring all staff and visitors to sign in at the Kiosk. Review of the Employee Screening logs and employee time sheets revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 8/12/2022- Agency LPN #3 and #6, CNA #1 and #3. b. 8/13/2022- Agency LPN #5, and #6, CNA #4, and Agency CNA #3. c. 8/14/2022- Agency LPN #2 and #4, CNA #3, Agency CNA #1 and #2. During an interview on 8/19/2022 at 5:06 PM, Assistant Director of Nursing (ADON) #1 reviewed the employee schedules, screening logs, and time sheets for 8/12/2022, 8/13/2022 and 8/14/2022, and confirmed all staff should screen in before entering the patient care area and confirmed these 11 staff members did not screen. During an interview on 8/19/2022 at 7:07 PM, the Administrator and Regional Nurse Consultant confirmed all staff should screen for COVID-19 prior to working. Observation in the resident's room on 8/15/2022 at 11:38 AM, revealed Agency LPN #1 entered Resident #91's room, donned her gloves, checked the resident's blood glucose, put the lancet and strip in her gloves, and placed the gloves into the trash can in the resident's room. During an interview on 8/15/2022 at 11:40 AM, Agency LPN #1 confirmed she placed the lancet in her gloves and then put them in the trash can. During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant confirmed that, after using a lancet for glucose check, the lancet should go into a sharps container and should not be rolled up in the gloves and placed in the trash bin. Observation in the resident's room on 8/17/2022 at 8:52 AM, LPN #2 entered Resident #71's room, administered the inhaler medication to the resident, and failed to clean the mouth piece after the administration of the inhaler medication. LPN #2 then placed the uncleaned inhaler medication into the medication cart. During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed nursing staff should clean the mouth piece of an inhaler after each use. Observation in the resident's room on 8/17/2022 at 12:57 PM, revealed Restorative CNA #1 weighed Resident #7 using the lift. She then exited the room with the lift and placed the lift outside in the hallway next to Resident #64's room. Restorative CNA #1 failed to clean the lift after use. Observation in the resident's room on 8/17/2022 at 1:24 PM, revealed Restorative CNA #1 entered Resident #64's room with the lift without cleaning it. She exited Resident #64's room and placed the lift at the nursing station and failed to clean the lift after use. During an interview on 8/17/2022 at 1:24 PM, Restorative CNA #1 confirmed that she did not clean the equipment after each resident use. She stated the equipment is cleaned at the end of the shift. During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed the reusable equipment should be cleaned after each use.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when staff failed to provide privacy for 3 of 7 sampled residents (Resident #54, #57 and #91) reviewed during medication administration and when an indwelling urinary catheter was uncovered and visible to hallway traffic for 1 of 2 sampled residents (Resident #99) reviewed for urinary catheters. The findings include: Review of the facility's undated policy titled, .Medication Administration, revealed .Provide privacy . Review of the facility's undated policy titled, .Resident Rights, revealed .The resident has a right to be treated with respect and dignity . Observation in the resident's room on 8/15/2022 at 11:37 AM, revealed Licensed Practical Nurse (LPN) #1 exposed Resident #91's abdomen during insulin administration, the door to the room was open and the privacy curtain was not pulled. LPN #1 did not provide privacy for Resident #91 during insulin administration. The resident's abdomen would be visible to anyone walking in the hallway. Observation in the resident's room on 8/16/2022 at 4:05 PM, revealed LPN #1 did not pull the privacy curtain for Resident #54 and administered a medication patch to Resident #54's chest, exposing the right upper chest. LPN #1 did not provide privacy for Resident #54 during administration of a medicated patch. The resident's chest would be visible to anyone walking in the hallway. Observation in the resident's room on 8/17/2022 at 8:40 AM, revealed LPN #2 did not pull the privacy curtain and exposed Resident #57's lower back when applying a medication patch. The resident's lower back would be visible to anyone walking in the hallway. During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant was asked if a nurse should provide privacy when exposing a resident's body to administer an injection or to apply a medication patch. The Regional Nurse Consultant stated, Yes. Review of the medical record, revealed Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physicians Orders dated 7/22/2022, revealed .catheter . Observation in the resident's room on 8/15/2022 at 9:48 AM, revealed Resident #99 had an indwelling urinary catheter bag that was on the left side of the bed, uncovered, facing the door and visible from the hallway with approximately 20 milliliters of amber urine in the catheter bag. Observation in the resident's room on 8/16/2022 at 9:43 AM at 2:06 PM, revealed Resident #99's indwelling urinary catheter bag was on the left side of the bed, uncovered, facing the door and visible from the hallway with urine visible in the bag. During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed the indwelling catheter bag should be covered.

Based on the Board of Examiners of Nursing Home Administrators (BENHA) form review, job description review, medical record review, observation, and interview, facility Administration failed to ensure a safe environment that provided supervision to eliminate an incident of entrapment, 2 incidents of elopement, and an incident of unsupervised smoking, failed to thoroughly investigate an injury of unknown origin, and failed to timely report and thoroughly investigate the entrapment, elopements, and unsupervised smoking to the State Survey Agency. The facility's failure to ensure a safe environment that provided supervision and failure to thoroughly investigate and report these incidents resulted in Immediate Jeopardy (IJ) when Resident #1 expired while entrapped in a grab bar, when Resident #3, a vulnerable and cognitively impaired resident was found with an injury of unknown origin, when Resident #4 traveled to an unsafe area of the facility and was found unsupervised in the facility parking lot lying face down on the concrete pavement, when Resident #6, a vulnerable resident assessed to be cognitively impaired, exited through a door, and was found 33 feet from the door of the facility, and when Resident #7 was located outside the facility on the back patio unsupervised sleeping with a burning cigarette in his hand. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and the Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on [DATE] at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-700, F-835, F-837, and F-867. The facility was cited at F-700 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-609, F-610 and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 9:20 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's BENHA form revealed the facility has had 2 Administrators since [DATE]. Review of the facility's Nursing Home Administrator job description revised on ,[DATE], showed, .To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities .Monitor each department's activities, communicate policies .Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .Consult with department managers concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Protect residents from neglect, mistreatment, and abuse .Comply with the Residents' Rights and Facility Policies and Procedures . Review of the facility's Director of Nursing job description revised on ,[DATE], showed, .To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .In the absence of the Administrator and Assistant Administrator .assume responsibility of the facility .Monitor the Level of Care Reports .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing department .Meet monthly with nursing staff regarding Chart Audit and physician's orders [REDACTED].Interview, orient, train, evaluate and supervise nursing department personnel .Delegate to nursing services supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guideline .Perform nursing services and deliver resident care services in compliance with Corporate policies and State and Federal regulation .Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the residents request .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Monitor nursing service personnel to verify that they are following established safety regulation in the use of equipment and supplies .Assure residents a comfortable, clean, orderly and safe environment .Monitor stock level of .medical supplies, equipment .to verify they are maintained on premises at all times to adequately meet the needs of the resident .Create and implement procedures for department equipment to be operated only by trained, authorized personnel in a safe manner .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines .Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Health Status Note dated [DATE], showed, .This nurse was called to room at approx. (approximately) 1530 (3:30 PM) by (named Registered Nurse (RN) #1). Pt. (Patient) found unresponsive, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directive and signed DNR (Do Not Resuscitate) order in chair (chart). Death pronounced by (Named RN #1) at 1540 (3:40 PM). This nurse did contact .resident's (family member) was able to visit resident . During an interview on [DATE] at 2:15 PM, Confidential Interviewee (employee) #1 stated he/she saw Resident #1 hanging off the bed with her legs caught in the overbed table, and her neck was pinned between the mattress and the grab bar. During an interview on [DATE] at 3:45 PM, Maintenance Staff #2 was asked if the facility monitors residents' beds for safety. He stated, Yes, we do .check every function of the bed. If someone leaves, we go and check everything on the bed . Maintenance Staff #2 was asked about the bed safety checks following the accident with Resident #1. He stated, We had to go through and check every single bed .We checked every aspect of the bed .I don't know about the mattress, that is environmental services .We take care of the frame they take care of the mattress . During a telephone interview on [DATE] at 1:29 PM, Resident #1's physician stated she received a text notifying her that Resident #1 had died . Resident #1's physician looked up the text on her phone and stated, It was a text at 5:38 PM, (Named Resident #1) expired (died ). Resident #1's physician confirmed she was not told about the circumstances surrounding Resident #1's death. Resident #1's physician was asked if she should have been told about the circumstances surrounding the death. Resident #1's physician stated, .if they (staff) think something is questionable, yeah, I think so. No one told me about that. They should have talked to the Medical Director. They should have let me know the circumstances about her death. During a telephone interview on [DATE] at 4:00 PM, the former Administrator (who had been employed at the facility from [DATE]-[DATE]) stated, .They said the patient had fallen in a weird position out of the bed. They were really nervous . He confirmed he and the DON came to the facility. He had Certified Nursing Assistant (CNA) #5 re-enact the scene and took some pictures. He stated that he sent that information to the corporate management team. The former Administrator was asked what the staff told him about Resident #1's position when they found her. He stated, .they told me she had trouble getting her feet out, tangled, couldn't get her out. The former Administrator stated, .I feel terrible .I get it .they may have been scared to tell me .the guidance I had, didn't know I had to report it. I know exactly how it looks . The former Administrator was asked if he should have reported the incident to the State Survey Agency. He stated, .If we reported, we were setting ourselves up for something worse .they asked me if I thought she had choked. I knew she was terminal. I had been there 7 days . During an interview on [DATE] at 12:51 PM, the Regional Director of Plant Operations, Maintenance Staff #1 and Maintenance Staff #2, confirmed they were not asked to check overbed tables for safety after the incident with Resident #1. During an interview on [DATE] at 3:00 PM, CNA #6 was asked if she had received in-service training about positioning or grab bars since the incident with Resident #1. She stated, Not that I can remember. During an interview on [DATE] at 3:10 PM, Licensed Practical Nurse (LPN) #3 was asked if he had received an in-service about positioning or grab bars following the incident with Resident #1. LPN #3 stated, No. During an interview on [DATE] at 12:10 PM, the Housekeeping Supervisor was asked if he was involved in checking the grab bars and mattresses. He stated, No. I wasn't instructed to. If I was instructed to, I would have. During a telephone interview on [DATE] at 5:07 PM, RN #1 was asked if she had received in-services after the incident with Resident #1. She stated, I heard a staff in-service called over the intercom. I was busy with care and couldn't attend at that moment. After I was finished with resident care .I went to the Staffing Development Coordinator and asked her if she could do the in-service for me. She told me she was not going to repeat, it was too much information. She handed me an in-service signature sheet and told me to use it to in-service staff on the information. I told her I hadn't gotten the information, because she didn't give me the in-service. During an interview on [DATE] at 3:42 PM, the Interim Administrator confirmed a conference call was held immediately after Resident #1's death The conference call included the DON, former Administrator, Weekend RN Supervisor, Vice President of Clinical Services, Regional Nurse Consultant, Regional Director of Operations, and Chief Operating Officer. The Interim Administrator confirmed neither the Medical Director nor Resident #1's physician participated in the conference call. During a telephone interview on [DATE] at 8:13 AM, Confidential Interviewee (employee) #2 confirmed she was asked to come to Resident #1's room on [DATE]. She went to the room and saw Resident #1 on her knees on the floor with her head stuck in the grab bars, and the nurse was trying to get her out. She stated, .by the time they got her head out, they said she took her last breath. There was no statement in the investigation from this eyewitness. During an interview on [DATE] at 1:41 PM, the DON was asked what she considered to be an unusual incident. She stated, A fall in a questionable position, something I cannot explain. The DON was asked if Resident #1's physician should have received verbal notification of the circumstances surrounding Resident #1's death. She confirmed Resident #1's physician should have been involved in the investigation and stated, She should have been told the details. The DON was asked if the facility did a thorough investigation of the circumstances surrounding Resident #1's death. She stated, .It probably wasn't as thorough as it could have been .because of the way they (staff) stated she was laying .that's why I came. They notified me. They notified (Named Former Administrator) . The DON was asked what was immediately implemented after the event with Resident #1. She stated, Because of the possibility that anything could have happened with that grab bar on there, it became real that this could be a really serious problem. So, we assessed the grab bars, measured (grab bars), we in-serviced, brought it up in the IDT (Interdisciplinary Team) meeting Monday morning. Maintenance got (Named RN #1's) list (list of grab bars) and did the full building .then therapy did all new assessments right after that. She confirmed that once therapy made the recommendations on which residents no longer met the grab bar criteria, Maintenance was to remove those grab bars. During an interview on [DATE] at 1:51 PM, the DON confirmed the Rehabilitation Manager had re-screened the residents listed on the handwritten list of residents selected for grab bar removal. She stated, When she brought it to the meeting, it wasn't because there was any danger or something wrong with them. But we know they can be dangerous, possibility. The DON was asked how long it should take to implement a recommendation made by the Rehabilitation Manager. She stated, It does not usually take long .We implemented it in IDT. I wouldn't say immediate, I didn't feel like the rails had done anything, if they don't need them, let's just don't have them there. The DON was asked when the removal of the grab bars was completed. The DON stated, It's just now been completed, this week. During an interview on [DATE] at 3:24 PM, the Interim Administrator was asked when the grab bars were removed from resident beds who didn't meet the criteria, according to the Rehabilitation Manager's [DATE] - [DATE] screening. She confirmed they started taking them off this week (the week of [DATE]). The facility failed to remove the grab bars that had been identified as no longer appropriate by the Rehabilitation Manager on the [DATE]-[DATE] screening until after the surveyors entered the facility on [DATE]. All of the grab bars were not removed until [DATE]. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Health Status Note dated [DATE], showed, NEW SKIN TEAR TO RIGHT SHOULDER BROUGHT TO MY ATTENTION BY Certified Nursing Assistant. 7.5 X (times) 0.2. WAS ABLE TO PULL SKIN BACK TOGETHER, X 8 STERI-STRIPS ARE NOW IN PLACE . During an interview in Resident #3's room on [DATE] at 1:50 PM, Maintenance Staff #2 was asked to look at Resident #3's bilateral upper grab bars. He was asked if the foam was safe and secure. Maintenance Staff #2 stated, It's been on there a long time .that tape can cause skin tears . During an interview on [DATE] at 3:40 PM, LPN #4 confirmed she had assessed a new skin tear to Resident #3's right upper arm and had applied 8 steri-strips to the skin tear. She confirmed the skin tear was unwitnessed. During an interview on [DATE] at 10:04 AM, the DON confirmed Resident #3's skin tear that was identified on [DATE] had not been investigated. The DON was asked about Resident #3's bilateral grab bars. The DON stated, .they were bad .I saw them .they were ragged . During an interview on [DATE] at 11:04 AM, the Assistant Director of Nursing (ADON) confirmed the facility did not start an investigation into Resident #3's skin tear on her right upper arm until [DATE], and it should have been investigated when the skin tear was discovered on [DATE]. The ADON stated, .it just got missed . The facility was unable to provide documentation that a thorough investigation was conducted to determine the cause of the injury of unknown origin and to rule out abuse for Resident #3. