Every finding on record at Meadowbrook Health & Rehabilitation

Based on record review, observation, staff, physician, and pharmacist interviews, the facility failed to have a medication administration error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 9 residents observed for medication administration (Resident #4).The findings included:Resident #4 was admitted to the facility 12/5/17 with diagnoses including stroke, epilepsy (seizures), and hypertension (high blood pressure).An order dated 4/13/26 specified Resident #4 required a regular diet, with mechanical soft food and nectar thick liquids (liquids thickened to the consistency of nectar).During an observation with Nurse #1 on 8/26/26 at 9:43 AM, medications for Resident #4 were prepared for administration. Nurse #1 explained as she prepared the medications that Resident #4 required her medication crushed and put in applesauce because she had difficulty swallowing due to her stroke. The nurse prepared the medications, including metoprolol succinate ER and levetiracetam, crushed them together and mixed the crushed medication in applesauce and administered the medications to Resident #4. The medical record for Resident #4 was reviewed after the medication administration observation on 8/26/26 at 10:00 AM. Physician orders for Resident #4 included an order dated 5/19/21 that specified medications may be crushed and mixed with applesauce or pudding, expect those that cannot be crushed.A physician order dated 9/8/25 for metoprolol succinate ER (extended release) 50 milligrams (mg), one half tablet to be administered daily for hypertension. The physician order included instructions Do not crush or chew. Review of the medication administration record (MAR) also noted not to crush or chew the metoprolol succinate ER. A physician order which was dated 8/20/26 for levetiracetam 750 mg 2 times per day for seizures instructed Do not crush or chew; Swallow tablet whole. Review of the MAR also noted to not crush or chew; swallow tablet whole. A follow up interview was conducted with Nurse #1 on 8/26/26 at 12:25 PM. Nurse #1 read the instructions for Resident #4's medications metoprolol succinate ER and levetiracetam and stated she was not aware those 2 medications should not be crushed. Nurse #1 reported she had not noticed the instructions and reported she did not understand why the medications said not to crush when Resident #4 required all her medications crushed due to her stroke and difficulty swallowing pills. The Director of Nursing (DON) was present during the interview on 8/26/26 at 12:25 PM and reported she would notify the Physician of the errors. The DON reported a resident who required medications to be crushed because of swallowing issues should have medications that were appropriate to be crushed. The DON reported levetiracetam was available as a liquid and she would get a physician order to change the medication.Resident #4's Physician was interviewed by phone on 8/26/26 at 4:15 PM. The Physician reported he had been notified the metoprolol succinate ER and the levetiracetam were crushed and administered to Resident #4. The Physician reported he was not certain the administration of the medications in the crushed form would be a significant medication error or if the administration of the crushed medications would harm Resident #1. The Physician reported he would need to look up the reasons those medications should not be crushed before he could determine the seriousness of the error.A phone interview was conducted on 8/27/26 at 2:46 PM with the Pharmacist. The Pharmacist reported the concern with crushing metoprolol succinate ER would be a change in Resident #4's blood pressure, because the medication would be released all at once, and the levetiracetam would be extremely bitter to swallow in the crushed form. The Pharmacist reported she did not believe crushing the levetiracetam or metoprolol succinate were significant medication errors for Resident #4 because the facility was monitoring her and should not have caused her harm.A follow-up interview was conducted on 8/27/26 at 9:58 AM by phone with the DON and she reported she did not know why Nurse #1 would crush the medications when the instructions said to not crush or chew. The DON reported Nurse #1 may have been nervous during the observation. The DON reported she expected nurses to follow medication administration orders and recommendations, and for all residents to have medications in a form they can swallow.