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #4's Incident Note dated [DATE], showed, Resident got through main entrance doors; 1st set of doors did not alarm. Alarmed (alarm) sounded to entry doors in front lobby. resident noted going through main entrance door; nurse ran after resident. once outside nurse noted resident laying on gravel; to left side and w/c (wheelchair) flipped over. resident assisted back into chair and back into facility. resident noted with a large hematoma (a collection of blood outside of blood vessels caused by an injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues) to forehead; Golf ball size. bruising noted to nose . Review of a Witnessed Fall Report dated [DATE] showed, .alarm sounded. Noted resident (Resident #4) going through main entrance door; ran after resident. Noted resident laying on gravel; to left side. This note was signed by LPN #1. There was no investigation included on this report. During an interview on [DATE] at 1:18 PM, the DON was asked if a resident exited the building, would that be something she would investigate. She stated, Yes. (Named Resident #4) rolled through the front door, but she was in the view of a staff member. She rolled through the double doors, touched these doors, and dipped .confused, she rolled so quickly, they could not get to her fast enough before she fell . They were right there, running behind her. The DON was asked if she did a full investigation of the elopement. The DON stated, We saw her, they watched her roll out that door. The DON was asked if she could provide a copy of the investigation. She stated, It's different now, it's right there in the chart. The DON pointed to the Witnessed Fall Report and confirmed that was the investigation. The DON was asked if she obtained witness statements. The DON pointed to the [DATE] Witnessed Fall Report signed by LPN #1, and stated, It's right there. There was one statement on this report written by LPN #1. There was one statement on this fall report and there was no investigation on this Fall Report. During a telephone interview on [DATE] at 7:45 AM, LPN #1 confirmed he worked the night shift the morning Resident #4 eloped. He stated, .I was sitting at the nurses' station. I knew she had been in her chair rolling around, she does that. She had gotten to the double doors (double doors that lead into the lobby area) right beside the nurse's station. I'm sitting in my chair. My chair is facing the opposite way, and my back was to those double doors. I heard the alarm go off. I got up and looked at the lights (lights on a panel at the nurses' station that show where a door has been breached by a resident) and it says front door. I opened the first set of double doors. The sliding doors are completely open .By the time I saw her, she was off to the left. Her wheelchair was flipped on its side and she was lying on her side. There was about a 6-inch curb she went over. I didn't realize she had gotten out until the alarm sounded for the front door. He confirmed he did not see her go through the first set of double doors into the lobby area. He stated, First set should just lock down. I didn't realize the gravity of the situation until I saw her going out the sliding doors. I didn't think she could get through . During a telephone interview on [DATE] at 12:50 PM, the Maintenance Director was asked if he had identified any problems with the double doors leading to the lobby area. He stated that a week prior to Resident #4's elopement, a storm came through that interfered with the code alerts for the Wanderguards. He stated, I did tweak that one (the one for the double doors) the week before. I turned down the antenna just a fraction .sensitivity was high .turned it down a little bit. When we found out what had happened (with Resident #4) we were going a completely different route. The Mag (Magnetic) locks have a code to get through, now. The Maintenance Director Confirmed he was the only staff with access to the video recordings. During a telephone interview on [DATE] at 4:00 PM the former Administrator was asked if he had been notified of Resident #4's elopement. He stated, .said she went through the front doors . The former Administrator was asked if Resident #4 had a wander guard. He stated, I don't know. He was asked if he watched the video recording of the incident. He stated, No, Ma'am. He confirmed the facility did not do a thorough investigation of the incident and the facility did not report it to the State Agency. He stated, .debated whether we had to .there was a discussion with corporate not to report it. It was a group decision .went with the group decision. During observations and interview on [DATE] at 12:30 PM, the Regional Maintenance Director, Maintenance Staff #1, and Maintenance Staff #2 demonstrated how the door alarm system works. The Regional Maintenance Director and Maintenance Staff #1 showed the double doors that lead out into the lobby area and both confirmed the lobby area was not a safe area for residents to go without supervision. The Regional Maintenance Director showed a keypad used for the activation of the double doors and confirmed that no one would be able to get through the double doors now without putting in a code on the keypad. The Regional Maintenance Director was asked if anyone could get through the double doors prior to the keypad being installed. The Regional Maintenance Director stated anyone not wearing a Wanderguard could have gotten through those doors before the incident. The Regional Maintenance Director confirmed the keypad was added after Resident #4 eloped. Maintenance Staff #2 demonstrated how the lobby exit door would alarm once a resident wearing a Wanderguard passed through the doors. He confirmed that by the time the alarm was sounding, the resident with a Wanderguard would have already passed through the doors. During a telephone interview on [DATE] at 3:17 PM, the Maintenance Director confirmed he had seen video footage of Resident #4 leaving the building. The Maintenance Director was asked if the video footage of the incident had been saved. The Maintenance Director confirmed it had not been saved and stated, I never was asked to. The Maintenance Director was asked to give a step by step account of what he saw on the video. He confirmed no one was with Resident #4 when she went through the front door and propelled herself in her wheelchair outside the building. He stated, .Her wheelchair rolled to the left .she was off a little, and the first wheel dipped her off and pitched her forward. She was lying on the concrete, and then it shows the nurse running down the hall . The Maintenance Director confirmed Resident #4 was alone from the time she went through the front door until the nurse ran down the hall and outside to find her lying on the concrete driveway. During an interview on [DATE] at 5:52 PM, the DON was asked if she had looked at the video footage of Resident #4 leaving the facility. She stated, No. I never knew it existed. During a telephone interview on [DATE] at 7:53 AM, RN #4 confirmed she was working the night shift the morning Resident #4 eloped. RN #4 was asked if she knew Resident #4 had left the building. RN #4 stated, No, until after the fact . Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Incident Note dated [DATE], showed, .Resident noted to have increased confusion prior to incident. Multiple exit seeking behaviors this shift. Fire alarm was set off after dinner .Found emergency exit at end of 200 hall open and patient wandering outside of building with pocket book (pocketbook) and non slip (non-slip) socks on. Patient redirected back into building with wheelchair . Observation on [DATE] at 1:13 PM, showed there was an exit door at the end of the 200 Hall. LPN #5 showed the area where Resident #6 was found after she got out of the building. The Regional Director of Plant Operations used a rolling measuring device to measure the area from the exit door to the area where Resident #6 was found. The area was 33 feet from the exit door. The Regional Director of Plant Operations used a rolling measuring device to measure the area from the area where Resident #6 was found to a nearby heavily wooded area. The distance was 38 feet. During a telephone interview on [DATE] at 5:32 PM, the Medical Director was asked if the facility should have completed a thorough investigation after Resident #6's elopement. The Medical Director stated, Yes. During an interview on [DATE] at 10:55 AM, the Interim Administrator confirmed the last time Resident #6 was seen was at 6:20 PM. She confirmed the fire alarm went off at 6:55 PM. Resident #6 was found outside on the sidewalk at approximately 7:00 PM. 40 minutes had passed between the time Resident #6 was last seen by staff and the time she was found outside the facility. During a telephone interview on [DATE] at 11:05 AM, CNA #3 stated, .I was facing the hall .she just snuck past me .she was on a roll .she was going in other resident's room .start searching for her .saw back door was cracked .she was there on the sidewalk .almost around the corner . During an interview on [DATE] at 1:42 PM, the DON confirmed the facility did not complete a thorough investigation after Resident #6's elopement. Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Behavior Note dated [DATE] at 2:51 PM, showed, .Resident was observed on the back patio smoking a cigarette unattended after the approved smoke break. Staff member that supervised the smoke break stated that (named Resident #7) missed the 2:30 PM smoke break . During a telephone interview on [DATE] at 7:29 AM, CNA #1 confirmed she was outside smoking when Resident #7 rolled out on the patio in his wheelchair. She stated, I went in and got him a cigarette. I put mine out in one can, and he put his out in the other can. I thought he put his out, so I came in, and he stayed out on the back patio. CNA #1 confirmed the last time she saw him was between 2:40 and 2:50 PM. When CNA #1 was asked how long Resident #7 was unsupervised on the patio, she stated she did not know. CNA #1 was asked if a Resident should be on the back patio, asleep, with a burning cigarette in their hand. She stated, No, Ma'am. During a telephone interview on [DATE] at 12:14 PM, RN #1 confirmed she had found Resident #7 sitting outside and unsupervised on the patio on [DATE], asleep, holding a burning cigarette in his hand. RN #1 was asked if she had performed a head to toe assessment on Resident #7 after she found him smoking alone outside. She stated, No. During an interview on [DATE] at 1:40 PM, The DON was asked if she had reviewed the [DATE] Behavior note for Resident #7. The DON stated, .for some reason I did not read that one .I don't know what happened there. The DON was asked for the investigation of the unsupervised smoking of Resident #7. The DON stated, .Nothing at the time because I didn't know . The DON was asked if the facility had a Quality Assurance Performance Improvement (QAPI) meeting after the entrapment and the 2 elopements. She stated, .no, the former Administrator was talking about it, we needed to sit down, but we have not scheduled it . The DON was asked if the facility had identified concerns for the time period of [DATE]-[DATE], since an entrapment and 2 elopements occurred during that time period. The DON stated, I don't know that I could put my finger on it . The DON was asked when the facility had conducted a QA review of the medical records for Resident #1, #3, #4, #6, and #7. The DON stated, This week. The DON was asked if the facility had identified any problems or concerns with communication between administration, staff, and other departments. She stated, Yes, I think there has been a lack of communication. During an interview on [DATE] at 3:24 PM, the Interim Administrator confirmed the facility did not do a thorough investigation on Resident #1's entrapment, Resident #3's injury of unknown origin, Resident #4 and #6's elopement and Resident #7's unsupervised smoking. The Interim Administrator stated, We do admit we did not do a thorough investigation .we should have done more . Refer to F-609, F-610, F-689, and F-867 The surveyors verified the Removal Plan by: 1. On [DATE], the QAPI team reviewed and revised the Daily QA Meeting (Monday - Friday) format. The 24-hour shift report, RN supervisor notebook, and electronic documentation, and progress notes will be reviewed at each meeting with documentation from Friday - Monday morning reviewed on Mondays. All Maintenance requests in (Named Maintenance Computer Program) will be reviewed to ensure audits and bed rail changes were added in the (Named Maintenance Computer Program), completed and documented to improve communication with implementation of removing or adding a bed rail and completing a safety inspection. to ensure proper oversight of nursing and facility staff, oversight of maintenance services related to resident equipment safety and security. The surveyors made observations of the computer demonstration of the QA format, interviewed the DON and Interim Administrator, made observations of the (Named Maintenance Computer Program) system and interviewed the Maintenance Director. 2. On [DATE], the Regional Nurse Consultant or designee educated the facility leadership team regarding the updated policies and corresponding tools. Tools to assist with investigation and determination of reporting status were included along with a post-test to verify understanding. The Director of Nursing or designee educated current staff, prior to their next scheduled shift on wandering, elopement, and resident safety. Any staff on leave will receive education on their next scheduled workday. New hires will receive education on the abuse policy, wandering and elopement policy, incident reporting policy, incident investigation policy, and the smoking policy. These in-services will include review of policy and procedure with the use of post-test to gauge understanding. The surveyors reviewed the in-service sign in sheets, and interviewed staff on multiple shifts. 3. The Daily QA meeting copy will be shared to all participants after each morning meeting to improve communication. Regional Nurse Consultant, Regional Director of Plant Operations, Chief Operating Officer or designee will monitor facility Daily QA M(TRUNCATED)

Based on policy review, medical record review, observation, and interview, the facility failed to report an incident of entrapment which resulted in death for 1 of 5 sampled residents (Resident #1) reviewed for grab bar use, failed to report incidents of elopement for 2 of 4 sampled residents (Resident #4 and #6) reviewed for wandering behaviors and elopement, and failed to report an incident of alleged neglect of unsupervised smoking for 1 of 3 sampled residents (Resident #7) reviewed for smoking. The facility's failure to report alleged allegations of neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #1 died while entrapped in a grab bar, when Resident #4 exited the facility and was found unsupervised in the facility parking lot, when Resident #6 exited the facility, was found unsupervised 33 feet from the door of the facility, and when Resident #7 was unsupervised and sleeping with a burning cigarette in his hand. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and the Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on [DATE] at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 9:20 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's policy titled, ABUSE PREVENTION POLICY & (and) PROCEDURE, revised on ,[DATE], showed, .The purpose of the written Resident Abuse, Neglect and Misappropriation Prevention Program .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator (Administrator) of the facility, to the other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .All allegations of abuse will be reported within 2 hours to the state agency by the Administrator or designee. The completed investigation will be posted to the state agency website within 5 days . Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS - INVESTIGATING AND REPORTING, showed, .All accidents or incidents involving residents, employees, visitors, vendors .occurring at our facilities must be investigated and reported to the administrator (Administrator) .Regardless of how minor an accident or incident may be, including injuries of an unknown origin, it must be reported to the department supervisor as soon as the accident/incident is discovered .The nurse supervisor (Nurse Supervisor)/charge nurse (Charge Nurse) must be immediately informed of accidents or incidents .STEPS IN THE PROCEDURE .The Incident Report .Complete an Incident Report Form in PCC (abbreviation for Named electronic documentation system) .Complete all Medical Record and Resident Event Documentation .Complete the assessment of the resident .and complete information required and give a full description of the occurrence. Record time of incident, and describe exactly what occurred or was observed .Notify the physician, and document the name of the family member or responsible party who was contacted .Complete the report by signing the date and time completed .All incidents will be reported and reviewed by the Quality Assurance Committee .Recommendations and follow-up will be reported to the Quality Assurance Committee as appropriate .The attending physician or designee will be notified of resident accident/incidents at the time of occurrence .The Medical Director shall review all accident and incident reports .All recommendations will be reviewed by the Administrator and the Director of Nursing and appropriate action taken .report to state system . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Health Status Note dated [DATE], showed, .This nurse was called to room at approx. (approximately) 1530 (3:30 PM) by (named Registered Nurse (RN) #1). Pt. (patient) found unresponsive, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directive and signed DNR (Do Not Resuscitate) order in chair (chart) .Death pronounced by (named RN #1) at 1540 (3:40 PM) . Review of an Un-witnessed Fall Report for Resident #1 dated [DATE] showed, .This nurse was called to room at approx. (approximately) 1530 (3:30 PM) .by (Named RN #1). Pt. (Patient) found unresponsive, no respirations, no pulse, no heart or breath sounds .Resident was on kneeling knees with head on bed and feet towards door . During the an interview on [DATE] at 9:25 AM, the Administrator and DON were asked if they had any reportable incidents or any occurrences the facility had investigated. They stated they did not have anything outstanding . During an interview on [DATE] at 1:15 PM, the Administrator and DON were asked, a second time, for any outstanding investigations or incidents reported to the State Survey Agency. The Administrator and DON confirmed they had nothing since May, and that had been closed out (already investigated by the State Survey Agency). During an interview on [DATE] at 2:15 PM, Confidential Interviewee (employee) #1 stated he/she found Resident #1 in the resident's room with her neck pinned in between the mattress and the side rail (grab bar) of her bed. Confidential Interviewee #1 stated, She (Resident #1) couldn't move, she was on her knees on the floor with her neck caught between the rail (grab bar) and the mattress, but because of her weight it was a struggle to get her out from that rail (grab bar) . During an interview on [DATE] at 4:50 PM, Licensed Practical Nurse (LPN) #6 was asked if she was aware of any incidents that occurred on [DATE] on the 200 Hall. She confirmed she had been working on the 200 Hall that day, and stated, I do remember something about they said her (Resident #1's) head was lodged in the space between the mattress and the rail (grab bar). She confirmed she completed an Un-witnessed Fall Report and notified the physician and the family. During an interview on [DATE] at 12:45 PM, the DON and Interim Administrator presented documents related to Resident #1's incident, and both confirmed they had worked on it last night ([DATE]). The documents included a timeline, written by the Interim Administrator and was dated [DATE]. During a telephone interview on [DATE] at 4:00 PM, the former Administrator (who had been employed at the facility from [DATE]-[DATE]) stated, .They (staff) said the patient had fallen in a weird position out of the bed. They were really nervous . He confirmed he and the DON came to the facility. He had Certified Nursing Assistant (CNA) #5 re-enact the scene and took some pictures. He stated that he sent that information to the corporate management team. The former Administrator was asked what the staff told him about Resident #1's position when they found her. He stated, .they (staff) told me she had trouble getting her feet out, tangled, couldn't get her out. The former Administrator stated, .I feel terrible .I get it .they (staff) may have been scared to tell me .the guidance I had, didn't know I had to report it (entrapment). I know exactly how it looks . The former Administrator was asked if he should have reported the incident to the State Survey Agency. He stated, .If we reported, we were setting ourselves up for something worse .they asked me if I thought she had choked. I knew she was terminal. I had been there 7 days . During an interview on [DATE] at 3:42 PM, the Interim Administrator confirmed a conference call was held immediately after Resident #1's death The conference call included the DON, former Administrator, Weekend RN Supervisor, Vice President of Clinical Services, Regional Nurse Consultant, Regional Director of Operations, and Chief Operating Officer. The Interim Administrator confirmed neither the Medical Director nor Resident #1's physician participated in the conference call. During a telephone interview on [DATE] at 8:13 AM, Confidential Interviewee (employee) #2 stated he/she was asked to come to Resident #1's room on [DATE]. He/she went to the room and saw Resident #1 on her knees on the floor with her head stuck in the grab bar and the nurse was trying to get her out. He/she stated, .by the time they got her head out, they said she took her last breath. During an interview on [DATE] at 1:41 PM, the DON was asked what she considered to be an unusual incident. She stated, A fall in a questionable position, something I cannot explain. The DON stated that the facility had not reported Resident #1's death to the state. She stated that Resident #1's physician had not been told of the unusual circumstances surrounding Resident #1's death. The DON was asked if Resident #1's physician should have received verbal notification of the circumstances surrounding Resident #1's death. She confirmed Resident #1's physician should have been involved in the investigation and stated, She should have been told the details. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a Telehealth (examination performed by a practitioner remotely with a computer) progress note of the elopement incident dated [DATE], showed, .Notified patient (Resident #4) was with wheelchair outside and fell on to concrete outside; hit head. hematoma to forehead and bruised nose noted, no apparent deformities noted .Patient is alert and verbal, c/o (complains of) pain on her face, she does takes eliquis (anticoagulant medication used to prevent blood clots) .Neurochecks (an evaluation of the nervous system) started and monitoring. ice applied .will also obtain facial xray (x-ray) to rule-out nose injury . During a telephone interview on [DATE] at 7:45 AM, LPN #1 confirmed he worked the night shift the morning Resident #4 eloped. He stated, .I was sitting at the nurses' station. I knew she had been in her chair rolling around, she does that. She had gotten to the double doors (double doors that lead into the lobby area) right beside the nurse's station. I'm sitting in my chair. My chair is facing the opposite way, and my back was to those double doors. I heard the alarm go off. I got up and looked at the lights (lights on a panel at the nurses' station that show where a door has been breached by a resident) and it says front door. I opened the first set of double doors. The sliding doors are completely open .By the time I saw her, she was off to the left. Her wheelchair was flipped on its side and she was lying on her side. There was about a 6-inch curb she went over. I didn't realize she had gotten out until the alarm sounded for the front door. He confirmed he did not see her go through the first set of double doors into the lobby area. He stated, First set should just lock down. I didn't realize the gravity of the situation until I saw her going out the sliding doors. I didn't think she could get through . During a telephone interview on [DATE] at 4:00 PM, the former Administrator was asked if he was aware of Resident #4's elopement. He stated, .had maintenance adjust codes on the doors . He was asked if he watched the video footage for [DATE]. He stated he had not. He was asked if the facility reported the occurrence to the State Survey Agency. He stated, No, Ma'am .debated whether we had to do that .There was a discussion with Corporate not to report it. It was a group decision. During observation and interview on [DATE] at 12:30 PM, the Regional Maintenance Director, Maintenance Staff #1, and Maintenance Staff #2 demonstrated the door alarm system. The Regional Maintenance Director and Maintenance Staff #1 confirmed the lobby area was not a safe area for residents to go without supervision. He confirmed that by the time the alarm on the double doors sounded, a resident with a Wanderguard would have already gone through the doors. During a telephone interview on [DATE] at 3:17 PM, the Maintenance Director confirmed he had reviewed the video footage of Resident #4 leaving the building. The Maintenance Director stated the video footage of Resident #4 exiting the facility had not been retained and stated, I never was asked to retain it. The Maintenance Director confirmed on his review of the video footage, no one was with Resident #4 when she exited the front door in her wheelchair and propelled herself out of the building. He stated, .Her wheelchair rolled to the left .she was off a little, and the first wheel dipped her off and pitched her forward. She was lying on the concrete, and then it shows the nurse running down the hall . The Maintenance Director confirmed Resident #4 was alone from the time she went through the front door until the nurse ran down the hall and outside to find her lying on the concrete driveway. During an interview on [DATE] at 5:50 PM the DON was asked if she had seen the video of Resident #4's elopement. She stated, .no, I never knew it existed. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Incident Note dated [DATE], showed, .Resident noted to have increased confusion prior to incident. Multiple exit seeking behaviors this shift. Fire alarm was set off after dinner .Found emergency exit at end of 200 hall open and patient wandering outside of building with pocket book (pocketbook) and non slip (non-slip) socks on. Patient redirected back into building with wheelchair . During an interview on [DATE] at 5:41 PM, the DON was asked if resident elopements should be reported to the State Survey Agency. The DON stated she thought it had to be reported when a resident left the building and got off the premises. During a telephone interview on [DATE] at 5:32 PM, the Medical Director was asked if the facility should report an elopement to the State Survey Agency. The Medical Director stated, Yes. During an interview on [DATE] at 10:55 AM, the Interim Administrator confirmed the last time Resident #6 was observed by staff on [DATE] was 6:20 PM and the fire alarm sounded at 6:55 PM. Resident #6 was found outside on the sidewalk at approximately 7:00 PM. Resident #6 was not seen by facility staff for 40 minutes, was found at dusk, 33 feet from the exit door and 38 feet from a heavily wooded area. Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Behavior Note dated [DATE] at 2:51 PM, showed, .Resident was observed on the back patio smoking a cigarette unattended after the approved smoke break. Staff member that supervised the smoke break stated that (Named Resident #7) missed the 2:30 pm (PM) smoke break . During a telephone interview on [DATE] at 7:29 AM, CNA #1 confirmed she was outside smoking when Resident #7 rolled out on the patio in his wheelchair. She stated, I went in and got him a cigarette. I put mine out in one can, and he put his out in the other can. I thought he put his out, so I came in, and he stayed out on the back patio. CNA #1 confirmed the last time she saw him was between 2:40 PM and 2:50 PM. CNA #1 was asked how long Resident #7 was on the patio unsupervised. CNA #1 stated she did not know. CNA #1 was asked if a Resident should be on the back patio, asleep, with a burning cigarette in their hand. She stated, No, Ma'am. During a telephone interview on [DATE] at 12:14 PM, RN #1 confirmed she had found Resident #7 outside on the patio sleeping and holding a burning cigarette. He was alone and unsupervised. During an interview on [DATE] at 1:48 PM, the DON confirmed that she did not know that Resident #1 had been located alone on the back porch sleeping with a burning cigarette in his hand. The DON was asked if she had reviewed the Behavior Note in the electronic documentation system. She stated, For some reason, I did not read that one. I don't know what happened there. The DON confirmed the incident had not been reported to the State Survey Agency. During an interview on [DATE] at 1:52 PM, the DON was asked what incidents should be reported to the State Survey Agency. The DON stated, .now that I have learned from going to safe area to an unsafe area .in here with ya'll .in-serviced on it last night .any kind of unusual occurrence .I have learned so much this week .injury that I cannot figure out what happened .any suspected abuse During an interview on [DATE] at 3:24 PM, the Interim Administrator was asked if the facility reported Resident #1's entrapment, Resident #4 and #6's elopements, and Resident #7's unsupervised smoking. The Interim Administrator stated, We did not. Refer to F-610 and F-689. The surveyors verified the Removal Plan: 1. Resident #4 and #6 who eloped from the facility have no longstanding injury from the deficient practice. Resident #4 and #6's Care Plans were updated on or before [DATE] with interventions added to prevent further elopements. The surveyors reviewed the Care Plans. 2. Resident #7 had no injury from smoking unsupervised. Resident #7's room was searched for smoking items on [DATE] and none were identified. Assessment and Care Plan for Resident #7 was reviewed on [DATE] to address physical and cognitive factors affecting the ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions on [DATE]. The surveyors reviewed the assessment and the Care Plan. 3. On [DATE], the DON reviewed the RN shift supervisor book, 24-hour shift report, electronic medical record, and progress notes dating back to [DATE] to ensure no other reportable events or incidents were indicated. One incident was identified by the DON and a thorough investigation was completed by [DATE] to rule out injury of unknown origin. Interviewable residents were interviewed on [DATE] by Social Services to ensure no other reportable events were noted. One resident interviewed reported an allegation of misappropriation which was reported, investigated and resolved. The surveyors interviewed the DON and Social Worker. 4. On [DATE], the following policies were updated Unexplained Injuries, Elopements and Wandering, Abuse, Neglect, and Exploitation, Resident Abuse Prevention and Reporting, Accidents and Supervision, Compliance with Reporting Allegations of Abuse, Neglect and Exploitation, and QAPI (Quality Assurance Performance Improvement), to ensure proper reporting guidelines are met to include: what is reportable, to whom to report- Administrator, State Survey Agency, and other outside agencies as required, what time frame reporting is required- immediately but not later than 2 hours after the event is identified and results in serious bodily injury or no later than 24 hours if the event that caused the incident did not result in serious bodily injury. Corresponding tools were updated or added to ensure proper procedure is followed as it relates to reportable events. The surveyors reviewed the updated polices and tools. 5. On [DATE], the Regional Nurse Consultant educated the Administrator, DON, and Interdisciplinary Team members on updated policies. The surveyors interviewed the Interim Administrator and the DON. 6. The DON or designee educated current staff on updated policies and tools by [DATE]. The surveyors reviewed the in-service sign in sheets and interviewed staff on multiple shifts. 7. A book will be placed at the nurses' station with policies on reporting and investigating elopement, entrapment, smoking, and incidents of unknown origins with tools to assist staff. The surveyors verified the book with polices and updated tools was at the nurses' station. 8. On [DATE], the QAPI team reviewed and revised the QAPI Monday - Friday meeting format. The 24-hour shift report, RN Supervisor notebook, and electronic documentation will be reviewed at each QAPI meeting with documentation from Friday - Monday morning reviewed on Mondays. Elopements, incidents and accidents including possible entrapment and smoking supervision forms will be reviewed to ensure timely reporting guidelines were followed. The QAPI audit tool will be used by the QAPI team to ensure all elements of reporting are complete. The surveyors reviewed the revised QAPI format, audit tools, and interviewed the Interim Administrator, the DON, and Assistant Director of Nursing (ADON). 9. On [DATE], signage and education were initiated to update staff on change in Abuse Coordinator to the current Administrator. The surveyors reviewed in-service sign in sheets and interviewed staff on multiple shifts. 10. Administrator will report any suspected reportable events to the Governing Body immediately to ensure proper reporting procedure is followed. Regional Nurse Consultant, Regional Director of Plant Operations, Chief Operating Officer or designee will monitor facility Daily QA Meeting form to ensure proper reporting occurs. Monitoring will occur Monday-Friday for 2 weeks, weekly for 4 weeks, then monthly for 3 months or until compliance is maintained. Any events identified as reportable will be investigated thoroughly using updated investigation tools. Regional Nurse Consultant, Regional Director of Operations, Chief Operating Officer or designee will review reportable incident file to ensure all reporting guidelines were met, investigated completely and initiate immediate correction as indicated. All reportable events will be reviewed in facility Quality Assurance and Performance Improvement meeting consisting of at minimum, the Administrator, DON, Infection Preventionist and Medical Director, with attendance and input of other facility staff members as indicated. Findings will be reviewed in the QAPI meeting to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified. The surveyors reviewed the audit tools. Noncompliance of F-609 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, Interdisciplinary Team (IDT) meeting minutes review, and interview, the Governing Body failed to provide oversight to ensure systems and processes were developed and consistently followed for oversight of administration and nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by contract and permanent facility staff. The Governing Body failed to provide oversight that established and implemented policies and procedures to ensure a safe environment to eliminate an incident of entrapment, failed to thoroughly investigate and report an incident of entrapment for 1 of 5 sampled residents (Resident #1) reviewed for grab bar use, failed to investigate an injury of unknown origin for 1 of 3 sampled residents (Resident # 3) reviewed for injuries of unknown origin, failed to provide supervision, thoroughly investigate and report elopements for 2 of 4 sampled residents (Resident #4 and #6) reviewed for wandering behaviors and elopement, and failed to provide supervision and to investigate unsupervised smoking for 1 of 3 sampled residents (Resident #7) reviewed for smoking. The Governing Body failed to provide oversight and and failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was established which resulted in Immediate Jeopardy for Residents #1, #3, #4, #6, and #7. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and the Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on 10/10/2020 at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-700, F-835, F-837, and F-867. The facility was cited at F-700 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-609, F-610 and F-689 at a scope and severity of K, which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 10/16/2020 at 9:20 AM, and was validated onsite by the surveyors on 10/16/2020 through 10/18/2020 by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's undated policy titled, Governing Body showed, .The facility will have a governing body, or designated person functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility .The governing body will appoint an administrator who is .Responsible for management of the facility .Reports to and is accountable to the governing body .The governing body is responsible and accountable for the QAPI (Quality Assurance Performance Improvement) program .The governing body refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individual who are legally responsible to establish and implement policies regarding the management and operations of the facility .The governing body will have a process in place by which the administrator .Reports to the governing body .Method of communication between administrator and governing body .How the governing body responds back to the administrator .What specific types of problems and information .allegations of abuse or neglect, complaints .are reported or not reported .How the administrator is held accountable and reports information about the facility's management and operation .How the administrator and the governing body are involved with the facility wide assessment . Review of the facility's Nursing Home Administrator job description revised on 6/2006, showed, .To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in conjunction with facility's operational budget and state and federal regulations .Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies .Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .Consult with department managers concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Protect residents from neglect, mistreatment, and abuse .Comply with the Residents' Rights and Facility Policies and Procedures . Review of the facility's Director of Nursing job description revised on 6/2006, showed, .To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .In the absence of the Administrator and Assistant Administrator .assume responsibility of the facility .Monitor the Level of Care Reports, Dietary Consultant Reports, and Pharmacy Consultant Reports and take appropriate actions .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing department .Meet monthly with nursing staff regarding Chart Audit and physician's orders [REDACTED].Interview, orient, train, evaluate and supervise nursing department personnel .Delegate to nursing services supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guideline .Perform nursing services and deliver resident care services in compliance with Corporate policies and State and Federal regulations .Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Monitor nursing service personnel to verify that they are following established safety regulations in the use of equipment and supplies .Assure residents a comfortable, clean, orderly and safe environment .Monitor stock level of .medical supplies, equipment .to verify they are maintained on premises at all times to adequately meet the needs of the resident .Create and implement procedures for department equipment to be operated only by trained, authorized personnel in a safe manner .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines .Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided . Review of an Interdisciplinary Report (IDT) report titled, Meeting Summary, dated 8/16/2020, .Related to Investigation of Potential Entrapment .After the TI (Trends Identified) items have been listed, analyzed for the root cause, and scored on the Prioritization worksheet .List items in order of rank on this sheet with the highest score being number 1 .Then indicate if a PIP (Performance Improvement Process) is to be initiated .List items from Prioritization Worksheet .IDT met on 8/16/20 to investigate potential of entrapment .Team members include .(listed everyone present, including the Owner, Chief Operating Officer, and the Interim Administrator (Regional Director of Plant Operations) .Team discussed potential for entrapment. Investigation into resident (initials of Resident #1) determined no entrapment occurred .RN (Registered Nurse) Supervisor audited all beds on 8/16/2020. Maintenance Director to also complete full house audit on 8/17/2020 . The Medical Director and Resident #1's physician were not listed as attending the IDT meeting. During a phone interview on 10/2/2020 at 4:00 PM, the former Administrator (who had been employed at the facility from 8/7/2020-9/30/2020) was asked if he had been notified about Resident #4's elopement. He stated, .said she went through the front doors . The former Administrator was asked if Resident #4 had on a Wanderguard. He stated, I don't know. He was asked if he watched the video recording of the incident. He stated, No, Ma'am. He confirmed the facility did not do a thorough investigation of the incident and the facility did not report it to the State Agency. He stated, .debated whether we had to .there was a discussion with corporate not to report it. It was a group decision .went with the group decision. During an interview on 10/7/2020 at 3:42 PM, the Interim Administrator was asked if the Medical Director or Resident #1's physician attended the telephone IDT meeting on 8/16/2020. The Interim Administrator stated, No. The Interim Administrator/Regional Director of Operations confirmed the meeting summary was done afterward and stated, I prepared this form when I got here this week, Thursday . During a telephone interview on 10/8/2020 at 5:32 PM, the Medical Director was asked, have you ever met with the Governing Body. The Medical Director stated, I have met with some corporate .(named Interim Administrator) .one other lady .can't remember her name .a year ago .informal meeting . During an interview on 10/9/2020 at 3:24 PM, the Chief Operating Officer and Interim Administrator (Regional Director of Plant Operations) were asked if they determined a root cause of entrapment, elopements, and unsupervised smoking. The Chief Operating Officer stated, .(referring to Resident #1) the root cause she was end of life, she had [MEDICAL CONDITION], it was an anticipated death .(referring to Resident #4) Wanderguard did not function as it should .(referring to Resident #6) redirected .took her back to the room to her meal. Another intervention .should have tried something else .(referring to Resident #7). We should have made sure the cigarette was out . The Interim Administrator was asked to review the 8/16/2020 IDT Meeting Summary and was asked if there was TI items analysis during the meeting. She stated, No. She confirmed there was only one item listed and it was to investigate the potential of entrapment. She was asked if the IDT team initiated a PIP. She stated, It did not. During a telephone conference interview on 10/9/2020 at 3:40 PM, the Owner (by telephone), the Chief Operating Officer and the Interim Administrator (who is also the Regional Director of Plant Operations) were in attendance. The Owner confirmed 3 people comprised the Governing Body and named himself, the Chief Operating Officer, and the Regional Director of Plant Operations. The Owner stated, The governing body is myself and other people acting on my behalf. The Owner was asked how often he attended the Quality Assurance and Performance Improvement (QAPI) meetings. The Owner stated, .monthly or something similar. The Owner was asked when he was notified about the circumstances surrounding Resident #1's death. The Owner stated, I was notified that Sunday, it was text messages .we, at the time felt this was something that was expected .we felt the possibility she was trapped was ruled out. The Owner was asked when he was notified about the elopements. The Owner stated, I was not notified. The Owner was asked if he should have been notified about the elopements. He stated, Yes, on the elopements .I was not notified on all three, notified this week on elopement and smoking. The Owner was asked how often he visited the facility. The Owner stated he had been on the phone with the facility constantly during all of this. He stated, We haven't been in the building for a long time due to COVID . During an interview on 10/14/2020 at 2:34 PM, the DON confirmed the facility was purchased by (Named Company) on 1/1/2017 During a telephone interview on 10/14/2020 at 3:46 PM, the Interim Administrator was asked how often the corporate consultants had been in this facility since January of 2020. She stated, It would be hard to say, we don't have a calendar, we just started keeping one. I'd have to go through my emails. It's going to be difficult to pin that down. 1. The Governing Body failed to maintain oversight to provide consistent Administrative staff including an Administrator and Director of Nursing. Refer to F-835. 2. The Governing Body failed to maintain oversight and ensure a safe environment for residents to prevent entrapment resulting in death and resident elopements from a safe to an unsafe area and the Governing Body failed to provide oversight and implementation for the Administrative team for reporting and investigating incidents of Abuse/Neglect, Accidents and Injuries of Unknown Origin and Unusual Incidents. This failure resulted in Immediate Jeopardy to Resident #1, #3, #4, #6 and #7 when the facility failed to report and/or thoroughly investigate the incidents. Refer to F-609, F-610, F-689. 3. The Governing Body failed to ensure Administration provided oversight to implement facility policies related to Accident/Incident, Elopement and Wandering, Risk Management Process for investigation and root cause analysis, failed to provide oversight for resident alarm systems and failed to ensure the alarm systems were in working order at all times. Refer to F-689. 4. The Governing Body failed to provide oversight and assure the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was established which resulted in Immediate Jeopardy for Residents #1, #3, #4, #6, and #7. Refer to F-867. The surveyors verified the Removal Plan by: 1. On 10/14/2020, the facility has a Governing Body, or designated persons functioning as a Governing Body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body has reviewed and understands the Governing Body policy. The Quality Assurance and Performance Improvement (QAPI) team, to include the Medical Director, with input from the Governing Body, developed and implemented the policies and procedures below to identify issues, develop the corrective actions, and monitor for effectiveness. Policies Updated were: Abuse, Neglect, and Exploitation Tools: Abuse- Complainant Statement, Incident Investigation Checklist, Investigation Statement, Non-Witness Statement Compliance with Reporting Allegations of Abuse/Neglect Accidents and Supervision Tools: Incident Investigation Checklist, Investigation Statement, Non-Witness Statement, Incident Review Quality Assurance Form Fall Prevention Program Fall Risk Assessment Unexplained Injuries Tools: Resident Smoking Tools: Resident Smoke Break Attendance Proper Use of Side Rails Elopements and Wandering Residents Tools: Elopement Drill QAPI Daily Quality Assurance (QA) Meeting (with template) Tools: PIP Worksheet, Plan DO Study Act (PDSA) Planning Worksheet, Daily QA Meeting Sign-In Sheets The surveyors interviewed the Director of Nursing and the Assistant Director of Nursing and made observations of the new white board on the computer. 2. Findings are reported to the Quality Assurance and Performance Improvement team, to include at minimum the Medical Director, Administrator, Director of Nursing and Infection Preventionist with input from other facility staff as indicated, via new tool. Oversight of newly implemented policies as well as effectiveness of the facility's investigations, reportable incidents, adverse events will occur via Regional Nurse Consultant, Regional Director of Plant Operations, or Chief Operating Officer via regular facility visits, and The Daily QA meeting copy will be shared to all participants and Regional Nurse Consultant, Regional Director of Operations or Chief Operating Officer after each morning meeting to improve communication. Regional Nurse Consultant, Regional Director of Operations, Chief Operating Officer or designee will monitor facility Daily QA Meeting form and oversee Administration either remotely or in the facility to ensure proper oversight and follow through, any items requiring correction will be addressed. Monitoring will occur Monday-Friday for 2 weeks, weekly for 4 weeks, then monthly for 3 months or until compliance is maintained. Any issues identified as reportable, requiring further investigation, equipment safety/security risk to residents will be investigated thoroughly using updated policies and/or investigation tools. Regional Nurse Consultant, Regional Director of Operations, or Chief Operating Officer will guide immediate action for any events identified as requiring further intervention. All audits will be discussed at the QAPI meeting, overseen by Regional Nurse Consultant, Regional Director of Operations, or Chief Operating Officer, and consisting of at minimum the Medical Director, Administrator, Director of Nursing and Infection Preventionist with attendance and input from other facility staff as indicated. Findings will be reviewed in the QAPI meeting to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified for a minimum of three months or until the pattern of compliance is maintained. The surveyors interviewed the DON, Administrator, and reviewed the auditing tools. Noncompliance of F-837 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the policy review, the Administrator job description, the Director of Nursing job description, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to completion of grab bar/side rail safety assessments, developed plans of action and interventions for exit seeking behaviors and injuries of unknown origin, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to entrapment, injuries of unknown origin, elopement and resident smoking, failed to ensure the facility timely reported and thoroughly investigated incidents of entrapment, elopement, and unsupervised smoking, and failed to thoroughly investigate an injury of unknown origin. The QAPI committee failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure a safe environment resulted in Immediate Jeopardy (IJ) when Resident #1 died while entrapped in a grab bar, Resident #3 was found with a 7.5 inch skin tear to her right shoulder with no known origin, Resident #4 eloped from the facility in her wheelchair and was found lying on the concrete pavement in the facility parking lot, Resident #6 exited the building and was found 33 feet from the facility exit door, and Resident #7 was found outside, unsupervised on the backyard patio, asleep, holding a burning cigarette in his hand. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and the Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on [DATE] at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-700, F-835, F-837, and F-867. The facility was cited at F-700 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-609, F-610 and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 9:20 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's undated policy titled, Quality Assurance Performance Improvement Plan (QAPI), showed, An effective (QAPI) plan at all levels of our organization is vital for success. This process will enable the identification of problem areas at every level and will ensure appropriate measures are taken. Once corrective actions have been taken, monitoring and follow up will ensure that improvements are sustained .Basic Principles .QAPI is the program for systematic monitoring and assessment of indicators to ensure that facility standards are driven for resident positive outcomes .Root Cause Analysis is essential to provide solution interventions that are effective and sustainable .Prioritization is key .Focus on the Opportunities for Improvement that will make a difference .Performance improvement Projects (PIPS) must be implemented and monitored for effectiveness. Modify PIPS as needed to achieve the desired outcome .Maintain accurate, complete records of each meeting .Quality is everyone's job: All disciplines. All Shifts . Review of the facility's undated policy titled, QAPI Meeting Instructions - Administrator, showed, .Although there are several clinical thresholds already set, each facility should set additional thresholds from sources such as .state and national data and other comparison data .Complete a Root Cause Analysis .List the items on the .form from highest to lowest scores .Conduct your QAPI meeting at least quarterly, and as needed on a day/time the medical director (Medical Director) can attend .The facility QAPI committee should set additional thresholds for other pertinent agenda items to maintain desired facility standards .Rank the areas in order of importance .by listing the highest to lowest ranked item . Review of the facility's policy titled, Risk management process, dated ,[DATE], showed, Witness statements are taken by the charge nurse and placed directly in incident note .IF a route (root) cause for occurrence can be determined then the post occurrence evaluation is complete. If a route (root) cause cannot be determined, then complete post occurrence tool. We should never have an unknown. If you feel unknown is the answer, you must call the administrative staff .MD (Medical Doctor) and family made aware should be documented in PCC (abbreviation for Named electronic medical record) action tab of incident . Review of the facility's Nursing Home Administrator job description revised on ,[DATE], showed, .To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in conjunction with facility's operational budget and state and federal regulations .Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies .Verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .Consult with department managers concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services .Protect residents from neglect, mistreatment, and abuse .Comply with the Residents' Rights and Facility Policies and Procedures . Review of the facility's Director of Nursing job description revised on ,[DATE], showed, .To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents .In the absence of the Administrator and Assistant Administrator .assume responsibility of the facility .Monitor the Level of Care Reports, Dietary Consultant Reports, and Pharmacy Consultant Reports and take appropriate actions .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing department .Meet monthly with nursing staff regarding Chart Audit and physician's orders [REDACTED].Interview, orient, train, evaluate and supervise nursing department personnel .Delegate to nursing services supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guideline .Perform nursing services and deliver resident care services in compliance with Corporate policies and State and Federal regulation .Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the residents request .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided .Review Quality Indicator reports and submit to Vice President of Clinical Services on a monthly basis . Review of a Quality Assurance Performance Improvement report titled, Meeting Summary, dated [DATE], showed, .Related to Investigation of Potential Entrapment .After the TI (Trends Identified) items have been listed, analyzed for the root cause, and scored on the Prioritization worksheet .List items in order of rank on this sheet with the highest score being number 1 .Then indicate if a PIP (Performance Improvement Plan) is to be initiated .List items from Prioritization Worksheet .IDT (Interdisciplinary Team) team met on [DATE] (2020) to investigate potential of entrapment .Team members include .(listed everyone present, including the Owner, Chief Operating Officer, and the Interim Administrator (Regional Director of Plant Operations) .Team discussed potential for entrapment. Investigation into resident (initials of Resident #1) determined no entrapment occurred .RN (Registered Nurse) Supervisor audited all beds on [DATE]. Maintenance Director to also complete full house audit on [DATE] . The Medical Director and Resident #1's physician were not listed as attending the IDT meeting. Review of the facility's QAPI meeting notes for [DATE], [DATE], and [DATE], showed no problems had been identified or discussed related to grab bar/side rail use, injuries of unknown origin, wandering residents with elopement risk, or smoking hazards. During an interview on [DATE] at 12:30 PM, the Interim Administrator was asked if there were any other QAPI meetings held after [DATE]. The Interim Administrator stated the Administrator was new and confirmed there had been no other QAPI meetings. During an interview on [DATE] at 1:29 PM, Resident #1's physician was asked if she had been included in any QAPI meeting since [DATE]. She stated, No I'm not included. Resident #1's physician confirmed she was not notified about the details of the circumstances surrounding Resident #1's death. During an interview on [DATE] at 3:00 PM, Certified Nursing Assistant (CNA) #6 was asked if she had received in-service training about positioning or grab bars since the incident with Resident #1. She stated, Not that I can remember. During an interview on [DATE] at 3:10 PM, Licensed Practical Nurse (LPN) #3 was asked if he had received an in-service about positioning or grab bars following the incident with Resident #1. LPN #3 stated, No. During a telephone interview on [DATE] at 5:07 PM, Registered Nurse (RN) #1 was asked if she had received in-services after the incident with Resident #1. She stated, I heard a staff in-service called over the intercom. I was busy with care and couldn't attend at that moment. After I was finished with resident care .I went to the Staffing Development Coordinator an asked her if she could do the in-service for me. She told me she was not going to repeat, it was too much information. She handed me an in-service signature sheet an told me to use to in-service staff on the information. I told her I hadn't gotten the information, because she didn't give me the in-service . During an interview on [DATE] at 1:46 PM, the DON was asked what the inspection of Resident #1's bed showed after Resident #1's possible entrapment. The DON stated, I don't have any more on that in writing for you. During an interview on [DATE] at 3:42 PM, the Interim Administrator was asked if the Medical Director or Resident #1's physician attended the telephone IDT meeting on [DATE]. The Interim Administrator stated, No. The Interim Administrator/Regional Corporate Administrator confirmed the meeting summary was done afterward and stated, I prepared this form (meeting summary) when I got here this week, Thursday ([DATE]) . During a telephone interview on [DATE] at 5:32 PM, the Medical Director was asked what input he had in the QAPI meetings. He stated his input is more from a medical standpoint, that QAPI does not always pertain to him, but more to quality issues such as nursing, food, and dining. He was asked if he had attended a QAPI meeting after Resident #1's possible entrapment. He confirmed he reviewed some statements but had not participated in a QAPI meeting. During an interview on [DATE] at 1:41 PM, the DON was asked if the facility had a QAPI meeting after the possible entrapment and the 2 elopements. She stated, .no, the former Administrator was talking about it, we needed to sit down, but we have not scheduled it . The DON was asked if the facility had identified concerns for the time period of [DATE]-[DATE], since an entrapment and 2 elopements occurred during that time period. The DON stated, I don't know that I could put my finger on it . The DON was asked when the facility had QA'd the medical records of Resident #1, #3, #4, #6, and #7. The DON stated, This week. The DON was asked if the facility had identified any problems or concerns with communication between administration and staff, different departments. She stated, Yes, I think there has been a lack of communication. During an interview on [DATE] at 3:24 PM, the Chief Operating Officer and Interim Administrator (Regional Director of Plant Operations) were asked if they determined a root cause for entrapment, elopements, and unsupervised smoking. The Chief Operating Officer stated, .(referring to Resident #1) the root cause she was end of life, she had [MEDICAL CONDITION], it was an anticipated death .(referring to Resident #4) wander guard did not function as it should .(referring to Resident #6) redirected .took her back to the room to her meal. Another intervention .should have tried something else (referring to Resident #7) .We should have made sure the cigarette was out . The Interim Administrator was asked to review the [DATE] IDT Meeting Summary and was asked if there was a TI items analysis during the meeting. She stated, No. She confirmed there was only one item listed and it was to investigate the potential of entrapment. She was asked if the IDT team initiated a PIP. She stated, It did not. Refer to F-609, F-610, and F-689 The surveyors verified the Removal Plan by: 1. Resident #4 and #6 who eloped from the facility have no longstanding injury from the deficient practice. Resident #4's and #6's Care Plans were updated on [DATE] with interventions added to prevent further elopements. The surveyors reviewed the Care Plans. 2. Resident #7 had no injury from the smoking unsupervised. Resident #7's room was searched for smoking items on [DATE] and none were identified. Assessment and Care Plan for Resident #7 was reviewed on [DATE] to address physical and cognitive factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions on [DATE]. The surveyors reviewed the assessment and Care Plan. 3. The QAPI team, to include the Medical Director, with input from the Governing Body, developed and implemented the policies and procedures below to identify issues, develop the corrective actions, and monitor for effectiveness. The Interdisciplinary team is reviewing current incidents, accidents with the updated policy and tools to ensure they were thoroughly investigated and reported per the guidelines and policies. The updated policies include a tool kit that provides guidance to determine if an event is reportable and investigated thoroughly. Findings are reported to the QAPI team, to include the Medical Director, by new tool. QAPI team was educated on the Quality Assurance and Performance Improvement program to ensure understanding of the functions of a QAPI program. The surveyors verified the policies were updated through policy review and interviewed QAPI members. 4. The facility QAPI meetings are being led by the Administrator and attended by the Medical Director. The Regional Director of Operations, Regional Nurse Consultant or Chief Operating Officer will attend and provide guidance and oversight to ensure the facility is administered in a manner that enables it to use its resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Immediate action will be initiated for any events identified as requiring further intervention. All findings will be discussed at the QAPI meeting, consisting of at minimum the Medical Director, Administrator, Director of Nursing and Infection Preventionist with attendance and input from other facility staff as indicated. Findings will be reviewed in the QAPI meeting by the Regional Director of Operations, Regional Nurse Consultant or Chief Operating Officer to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified for a minimum of three months or until the pattern of compliance is maintained. The surveyors interviewed the QAPI members. Noncompliance of F-867 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to thoroughly investigate an incident of entrapment resulting in death for 1 of 5 sampled residents (Resident #1) reviewed for grab bar use, failed to investigate an injury of unknown origin that could indicate abuse for 1 of 3 sampled residents (Resident #3) reviewed for injuries of unknown origin, failed to thoroughly investigate elopement for 2 of 4 sampled residents (Resident #4 and #6) reviewed for elopement and wandering, and failed to investigate unsupervised smoking for 1 of 3 sampled residents (Resident #7) reviewed for smoking. The facility's failure to thoroughly investigate alleged incidents of neglect, injury of unknown origin, and unsupervised smoking resulted in Immediate Jeopardy when Resident #1 died while entrapped in a grab bar, Resident #3 had an injury of unknown origin (a skin tear), when Resident #4 traveled to an unsafe area outside of the facility, when Resident #6 exited through a door, and was found unsupervised 33 feet from the door of the facility, and when Resident #7 was found outside, unsupervised, sleeping on the back patio, with a burning cigarette in his hand. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on [DATE] at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 9:20 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's policy titled, ABUSE PREVENTION POLICY & (and) PROCEDURE, revised on ,[DATE], showed, .The purpose of the written Resident Abuse, Neglect and Misappropriation Prevention Program .is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents .and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .The completed investigation will be posted to the state agency website within 5 days . Review of the facility's undated policy titled, ACCIDENTS AND INCIDENTS - INVESTIGATING AND REPORTING, showed, .All accidents or incidents involving residents, employees, visitors, vendors .occurring at our facilities must be investigated and reported to the administrator .Regardless of how minor an accident or incident may be, including injuries of an unknown origin, it must be reported to the department supervisor as soon as the accident/incident is discovered .An incident Report Form must be completed for all reported accidents or incidents .An employee witnessing an accident or incident involving a resident, employee, visitor .must report such occurrence to his or her immediate supervisor as soon as possible .The nurse supervisor/charge nurse must be immediately informed of accidents or incidents .Notify the medical director or the individual's personal or attending physician, and inform the physician of the accident or incident .STEPS IN THE PROCEDURE .The Incident Report .Complete an Incident Report Form in PCC (abbreviation for named electronic medical record) .Complete all Medical Record and Resident Event Documentation .Complete the assessment of the resident .and complete information required and give a full description of the occurrence. Record time of incident, and describe exactly what occurred or was observed .Notify the physician, and document the name of the family member or responsible party who was contacted .Complete the report by signing the date and time completed .All incident reports will be reported to the Quality Assurance Committee .All incidents will be reported and reviewed by the Quality Assurance Committee .Recommendations and follow-up will be reported to the Quality Assurance Committee as appropriate .The attending physician or designee will be notified of resident accident/incidents at the time of occurrence .The Medical Director shall review all accident and incident reports .All recommendations will be reviewed by the administrator and the Director of Nursing and appropriate action taken . Review of the facility's policy titled, Risk management process, dated ,[DATE], showed, Witness statements are taken by the charge nurse and placed directly in incident note .IF a route (root) cause for occurrence can be determined then the post occurrence evaluation is complete. If a route (root) cause cannot be determined, then complete post occurrence tool. We should never have an unknown. If you feel unknown is the answer, you must call the administrative staff .MD (Medical Doctor) and family made aware should be documented in PCC action tab of incident . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Health Status Note dated [DATE], showed, .This nurse was called to room at approx. (approximately) 1530 (3:30 PM) by (named Registered Nurse (RN) #1). Pt. (Patient) found unresponsive, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directive and signed DNR order in chair (chart). Death pronounced by (Named RN #1) at 1540 (3:40 PM). This nurse did contact .resident's (family member) was able to visit resident . The facility's investigation was provided to the surveyors on [DATE] at 12:45 PM, and included: a. a brief medical record review for Resident #1 b. a statement dated [DATE] signed by the DON c. a statement dated [DATE] and signed by Registered Nurse (RN) #5 d. a statement dated [DATE] and signed by Certified Nursing Assistant (CNA) #5 (the CNA assigned to Resident #1 and who found the resident entrapped in the grab bar) f. a statement dated [DATE] and signed by RN #1 g. a statement dated [DATE] (the incident occurred [DATE]) and signed by Licensed Practical Nurse (LPN) #2 h. an Interview Summary Worksheet (with an interview of CNA #5) dated [DATE] (the incident occurred [DATE]) and signed by the Interim Administrator, DON, and Assistant Director of Nursing (ADON) i. a timeline dated [DATE] (the incident occurred [DATE]) and signed by the Interim Administrator The investigation did not include a written statement from CNA #7, LPN #3, and LPN #6. These three employees were working on the unit at the time this incident occurred and responded to a call for help to Resident #1's room. The statement from LPN #2 was dated [DATE] (a month after the incident occurred). The Interview Summary Worksheet and the timeline were dated [DATE] (over a month after the incident occurred). During an interview on [DATE] at 2:15 PM, Confidential Interviewee (employee) #1 was asked about the circumstances surrounding the death of Resident #1. Confidential Interviewee #1 stated, .I saw her hanging off the bed .her legs were caught in the overbed table, she was on her side, her legs were angling off. Her neck was pinned in between the mattress and the side rail (grab bar). She wasn't moving or struggling . Confidential Interviewee #1 then stated, She (Resident #1) couldn't move, she was on her knees on the floor with her neck caught between the rail and the mattress, but because of her weight it was a struggle to get her out from that rail (grab bar) . During a telephone interview on [DATE] at 1:29 PM, Resident #1's physician stated she received a text notifying her that Resident #1 had died . Resident #1's physician looked up the text on her phone and stated, It was a text at 5:38 PM, (Named Resident #1) expired (died ). Resident #1's physician confirmed she was not told about the circumstances surrounding Resident #1's death. Resident #1's physician was asked if she should have been told about the circumstances surrounding the death. Resident #1's physician stated, .if they (staff) think something is questionable, yeah, I think so. No one told me about that. They should have talked to the Medical Director. They should have let me know the circumstances about her death . During a telephone interview on [DATE] at 4:00 PM, the former Administrator (who had been employed at the facility from [DATE]-[DATE]) was asked if he had been informed about Resident #1 getting entrapped in the grab bar. He stated, .They (staff) said the patient had fallen in a weird position in the bed. They were really nervous . He confirmed he and the DON came to facility. He had CNA #5 re-enact the scene and took some pictures. He confirmed he sent that information to the corporate management team. The former Administrator was asked if the staff had told him Resident #1's neck was caught between the grab bar and the mattress, but because of her weight it was a struggle to get her out from the grab bar. He stated, .they (staff) told me she had trouble getting her feet out, tangled, couldn't get her out . During an interview on [DATE] at 3:42 PM, the Interim Administrator confirmed a conference call was held immediately after Resident #1's death The conference call included the DON, former Administrator, Weekend RN Supervisor, Vice President of Clinical Services, Regional Nurse Consultant, Regional Director of Operations, and Chief Operating Officer. The Interim Administrator confirmed neither the Medical Director nor Resident #1's physician participated in the conference call. During a telephone interview on [DATE] at 8:13 AM, Confidential Interviewee (employee) #2 stated he/she was asked to come to Resident #1's room on [DATE]. He/she went to the room and saw Resident #1 on her knees on the floor with her head stuck in the grab bar and the nurse was trying to get her out. He/she stated, .by the time they got her head out, they said she took her last breath. During an interview on [DATE] at 1:41 PM, the DON was asked what she considered to be an unusual incident. She stated, A fall in a questionable position, something I cannot explain. The DON was asked if Resident #1's physician should have received verbal notification of the circumstances surrounding Resident #1's death. She confirmed Resident #1's physician should have been involved in the investigation and stated, She should have been told the details. The DON was asked if the facility did a thorough investigation of the circumstances surrounding Resident #1's death. She stated, .It probably wasn't as thorough as it could have been .because of the way they (staff) stated she was laying .that's why I came. They notified me. They notified (Named Former Administrator) . The DON was asked what was immediately implemented after the event with Resident #1. She stated, Because of the possibility that anything could have happened with that grab bar on there, it became real that this could be a really serious problem. So, we assessed the grab bars, measured (grab bars), we in-serviced, brought it up in the IDT (Interdisciplinary Team) meeting Monday morning. Maintenance got (Named RN #1's) list (list of grab bars) and did the full building .then therapy did all new assessments right after that. She confirmed that once therapy made the recommendations on which residents no longer met the grab bar criteria, Maintenance was to remove those grab bars. During an interview on [DATE] at 3:24 PM, the Interim Administrator was asked when the grab bars were removed from residents' beds who didn't meet the grab bar criteria, according to the Rehabilitation Manager's [DATE] - [DATE] screening. She confirmed they started taking them off this week (the week of [DATE]). The facility was unable to provide documentation that a thorough and timely investigation was conducted of Resident #1's possible entrapment in a grab bar. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised on [DATE], showed, Focus .Resident at risk for skin breakdown .has very fragile skin, history skin tears .Interventions XXX[DATE] ([DATE])-reinforce padding to grab bars . Review of Resident #3's Health Status Note dated [DATE], showed, NEW SKIN TEAR TO RIGHT SHOULDER BROUGHT TO MY ATTENTION BY Certified Nursing Assistant. 7.5 (length in centimeters (cm)) X (times) 0.2 (width in cm). WAS ABLE TO PULL SKIN BACK TOGETHER, X 8 STERI-STRIPS ARE NOW IN PLACE . The facility was unable to provide an investigation for this injury of an unknown origin. Review the quarterly Minimum Data Set ((MDS) dated [DATE], showed that Resident #3 had severe cognitive impairment and had a skin tear. During an interview on [DATE] at 3:40 PM, Licensed Practical Nurse (LPN) #4 confirmed she had assessed a new skin tear to Resident #3's right upper arm and had applied 8 steri-strips to the skin tear. She confirmed the skin tear was unwitnessed. During an interview on [DATE] at 10:04 AM, the DON confirmed Resident #3's skin tear, identified on [DATE], had not been investigated. The DON was asked about Resident #3's bilateral grab bars. The DON stated, .they were bad .I saw them .they were ragged . During an interview on [DATE] at 11:04 AM, the Assistant Director of Nursing (ADON) confirmed the facility did not start an investigation into Resident #3's skin tear on her right upper arm until [DATE], and it should have been investigated when the skin tear was discovered on [DATE]. The ADON stated, .it just got missed . The facility was unable to provide documentation that a thorough investigation was conducted to determine the cause of an injury of unknown origin and rule out abuse for Resident #3. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #4's Incident Note dated [DATE], showed, Resident got through main entrance doors; 1st set of doors did not alarm. Alarmed (alarm) sounded to entry doors in front lobby. resident noted going through main entrance door; nurse ran after resident. once outside nurse noted resident laying on gravel; to left side and w/c (wheelchair) flipped over. resident assisted back into chair and back into facility. resident noted with a large hematoma (a collection of blood outside of blood vessels caused by an injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues) to forehead; Golf ball size. bruising noted to nose . Review of a Witnessed Fall Report dated [DATE] showed, .alarm sounded. Noted resident (Resident #4) going through main entrance door; ran after resident. Noted resident laying on gravel; to left side. This note was signed by LPN #1. There was no investigation included on this report. During an interview on [DATE] at 1:18 PM, the DON was asked if a resident exited the building, would that be something that should be investigated. She stated, Yes. (Named Resident #4) rolled through the front door, but she was in the view of a staff member. She rolled through the double doors, touched these doors, and dipped .confused, she rolled so quickly, they could not get to her fast enough before she fell . They were right there, running behind her. The DON was asked if she did a full investigation of the elopement. The DON stated, We saw her, they watched her roll out that door. The DON was asked if she could provide a copy of the investigation. She stated, It's different now, it's right there in the chart. The DON pointed to the Witnessed Fall Report and confirmed that was the investigation. The DON was asked if she obtained witness statements. The DON pointed to the [DATE] Witnessed Fall Report signed by LPN #1, and stated, It's right there. There was one statement by LPN #1 on this report. During a telephone interview on [DATE] at 7:45 AM, LPN #1 confirmed he worked the night shift the morning Resident #4 eloped. He stated, .I was sitting at the nurses' station. I knew she had been in her chair rolling around, she does that. She had gotten to the double doors (double doors that lead into the lobby area) right beside the nurse's station. I'm sitting in my chair. My chair is facing the opposite way, and my back was to those double doors. I heard the alarm go off. I got up and looked at the lights (lights on a panel at the nurses' station that show where a door has been breached by a resident) and it says front door. I opened the first set of double doors. The sliding doors are completely open .By the time I saw her, she was off to the left. Her wheelchair was flipped on its side and she was lying on her side. There was about a 6-inch curb she went over. I didn't realize she had gotten out until the alarm sounded for the front door. He confirmed he did not see her go through the first set of double doors into the lobby area. He stated, First set should just lock down. I didn't realize the gravity of the situation until I saw her going out the sliding doors. I didn't think she could get through . During a telephone interview on [DATE] at 3:17 PM, the Maintenance Director confirmed he had seen video footage of Resident #4 leaving the building. The Maintenance Director was asked if the video footage of the incident had been saved. The Maintenance Director confirmed it had not been saved and stated, I never was asked to. The Maintenance Director was asked to give a step by step account of what he saw on the video. He confirmed no one was with Resident #4 when she went through the front door and propelled herself in her wheelchair outside of the building. He stated, .Her wheelchair rolled to the left .she was off a little, and the first wheel dipped her off and pitched her forward. She was lying on the concrete, and then it shows the nurse running down the hall . The Maintenance Director confirmed Resident #4 was alone from the time she went through the front door until the nurse ran down the hall and outside to find her lying on the concrete driveway. During an interview on [DATE] at 5:52 PM, the DON was asked if she had looked at the video footage of Resident #4 leaving the facility. She stated, No. I never knew it existed. During a telephone interview on [DATE] at 7:53 AM, RN #4 confirmed she was working the night shift the morning Resident #4 eloped. RN #4 was asked if she knew Resident #4 had left the building. RN #4 stated, No, until after the fact . The facility failed to perform a complete investigation when Resident #4 eloped from the building. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Incident Note dated [DATE], showed, .Resident noted to have increased confusion prior to incident. Multiple exit seeking behaviors this shift. Fire alarm was set off after dinner .Found emergency exit at end of 200 hall open and patient wandering outside of building with pocket book (pocketbook) and non slip (non-slip) socks on. Patient redirected back into building with wheelchair . The facility was unable to provide an investigation for this elopement. Observation on [DATE] at 1:13 PM, showed there was an exit door at the end of the 200 Hall. LPN #5 showed the area where Resident #6 was found after she got out of the building. The Regional Director of Plant Operations used a rolling measuring device to measure the area from the exit door to the area where Resident #6 was found. The area was 33 feet from the exit door. The Regional Director of Plant Operations used a rolling measuring device to measure the area from the area where Resident #6 was found to a nearby heavily wooded area. The distance was 38 feet. During a telephone interview on [DATE] at 5:32 PM, the Medical Director was asked if the facility should have completed a thorough investigation after Resident #6's elopement. The Medical Director stated, Yes. During an interview on [DATE] at 10:55 AM, the Interim Administrator confirmed the last time Resident #6 was seen was at 6:20 PM. She confirmed the fire alarm went off at 6:55 PM. Resident #6 was found unsupervised outside on the sidewalk at approximately 7:00 PM. Forty minutes had passed between the time Resident #6 was last seen by staff and the time she was found outside the facility. During a telephone interview on [DATE] at 11:05 AM, CNA #3 stated, .I was facing the hall .she just snuck past me .she was on a roll .she was going in other resident's room .start searching for her .saw back door was cracked .she was there on the sidewalk (alone) .almost around the corner . During an interview on [DATE] at 1:42 PM, the DON confirmed the facility did not do a thorough investigation after Resident #6's elopement. The facility failed to perform a complete investigation when Resident #6 eloped from the building. Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Behavior Note dated [DATE] at 2:51 PM, showed, .Resident (Resident #7) was observed on the back patio smoking a cigarette unattended after the approved smoke break. Staff member that supervised the smoke break stated that (Named Resident #7) missed the 2:30 pm (PM) smoke break . During a telephone interview on [DATE] at 7:29 AM, CNA #1 confirmed she was outside smoking when Resident #7 rolled out on the patio in his wheelchair. She stated, I went in and got him a cigarette. I put mine out in one can, and he put his out in the other can. I thought he put his out, so I came in, and he stayed out on the back patio. CNA #1 confirmed the last time she saw him was between 2:40 and 2:50 PM. When CNA #1 was asked how long Resident #7 was unsupervised on the patio, she stated she did not know. CNA #1 was asked if a Resident should be on the back patio alone sleeping with a burning cigarette in their hand. She stated, No, Ma'am. During a telephone interview on [DATE] at 12:14 PM, RN #1 confirmed she had found Resident #7 sitting outside unsupervised on the patio on [DATE] sleeping and holding a burning cigarette in his hand. RN #1 was asked if she had performed a head to toe assessment on Resident #7 after she found him smoking alone and asleep outside. She stated, No. During an interview [DATE] at 1:42 PM, the DON was asked if she had reviewed the [DATE] Behavior note for Resident #7. The DON stated, .for some reason I did not read that one .I don't know what happened there. The DON was asked for the investigation of Resident #7's unsupervised smoking outside the facility. The DON stated, Nothing at the time because I didn't know . The facility failed to complete a thorough investigation of Resident #7's unsupervised smoking. During an interview on [DATE] at 3:24 PM, the Interim Administrator confirmed the facility did not do a thorough investigation on Resident #1's entrapment, Resident #3's injury of unknown origin, Resident #4 and #6's elopement and Resident #7's unsupervised smoking. The Interim Administrator stated, We do admit we did not do a thorough investigation .we should have done more . Refer to F-609 and F-689. The surveyors verified the Removal Plan by: 1. Resident #4 and #6 who eloped from the facility have no longstanding injury from the deficient practice. Resident #4 and #6's Care Plans were updated on [DATE] with interventions added to prevent further elopements. The surveyors reviewed the Care Plans. 2. Resident #7 had no injury from smoking unsupervised. Resident #7's room was searched for smoking items on [DATE] and none were identified. Assessment and Care Plan for Resident #7 were reviewed on [DATE] to address physical and cognitive factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions. The surveyors reviewed the assessments and Care Plans. 3. Resident #3 with the injury of unknown origin was reassessed by the DON on [DATE] to verify the location, extent and root cause of the injury. Resident #3's Care Plan was updated on [DATE] with interventions to prevent reoccurrence. The physician and resident's responsible party were notified of the assessment, thorough investigation and updated Care Plan. The surveyors reviewed the Care Plan and investigation. 4. A book has been placed at the nurses' station with policies on reporting and investigating elopement, entrapment, smoking, and incidents of unknown origins with tools to assist staff with completion of a timely and thorough investigation. The surveyors verified the book containing the polices and updated tools was at the nurses' station and verified all policies were in the book. 5. On [DATE], the following policies were updated Unexplained Injuries, Elopements and Wandering, Abuse, Neglect, and Exploitation, Resident Abuse Prevention and Reporting, Accidents and Supervision, Compliance with Reporting Allegations of Abuse, Neglect and Exploitation, Proper use of Side Rails, and QAPI (Quality Assurance Performance Improvement), were all updated to ensure a timely and thorough investigation is conducted. Corresponding tools were updated or added to ensure proper procedure is followed. The surveyors reviewed the policies and corresponding tools. 6. On [DATE], the Regional Nurse Consultant educated the Administrator, DON and Interdisciplinary Team on the updated polices and tools and competencies were completed. The surveyors reviewed the in-services and competencies. 7. On [DATE], The DON or designee educated current staff on competencies, updated policies and tools. The surveyors reviewed the competencies and, in-services and interviewed staff on multiple shifts. 8. The QAPI team reviewed and revised the QAPI (Monday - Friday) meeting format and elopements, incidents, accidents and adverse events will be reviewed to ensure a timely and thorough investigation occurred using the QAPI audit tool. Immediate action will be initiated for any events identified as requiring further investigation using updated investigation tools and reviewed with the QAPI team. All audits will be discussed at the QAPI meeting, consisting at a minimum the Medical Director, Administrator, DON and the Infection Preventionist with attendance and input from other facility staff as indicated. Findings will be reviewed in the QAPI meeting to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified for a minimum of three months or until the pattern of compliance is maintained. The surveyors reviewed the revised QAPI meeting format, reviewed the white board daily meeting tool, reviewed revised policies, the auditing tools, and interviewed the Interim Administrator, the DON and Assistant Director of Nursing (ADON). Noncompliance of F-610 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to provide supervision to prevent elopement for 2 of 4 sampled residents (Resident #4 and #6) reviewed for wandering behaviors and elopement, and failed to provide supervision while smoking for 1 of 3 sampled residents (Resident #7) reviewed for smoking. The facility's failure to provide supervision to ensure a safe environment resulted in Immediate Jeopardy when Resident #4 exited the facility through the front entrance sliding doors, and was found lying face down on the concrete pavement in the facility parking lot, when Resident #6, a vulnerable resident assessed to be cognitively impaired, exited through a door unsupervised, and was found 33 feet from the door of the facility, and when Resident #7 was found outside, unsupervised, sleeping on the back patio, with a burning cigarette in his hand. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on 10/10/2020 at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from 8/15/2020 through 10/17/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 10/16/2020 at 9:20 AM, and was validated onsite by the surveyors on 10/16/2020 through 10/18/2020 by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's undated policy titled, .Accident-Incident-Elopement-Wandering Resident, showed, .Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .Should a wandering/elopement episode occur, the contributing factors as well as the interventions tried, will be documented on the resident's medical record and reviewed by the Interdisciplinary team (IDT) .If a resident repeatedly wanders off the unit, an increased supervision monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule .Upon return of the resident to the facility, the director of nursing (Director of Nursing) services or charge nurse (Charge Nurse) should .Examine the resident for injuries .Contact the attending physician and report what happened .Contact the resident's responsible party/POA (Power of Attorney) and inform him/her of the incident .Complete and file an incident report .Make appropriate notations in the resident's medical record .Interdisciplinary team make revisions and update care plan as appropriate .report to state system . Review of the facility's undated policy titled, Resident Alarms, showed, .An 'alarm' is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected .The use of alarms do not eliminate the need for adequate supervision of the resident. Types of alarms include .Wander/elopement alarms .includes devices such as bracelet .or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident's assistive device .walker, wheelchair .Supervision shall be provided to the resident in accordance with the resident's plan of care .The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary .When alarms are in use or are under consideration, risks of adverse consequences related to the alarms shall be identified .Supervision shall be provided to the resident in accordance with the resident's plan of care .verifying alarms are used in accordance with the resident's care plan .verifying alarms are working properly . Review of the facility's undated instructions titled, Wanderer Monitoring System Transmitter, showed how to test a Wanderguard device for functioning after placement on a resident. A device is held over the bracelet. If the bracelet is working, a green light will blink, and a tone will sound once every second. If the transmitter fails the test, the batteries should be checked, and replaced if needed, then the Wanderguard device should be checked again. The facility's undated policy titled, Resident Smoking, showed, .This facility provides a safe and healthy environment for residents .including safety as related to smoking .Safety measures for the designated smoking area will include .Provision of ashtrays made of noncombustible material and safe design .Accessible metal containers with self-closing covers into which ashtrays can be emptied .Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .Supervision will be provided as indicated on each resident's care plan . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Care Plan revised 2/20/2020, showed .The resident is an elopement risk/wanderer (resident that wanders) .check wanderguard/code alert bracelet, check placement and function q (every) shift . Review of the Physician order [REDACTED].Check Wanderguard/code alert bracelet, check placement and function every shift . Review of the quarterly MDS dated [DATE], showed Resident #4 had moderate cognitive impairment, required supervision while in her wheelchair, required extensive assistance from staff for activities of daily living, had impairment to the upper and lower extremities on one side, and wore a wander/elopement (Wanderguard) alarm daily. Review of an Incident Note dated 8/15/2020, showed, Resident got through main entrance doors; 1st set of doors did not alarm. Alarmed (alarm) sounded to entry doors in front lobby. resident (Resident #4) noted going through main entrance door; nurse ran after resident. once (Once) outside nurse noted resident laying on gravel; to left side and w/c (wheelchair) flipped over. resident (Resident #4) assisted back into chair and back into facility. resident (Resident #4) noted with a large hematoma (a collection of blood under the tissue developed from trauma) to forehead; Golf ball size. bruising noted to nose . Review of a Witnessed Fall report dated 8/15/2020, showed, .alarm sounded. Noted resident (Resident #4) going through main entrance door; ran after resident. Noted resident laying on gravel; to left side . This note was signed by LPN #1. Review of a Telehealth (examination performed by a practitioner remotely with a computer) progress note dated 8/15/2020, showed, .Notified patient was with wheelchair outside and fell on to concrete outside; hit head. hematoma to forehead and bruised nose noted, no apparent deformities noted .Patient is alert and verbal, c/o (complains of) pain on her face, she does takes eliquis (medication used to prevent blood clots) .Neurochecks (an evaluation of the nervous system) started and monitoring .ice applied .will also obtain facial xray (x-ray) to rule-out nose injury . Review of a radiology report dated 8/15/2020, showed, .FACIAL BONES .3 VIEWS .Conclusion: No definite acute fracture. Consider more sensitive imaging evaluation with CT (Computerized Tomography) (Scan) as clinically directed . During a telephone interview on 10/2/2020 at 7:45 AM, LPN #1 confirmed he worked the night shift the morning Resident #4 eloped. He stated, .I was sitting at the nurses' station. I knew she had been in her chair rolling around, she does that. She had gotten to the double doors (double doors that lead into the lobby area) right beside the nurse's station. I'm sitting in my chair. My chair is facing the opposite way, and my back was to those double doors. I heard the alarm go off. I got up and looked at the lights (lights on a panel at the nurses' station that show where a door has been breached by a resident) and it says front door. I opened the first set of double doors. The sliding doors are completely open .By the time I saw her, she was off to the left. Her wheelchair was flipped on its side and she was lying on her side. There was about a 6-inch curb she went over. I didn't realize she had gotten out until the alarm sounded for the front door. He confirmed he did not see her go through the first set of double doors into the lobby area. He stated, First set should just lock down. I didn't realize the gravity of the situation until I saw her going out the sliding doors. I didn't think she could get through . During a telephone interview on 10/2/2020 at 12:50 PM, the Maintenance Director was asked if he had identified any problems with the double doors leading out to the lobby area. He stated that a week prior to Resident #4's elopement, a storm came through that interfered with the code alerts for the Wanderguards. He stated, I did tweak that one (the one for the double doors) the week before. I turned down the antenna just a fraction .sensitivity was high .turned it down a little bit. When we found out what had happened (with Resident #4) we were going a completely different route. The Mag (Magnetic) locks have a code to get through, now. During observation and interview on 10/3/2020 at 12:30 PM, the Regional Maintenance Director, Maintenance Staff #1, and Maintenance Staff #2 demonstrated how the door alarm system works. The Regional Maintenance Director and Maintenance Staff #1 showed the double doors that lead out into the lobby area and both confirmed the lobby area was not a safe area for residents to go without supervision. During a telephone interview on 10/4/2020 at 2:24 PM, CNA #2 confirmed she was Resident #4's night shift CNA the morning she was found outside the building. CNA #4 confirmed she did not know Resident #4 had left the building and stated, She would get up in her wheelchair, and she would be gone .she's quiet, and she's quick . She confirmed she did not hear the alarm and stated, .it was said something was wrong with the alarm, one would go off, and the other one wouldn't. One of the alarms doesn't work, we had been telling them . CNA #2 was asked if she monitored the Wanderguards on residents. She stated, No. CNA #2 was asked if Resident #4 was considered a resident that wandered and stated, Yes. During a telephone interview on 10/4/2020 at 3:17 PM, the Maintenance Director confirmed he had seen video footage of Resident #4 leaving the building. The Maintenance Director was asked if the video footage of the incident had been saved. The Maintenance Director confirmed it had not been saved and stated, I never was asked to. The Maintenance Director was asked to give a step by step account of what he saw on the video. He confirmed no one was with Resident #4 when she went through the front door and propelled herself in her wheelchair outside of the building. He stated, .Her wheelchair rolled to the left .she was off a little, and the first wheel dipped her off and pitched her forward. She was lying on the concrete, and then it shows the nurse running down the hall . The Maintenance Director confirmed Resident #4 was alone from the time she went through the front door until the nurse ran down the hall and outside to find her lying on the concrete driveway. Observation in the resident's room on 10/5/2020 at 3:10 PM, 10/6/2020 at 10:00 AM, 10/11/2020 at 2:50 PM, 10/7/2020 at 10:05 PM, 10/8/2020 at 5:10 PM, showed Resident #4 with healing bruises noted above the right eye and to the right cheek area, with a Wanderguard alarm intact to her right ankle and a Wanderguard alarm intact to the right side of her wheelchair. During a telephone interview on 10/8/2020 at 4:08 PM, RN #3 was asked how she checked the Wanderguards on wandering residents. She stated she makes sure the Wanderguard is located where it should be on the resident. She was asked how she checked to make sure it functioned. She stated, Honestly, haven't checked it to make sure it works. She was asked if she knew of a device that could be used to make sure it was functioning. She stated, No, Ma'am. Review of the medical record, showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised 2/20/2020, showed, .The resident is an elopement risk/wanderer (resident that wanders) .check wanderguard/code alert bracelet, check placement and function q (every) shift . Review of the Care Plan for Resident #6 dated 5/20/2020, showed, .has impaired cognitive function, impaired thought processes r/t (related to) Dementia .resident has potential for elopement risk .Wanders at times . Review of the quarterly MDS dated [DATE], showed Resident #6 had severe cognitive impairment, required extensive assistance for transfers, limited assistance when up in her wheelchair, and had impairment to the lower extremity on one side. Review of the Wandering/Elopement assessment dated [DATE], showed Resident #6 had a [DIAGNOSES REDACTED]. Review of a Health Status Note dated 7/7/2020, showed, .Resident very restless today, in and out of room, frequent redirection required. Several attempts to go off hallway . Review of Resident #6's Incident Note dated 8/17/2020, showed, .Resident noted to have increased confusion prior to incident. Multiple exit seeking behaviors this shift. Fire alarm was set off after dinner .Found emergency exit at end of 200 hall open and patient wandering outside of building with pocket book (pocketbook) and non slip (non-slip) socks on. Patient redirected back into building with wheelchair . Observation on 10/8/2020 at 1:13 PM of the area where Resident #6 was located after she eloped, showed an exit door at the end of the 200 Hall which was the door Resident #6 exited when she eloped. The Regional Director of Plant Operations used a rolling measuring device to measure from the 200 Hall exit door to the place where LPN #5 indicated she found Resident #6. The distance measured was 33 feet. The Regional Director of Plant Operations used the rolling measuring device to measure the distance from where Resident #6 was found to a thickly wooded area adjacent to where Resident #6 was found. The distance was 38 feet. The Regional Director of Plant Operations confirmed it was a heavily wooded area. Observation in the resident's room on 10/8/2020 at 5:00 PM and 10/12/2020 at 12:45 PM, showed Resident #6 had a Wanderguard alarm intact to her right ankle. During a telephone interview on 10/8/2020 at 5:32 PM, the Medical Director was asked if he had been told of Resident #6's elopement on 8/17/2020. The Medical Director stated, Not that I'm aware . During a telephone interview on 10/9/2020 at 8:57 AM, RN #2 stated, .thought they were doing a fire drill .I knew she (Resident #6) was agitated .she would pack up .say she is leaving . During an interview on 10/9/2020 at 10:55 AM, the Interim Administrator confirmed the last time Resident #6 was seen was at 6:20 PM, and the fire alarm went off at 6:55 PM. Resident #6 was found outside on the sidewalk at approximately 7:00 PM. Resident #6 was not seen for 40 minutes, until she was located at dusk, outside the facility, 33 feet from the exit door and 38 feet from a heavily wooded area. During a telephone interview on 10/9/2020 at 11:05 AM, CNA #3 stated, .I was facing the hall .she just snuck past me .she was on a roll .she was going in other residents' rooms .turning on their call light .she was giving me a run for my money .fire alarm went off .the other CNA came back from lunch .and we started putting things in rooms and closing doors .resident check .I checked in her bathroom .her brief was in the floor .I go tell the nurse .start searching for her .saw back door was cracked .she was there on the sidewalk .almost around the corner . During an interview on 10/9/2020 at 1:42 PM, the DON was asked about the evening Resident #6 got out of the facility. The DON stated, .The night that happened, they had done the fire drill .she didn't get off the premises .she has done this .packed her suitcase .she has had this behavior .it happened on the 17th .this behavior .we can't do this (manage this behavior), could be a bad situation . During an interview on 10/9/2020 at 3:24 PM, the Interim Administrator was asked about Resident #6's elopement. Interim Administrator confirmed that Resident #6 was a high risk for wandering, was observed by multiple staff on the hall, before the incident, redirecting her twice. She stated, Another intervention should have been employed at that point, redirecting didn't help .we should have tried something else . Review of the medical record, showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Care Plan dated 4/8/2019 and revised on 3/27/2020 showed, .The resident is a smoker .Observe clothing and skin for signs of [MEDICAL CONDITION].The resident requires SUPERVISION while smoking . Review of the annual MDS dated [DATE], showed Resident #7 used tobacco. Review of a Smoking assessment dated [DATE], showed Resident #7 was a smoker and required supervision for safety when he was smoking. Review of a Behavior Note dated 8/23/2020 at 2:51 PM, showed, .Resident was observed on the back patio smoking a cigarette unattended after the approved smoke break. Staff member that supervised the smoke break stated that (Named Resident #7) missed the 2:30 pm smoke break . During a telephone interview on 10/9/2020 at 7:29 AM, CNA #1 confirmed she was outside smoking when Resident #7 rolled out on the patio in his wheelchair. She stated, I went in and got him a cigarette. I put mine out in one can, and he put his out in the other can. I thought he put his out, so I came in, and he stayed out on the back patio. CNA #1 confirmed the last time she saw him was between 2:40 and 2:50 PM. When CNA #1 was asked how long Resident #7 was unsupervised on the patio, she stated that she did not know. CNA #1 was asked if a Resident should be on the back patio, asleep, with a burning cigarette in their hand. She stated, No, Ma'am. During a telephone interview on 10/9/2020 at 12:14 PM, RN #1 confirmed she had found Resident #7 outside on the patio asleep, holding a burning cigarette. RN #1 asked if she had done a head to toe assessment on Resident #7. RN #1 stated, No, I did not . Observation on the back patio 10/9/2020 at 9:35 AM, and 10/15/2020 at 2:35 PM, showed Resident #7 smoking with other residents. A staff member was observed handing out cigarettes and lighting it for each resident and monitoring the residents as they smoked. Other staff members were observed out on the back-patio smoking during this time. Both residents and staff were observed to place the smoked cigarettes in a large dark gray ash receptacle that had an opening at the top. Cigarettes could be visualized smoldering in the ash receptacle and the opening was large enough that a burning cigarette could be obtained from the receptacle. The surveyors verified the Removal Plan by: 1. On 10/9/2020, Resident #4's and #6's Care Plans were updated to reflect current Wandering and Elopement Risk Assessments and added interventions to prevent recurrence. The surveyors verified the Care Plans and Elopement Risk Assessments through electronic record review. 2. On or before 10/14/2020, Resident #4's and #6's Wanderguards were checked to ensure proper functioning and that doors lock when the Wanderguard triggers. The surveyors verified the Wanderguards were checked through Maintenance interviews. 3. On 10/12/2020, Resident #7's room was searched for smoking items and none were identified. Assessment and Care Plan for Resident #7 was reviewed on 10/13/2020 to address physical and cognitive factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions on 10/13/2020. The Director of Nursing and Social Services met with Resident #7 and reviewed the smoking policy on 10/13/2020. Resident voiced understanding of policy and signed the policy. The surveyors verified the interventions and revisions to Resident #7's assessment and Care Plan through record review and staff interviews. 4. On 10/14/2020, a computer monitor for the facility camera system was placed at the nurses' station to view exits. The Wanderguard system was inspected and adjusted by Maintenance Director by 10/13/2020 to ensure doors were in working order. Residents with Wander guards in place were audited on 10/14/2020 to ensure Wanderguard bracelet was in place and properly functioning when tested . The surveyors verified the computer monitoring camera system, Wanderguard system, door system, audits, through an observation of a Code Pink Elopement Drill and staff interviews. 5. On 10/12/20, the ambulance exit door and the courtyard exit door had an alarm placed on the doors to alert staff that an individual is attempting to exit. All residents at risk for wandering/elopement were re-evaluated using an Elopement Risk Assessment tool. The Interdisciplinary team members reviewed the MDS and updated the Care Plans as indicated. The surveyors verified the ambulance exit door and courtyard exit door alarms and the Elopement Risk Assessment tool through observation of the doors and interviews with staff. 6. Maintenance will check exit doors weekly x 4 then monthly x 3, then quarterly to ensure proper function. Administrator or Designee to check residents with wanderguard bracelets weekly x 4, then monthly x 3, then quarterly to ensure proper function. The surveyors verified the maintenance checks of doors and Wander guards through Maintenance staff interviews. 7. On 10/14/2020, Elopement and Wandering Residents policy, to include tools and post-test was reviewed and revised with Quality Assurance and Performance Improvement (QAPI) team participation and Governing Body approval. The Director of Nursing or designee educated current staff, prior to their next scheduled shift on wandering, elopement, and resident safety. Any staff on leave will receive education on their next scheduled workday. The surveyors verified the policies, tools, and post-test, and staff education through reviews of policies, in services, posttests, and staff interviews. 8. On 10/12/2020, the smoking schedule was posted at the nurses' station. The smoking area receptacles were removed on 10/12/2020 and replaced with a cigarette receptacle that will not allow anyone to reach into the ashtray and retrieve any previously smoked partial cigarettes on 10/13/2020. The Smoking policy was revised by Quality Assurance and Performance Improvement team with Governing Body approval on 10/13/2020. The surveyors verified the smoking schedule, cigarette receptacle, and updated policy through schedule review, observations of smoking and policy review. 9. On 10/13/2020, assessments and Care Plans for all smoking residents were reviewed by the Interdisciplinary Team to address physical and cognitive factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions. The Director of Nursing or designee and Social Services met with each smoking resident and reviewed the smoking policy on 10/13/2020 and residents' responsible parties were called by Social Services to review the smoking policy and to remind them not to send patients cigarettes or smoking paraphernalia. The surveyors verified the Care Plans were updated with smoking interventions through electronic record review and staff interviews. 10. Nursing staff or designee will monitor residents while smoking daily to ensure appropriate supervision and implementation of safety interventions. The nursing management team will oversee assigned caregivers and residents during designated smoking times to ensure appropriate supervision and interventions are implemented. The surveyors verified the smoking safety interventions through staff interviews on multiple shifts. 11. Elopement drills will be completed to ensure correct procedure is followed; any discrepancies will be addressed at the time of the drill with in-service and will be reflected on the Elopement Drill Tool Comments Section. The drills will be weekly for 4 weeks, then monthly for 3 months, and then quarterly. The surveyors verified the elopement drill procedure through observation of a Code Pink Drill and staff interviews on multiple shifts. 12. The Director of Nursing, Administrator, or designee, will monitor smoking residents' rooms for cigarettes and smoking paraphernalia, review smoking assessments, and random visual audits during smoking times to ensure that all smoking residents are supervised while smoking that will occur weekly for 4 weeks and then, monthly for 3 months, and then quarterly. The surveyors interviewed staff on all shifts and reviewed the audit tools. 13. Immediate action will be initiated for any events identified as requiring further intervention. All audits will be discussed at the Quality Assurance and Performance Improvement (QAPI) meeting, consisting of at minimum the Medical Director, Administrator, Director of Nursing and Infection Preventionist with attendance and input from other facility staff as indicated. Findings will be reviewed in the QAPI meeting to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified for a minimum of three months or until the pattern of compliance is maintained. The surveyors verified the QAPI audits through review of the revised QAPI policy and interviews with the Interim Administrator. Noncompliance of F-689 continues at a scope and severity of E for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that prevented an incident of entrapment which resulted in death for 1 of 5 sampled residents (Resident #1) reviewed for grab bar use. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy when Resident #1, a vulnerable resident assessed to be cognitively impaired, became entrapped in a grab bar which resulted in death. 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 Interim Administrator (by telephone), Director of Nursing (DON), Chief Operating Officer, Regional Director of Plant Operations, and Director of Strategic Community Excellence, were notified of the Immediate Jeopardy on [DATE] at 5:00 PM, in the Activity Office. The facility was cited Immediate Jeopardy at F-700. The facility was cited at F-700 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 9:20 AM, and was validated onsite by the surveyors on [DATE] through [DATE] by policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: The facility's policy titled, .Side Rails/Assist Bars (Grab Bars), Proper Use of, dated ,[DATE], showed, .Our facility shall strive to prevent/reduce hazards such as resident entrapment associated with bed side rail .Assist bars (Grab bars) may be used to assist in mobility and transfer of residents .An assessment will be made to determine the resident's symptoms or reason for using partial side rails. When used for mobility or transfer, an assessment will include a review of the resident's .Bed mobility .Ability to transfer between positions, to and from bed or chair, to stand and toilet .The use of assist bars (grab bars)/partial side rails as an assistive device will be addressed in the resident care plan .A consent for the enabler bar (grab bar)/partial side rails will be obtained from the resident or responsible party .The resident will be assessed as needed for condition change for safety .When assist bar (grab bar)/side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment .Partial side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders .To reduce/prevent deaths or injuries from entrapment associated with facility bed side rails/assist bars (grab bars), the facility has beds and mattresses that have met all entrapment guidelines .Inspect all facility bed frames, bed side rails, assist bars (grab bars) and mattresses quarterly as part of our regular safety program to identify potential areas of possible entrapment .Ensure that no gap (between the mattress, bed frame or assist bars (grab bars)/side rail) is wide enough to entrap a resident's head or body .Observations must include when the resident is in the bed to observe situations that could be caused by the resident's weight, movement or bed position .Impose additional safety measures for residents who have been identified as high risk for entrapment .Altered mental status, restlessness . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Care Plan dated [DATE] and revised [DATE], showed, .Install grab bars to assist with improving independence bed mobility and transfers (Date Initiated: [DATE]) .Resident needs extensive assist of ,[DATE] with bed mobility . Review of an Admission Summary dated [DATE], showed, .readmitted to facility under long term care services Resident admitted from (Named Hospital) with [DIAGNOSES REDACTED]. Resident lethargic not responding to verbal cues. Resident is a DNR (Do Not Resuscitate) comfort measures. Resident is completely dependent on ADL's (Activities of Daily Living) . Review of an Assist Bar (Grab Bar)/Side Rail assessment dated [DATE] showed the resident and/or family requested the use of the enabler bar (grab bar), potential risks such as entrapment and death were discussed with the resident and family (if the resident was unable to respond), alternatives used prior to using the enabler bars (grab bars) included therapy was to screen/evaluate and treat, informed consent was obtained, and the resident would demonstrate the appropriate use of the bilateral grab bars through the review date. Resident #1 was not responding to verbal cues on [DATE]. Review of an Interdisciplinary Team (IDT) note dated [DATE], showed there was no documentation of discussion with the family regarding the grab bars on Resident #1's bed, after Resident #1 was readmitted to the facility with a decline in status. Review of an Incident Note dated [DATE], showed, .CNA (Certified Nursing Assistant) notified this nurse that resident was observed on floor. This nurse observed resident sitting on the floor to the left side of resident bed, holding on to the grab bar. Resident was assisted by staff back into bed and adjusted for comfort; bed in locked and lowest position; pillows positioned on both sides of resident to prevent resident from pulling to either side of bed . Review of the significant change Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had severe cognitive impairment, required extensive to total assistance from staff for activities of daily living, and had impairment of the upper extremity on one side. Review of a Health Status Note dated [DATE], showed, .This nurse was called to room at approx. (approximately) 1530 (3:30 PM) by (named Registered Nurse (RN) #1). Pt. (Patient) found unresponsive, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directive and signed DNR order in chair (chart). Death pronounced by (Named RN #1) at 1540 (3:40 PM). This nurse did contact .resident's (family member) was able to visit resident . Review of an Un-witnessed Fall Report for Resident #1 dated [DATE] showed, .This nurse was called to room at approx. 1530 (3:30 PM) .by (Named RN #1). Pt. found unresponsive, no respirations, no pulse, no heart or breath sounds .Resident was on kneeling knees with head on bed and feet towards door . Review of the Therapy Screenings for Residents and the Rehabilitation Manager's handwritten list of residents assessed for grab bar removal dated [DATE]-[DATE] (after Resident #1's death), and documented on a plain piece of 8 x 10 paper, showed 20 residents had been selected for not meeting criteria for grab bars, and the grab bars were to be removed by the Maintenance Department. During an interview on [DATE] at 2:15 PM, Confidential Interviewee (employee) #1 was asked about the circumstances surrounding the death of Resident #1. Confidential Interviewee #1 stated, .I saw her hanging off the bed .her legs were caught in the overbed table, she was on her side, her legs were angling off. Her neck was pinned in between the mattress and the side rail (grab bar). She wasn't moving or struggling . Confidential Interviewee #1 then stated, She (Resident #1) couldn't move, she was on her knees on the floor with her neck caught between the rail and the mattress, but because of her weight it was a struggle to get her out from that rail .(Named LPN #2) was trying to get her over (turned over) .table (overbed table) was caught between .wasn't thinking about moving the table .Me and (Named LPN #2) got her out of the siderails and laid her on the floor .she wasn't talking .like she was blowing bubbles .(Named LPN #3) was rubbing her chest .(Named Registered Nurse (RN) #1) came .I was still in shock .I had just left out of there (Resident #1's room), had been 20, 25 minutes .and found her like that .when I saw her it looked like she took her last breath .when (Named LPN #2) and I got her out of the siderail (grab bar), she took her last breath .I still can't get it out of my mind . During a interview on [DATE] at 2:17 PM, Confidential Interviewee #1 stated, .She was total care, but she could assist with rolling and moving her legs .could help you turn her side to side with assistance .she would throw her legs to try to help . During a interview on [DATE] at 2:30 PM, Confidential Interviewee #1 stated that Resident #1 had metal grab bars covered in thick, black padding. During a telephone interview on [DATE] at 3:58 PM, RN #1 stated that on [DATE] she was alerted by CNA #5 that Resident #1 had fallen. She called the Star Team (an alert that is announced overhead for staff to respond to that area to lend assistance for a fall), and went to the room where she found Resident #1 lying flat on the floor with abnormal breathing, which she described as agonal (gasping and struggling to breathe). RN #1 stated that it took several people to get her back in the bed and at one point Resident #1 was unresponsive. RN #1 stated that after completing an assessment and trying to obtain vital signs, Resident #1 was pronounced deceased . RN #1 stated, After she was pronounced, I called (Named DON) right away because of the concern about the bed rail (grab bar), she had been entangled in the bed rail (grab bar) is what I was told by (Named LPN #2) and (Named CNA #5). When she went down, her legs got caught underneath the bed causing them not being able to move her because of the position of the table . During a telephone interview on [DATE] at 4:50 PM, LPN #6 stated, I went down to her room. I saw her .I couldn't get a pulse, I couldn't get anything .she was not a full code .I do remember something about they said her head was lodged in the space between the mattress and the rail (grab bar) . During an interview on [DATE] at 2:50 PM, LPN #2 stated, .she (Resident #1) had her knees on the floor, she was facing the bed, the bedside (overbed) table was over the bed at the end of the bed, and the bottom part of her legs were across the bedside table stand (bottom of the overbed table). We were having to untangle her feet from the bedside table .I don't recall seeing her body moving at all. LPN #2 said she yelled, I don't think she's breathing! Get me some help! Then she said she started trying to get her out and stated, .she was in an unnatural position enough that I knew I had to get her up .(Named CNA #5) told me that she (Resident #1) was restless (that day prior to the incident) and kept putting her legs out (off the bed) During a telephone interview on [DATE] at 1:29 PM, Resident #1's physician stated she received a text notifying her that Resident #1 had died . Resident #1's physician looked up the text on her phone and stated, It was a text at 5:38 PM, (Named Resident #1) expired (died ). Resident #1's physician confirmed she was not told about the circumstances surrounding Resident #1's death. Resident #1's physician was asked if she should have been told about the circumstances surrounding the death. Resident #1's physician stated, .if they (staff) think something is questionable, yeah, I think so. No one told me about that. They should have talked to the Medical Director. They should have let me know the circumstances about her death . During a telephone interview on [DATE] at 4:00 PM, the former Administrator (who had been employed at the facility from [DATE]-[DATE]) stated, .They (staff) said the patient had fallen in a weird position out of the bed. They were really nervous . He had CNA #5 re-enact the scene and took some pictures. The former Administrator stated, .they told me they had trouble getting her feet out, untangled, couldn't get her out . The surveyors viewed the pictures of the reenactment which showed, CNA #5 with her head caught between the mattress and the grab bar, her legs were hanging off of the bed. During an interview on [DATE] at 12:00 PM, the Housekeeping Supervisor confirmed nursing would let him know what type of mattress a resident admitted to the facility would need. He was asked what type of safety checks are done when the mattress is put on the bed. He stated the frame ties are checked to make sure the mattress doesn't slide and to make sure there are no gaps between the grab bars and the mattress. He was asked where the safety checks were documented. He stated, I thought maintenance was checking it. During an interview on [DATE] at 12:42 PM, CNA #6 was asked how she positioned Resident #1 after she provided her bed bath. CNA #6 stated, .she was total (care) we did it .side to side, whenever I had her I would prop 2 pillows on each side of her . CNA #6 was then asked how she would position Resident #1 on her side. CNA #6 stated, .put a pillow between (Resident #1's) buttock and backside. She would get her feet off the bed, when I had her .she would lean toward the rail sometimes if an extra pillow was to her side. When they (her feet) go toward the rail you put a pillow there to keep them (feet) from leaning into the rail. That will keep them (feet) on the bed and keep them (feet from) falling into the rails. The pillows are on each side . During a telephone interview on [DATE] at 2:29 PM, RN #5 was asked about the circumstances surrounding Resident #1's death. She confirmed she was working on Resident #1's hall when she heard the Star Team called and she went to Resident #1's room. She stated, .she (Resident #1) was being held up by (Named LPN #3) in semi-fowler's position on the floor .she was dressed in a skirt, shirt and shoes .(Named CNA #5) was extremely upset and said her (Resident #1's) head or neck was caught in the grab bar rail and her legs were off the bed. It was horrible. I can't imagine . RN #5 was asked what happened next. She stated the staff kept talking about what happened, and she told them to get Resident #1 back in the bed, that her lips were gray and dusky. She stated, .Somebody said when she got her head out, she let out an exhale .I wasn't told anything, just to start doing measurements (of beds) . RN #5 stated when residents get padding placed on the grab bars, the padding doesn't stay on, and stated, .most are tearing or loose or sliding off. They (Staff) don't ever re-evaluate their ability to use them (grab bars) . During a telephone interview on [DATE] at 10:47 AM, LPN #5 confirmed she had completed the Assist Bar (Grab Bar)/Side Rail Assessment on [DATE]. She confirmed the Admission Summary assessment documented Resident #1 was lethargic and could not participate in the Assist Bar (Grab Bar)/Side Rail Assessment. She confirmed the family was not present and had not been included in the [DATE] Assist Bar (Grab Bar)/Side Rail Assessment, and stated, I thought since she had the consent from before (before she went to the hospital and then returned to the facility), she could continue to use them (the grab bars). During an interview on [DATE] at 1:20 PM, the Rehabilitation Manager and the Physical Therapist were asked about the [DATE] Assist Bar (Grab Bar)/Side Rail Assessment that included a therapy screen/evaluation. The Physical Therapist stated when he attempted to do the assessment, Resident #1 refused. The Physical Therapist was asked if he had made any more attempts to screen or evaluate her. The Rehabilitation Manager stated, We always try at least one or two more times. She confirmed there was no documentation of subsequent attempts by therapy to screen or evaluate Resident #1. The Rehabilitation Manager was asked how the Assist Bar (Grab Bar)/Side Rail Assessment was used. She confirmed it was a tool to determine whether a resident was safe to have the grab bars. She confirmed therapists completed those sometimes. During an interview with MDS Coordinator #1 and #2 on [DATE] at 3:00 PM, MDS Coordinator #1 confirmed Care Plans are updated daily. She was asked about the intervention on Resident #1's Care Plan for the grab bars. She stated the grab bars had been kept on the Care Plan after Resident #1's return from the hospital, according to the electronic documentation. She was asked if Resident #1 should have been reassessed for use of the grab bars on readmission to the facility on [DATE]. She stated, Yeah, if the bars are on the bed. MDS Coordinator #2 confirmed that before a grab bar is removed from the Care Plan, MDS Coordinators must get a verbal confirmation from the Maintenance Department it has been removed, a visual confirmation by the MDS Department to make sure they have been removed, and then it is removed from the Care Plan. The MDS Coordinators were asked how the interventions are determined. The MDS Coordinators agreed the interventions are a result of the Interdisciplinary Team (IDT) meeting, and MDS Department is included in the IDT meetings. During an interview on [DATE] at 12:55 PM, the Regional Maintenance Director confirmed maintenance was to remove the grab bars based on the [DATE] - [DATE] screen performed by the Rehabilitation Manager. The Regional Maintenance Director was asked when they started removing the grab bars. He confirmed they had started this week (the week of [DATE] after the survey began on [DATE]) and he stated, They're almost done, ½ hour to an hour . During an interview on [DATE] at 1:51 PM, the DON confirmed the Rehabilitation Manager had re-screened the residents listed on the handwritten list of residents selected for grab bar removal. The DON stated, When she brought it to the meeting, it wasn't because there was any danger or something wrong with them (grab bars). But we know they can be dangerous, possibility. The DON was asked how long it should take to implement a recommendation made by the Rehabilitation Manager. She stated, It does not usually take long .We implemented it in IDT. I wouldn't say immediate, I didn't feel like the rails had done anything, if they don't need them (grab bars), let's just don't have them (grab bars) there. The DON was asked when that was completed. The DON stated, It's just now been completed, this week (week of [DATE]). During an interview on [DATE] at 3:24 PM, the Interim Administrator was asked when the grab bars were removed from resident beds that did not meet the criteria, according to the Rehabilitation Manager's [DATE]-[DATE] screening. She confirmed they started taking them off the week of [DATE]. During a random observation on [DATE] at 12:22 PM, in the resident's room, a CNA left an overbed table over Resident #3's bed after she finished assisting the resident to eat. The CNA left the room. Several minutes later the Assistant Director of Nursing (ADON) entered the room and moved the overbed table to the side of the bed and stated, Overbed tables are not supposed to be left over residents unless they are eating. The surveyors verified the Removal Plan by: 1. Between [DATE] and [DATE], the Interdisciplinary Team reviewed and assessed all residents with grab bars to determine the appropriateness of continued grab bar placement and alternative interventions considered to aid in bed mobility, and risk of entrapment. The patient and responsible party consents were obtained if there were changes. Physician orders [REDACTED]. The surveyors verified the grab bar interventions, consents, and physician orders [REDACTED]. 2. Between [DATE] and [DATE], the Interdisciplinary Team reviewed and revised the Care Plans of residents with grab bars to ensure they had resident specific documentation to reflect the identified need for grab bars. The surveyors verified the Care Plans with grab bars were updated through electronic record review. 3. On [DATE], the Regional Maintenance Supervisor inspected all beds with grab bars to ensure no entrapment risk existed. The surveyors verified the bed/grab bar inspections through interview with the Maintenance Supervisor. 4. On [DATE], all facility policies and procedures regarding grab bars were reviewed/revised by the Quality Assurance and Performance Improvement team to include tools and post-test. The Governing Body reviewed and approved the policy and procedure revisions. The Regional Maintenance Supervisor added additional information into the facility's (Named Maintenance Computer program) for bed inspections related to entrapment. The Maintenance Supervisor was in-serviced on the (Named Maintenance Computer program) and documentation relating to bed inspections for entrapment by the Regional Maintenance Supervisor on [DATE]. The surveyors verified the policies and procedures and updates to the Maintenance Computer program through policy review, a review of the updated Computer Program, and interview with the Maintenance Supervisor. 5. On [DATE], the DON or designee educated current direct care staff, prior to their next scheduled shift, on entrapment related to Grab Bars policy and procedure. Upon receiving an order for [REDACTED]. and physical status, and the increased risk of injury and death when grab bars are used improperly. New hires will receive education on (Named Maintenance Computer program) program for reporting grab bar safety. The surveyors verified Grab Bars policy and procedure, orders for grab bars, and staff education through policy review, in service review, and staff interviews. 6. The DON, Administrator, or designee, will monitor the utilization of grab bars during rounds that will occur weekly for 4 weeks, then monthly for 3 months, and then quarterly. The surveyors verified the grab bar monitoring through Interview with the DON and Interim Administrator, and the surveyors reviewed the auditing tools. 7. Immediate action will be initiated for any events identified as requiring further intervention. All audits will be discussed at the QAPI meeting, consisting of at minimum the Medical Director, Administrator, DON and the Infection Preventionist with attendance and input from other facility staff as indicated. Findings will be reviewed in the QAPI meeting to identify patterns/trends, evaluate the effectiveness of the plan, and adjust the plan as needed based on outcomes identified for a minimum of three months or until the pattern of compliance is maintained. The surveyors verified the QAPI audits through review of the revised QAPI policy and interviews with the Interim Administrator. Noncompliance of F-700 continues at a scope and severity of D for the monitoring and the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.