Based on record review, observation, Pharmacist, Physician and staff interviews, the facility failed to administer medications in the correct form when Nurse #1 crushed 2 tablets with administration instructions to not crush for 1 of 9 residents reviewed for significant medication errors (Resident #4).The findings included:Resident #4 was admitted to the facility 12/5/17 with diagnoses including stroke, epilepsy (seizures), and hypertension.The quarterly Minimum Data Set assessment dated [DATE] documented Resident #4 was severely cognitively impaired.During an observation with Nurse #1 on 8/26/26 at 9:43 AM, medications for Resident #4 were prepared for administration. Nurse #1 explained as she prepared the medications that Resident #4 required her medication crushed and put in applesauce because she had difficulty swallowing due to her stroke. The nurse prepared the medications, including metoprolol succinate and levetiracetam, crushed them together and mixed the crushed medication in applesauce and administered the medications to Resident #4. Following the medication administration observation, the Physician orders for Resident #4 were reviewed and included an order dated 9/8/25 for metoprolol succinate (used for hypertension) ER (extended release) 50 milligrams (mg), 1/2 tablet to be administered daily for hypertension. The physician order included instructions Do not crush or chew.The Medication Administration Record (MAR) included instructions to not crush or chewA physician order which was dated 8/20/26 for levetiracetam (used for seizures), 750 mg 2 times per day for seizures instructed Do not crush or chew; Swallow tablet whole. The MAR included instructions to not crush or chew. A follow up interview was conducted with Nurse #1 on 8/26/26 at 12:25 PM. Nurse #1 read the instructions for Resident #4's medications metoprolol succinate ER and levetiracetam and stated she was not aware those 2 medications should not be crushed. Nurse #1 reported she had not noticed the instructions and reported she did not understand why the medications said not to crush when Resident #4 required all her medications crushed.The Director of Nursing (DON) was present during the interview on 8/26/26 at 12:25 PM and reported she would notify the Physician of the errors. The DON reported a resident who required medications crushed because of swallowing issues should have medication that was appropriate to be crushed, or a form that would allow them to swallow without difficulty.The Physician was interviewed by phone on 8/26/26 at 4:15 PM. The Physician reported he had been notified of the metoprolol succinate ER and the levetiracetam were crushed and administered to Resident #4. The Physician reported he was not certain the administration of the medications in the crushed form would be a significant medication error or if the administration of the crushed medications would harm Resident #1. The Physician reported he would need to look up the reasons those medications should not be crushed before he could determine the seriousness of the error.A follow-up interview was conducted on 8/27/26 at 9:58 AM by phone with the DON and she reported she did not know why Nurse #1 would crush the medications when the instructions said to not crush or chew. The DON reported Nurse #1 may have been nervous during the observation. The DON reported she expected nurses to follow medication administration orders and recommendations, and for all residents to have medications in the form they can swallow. A phone interview was conducted on 8/727/26 at 2:46 PM with the Pharmacist. The Pharmacist reported the concern with crushing metoprolol succinate ER would be a change in Resident #4's blood pressure, because the medication would be released all at once, and the levetiracetam would be extremely bitter to swallow in the crushed form. The Pharmacist reported she did not believe these were significant medication errors for Resident #4 because the facility was monitoring her and should not have caused her harm.

Based on record review, observation, and interviews with staff, Nurse Practitioner, and the Psychiatric Nurse Practitioner, the facility failed to provide effective supervision for a resident who had cognitive impairment, alcohol induced dementia, and a court appointed Guardian. On 12/2/2024 Resident #120 told the Director of Nursing he was upset because he had been told by a staff member that he was going to be moved to the secured unit. Later that same day Resident #120 stacked patio furniture in the enclosed courtyard and then proceeded to climb onto an awning, then up to the roof of the facility. Resident #120 was observed by staff to be running around on the roof and sitting on the edge of the roof with his legs dangling over the edge of the roof. To ensure safe rescue of the resident, the local fire department was called, and the resident was assisted off of the roof by firemen and the firemen aided in returning the resident to the ground. The Guardian stated when she saw Resident #120 at the hospital on [DATE] he told her he was not attempting to harm himself; he was trying to leave the facility when he climbed up on the roof from the courtyard. There was a high likelihood of a serious adverse outcome including life threatening injuries or death when Resident #120 climbed up onto the roof and while he was on the roof on 12/2/2024. The deficient practice was identified for 1 of 7 residents reviewed for accidents (Resident #120).In addition, the facility failed to complete a smoking assessment on admission and quarterly to determine if a resident was safe to smoke independently or required supervision for 1 of 3 residents reviewed for smoking (Resident #50).Example #2 was cited at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy).Findings included: A Letter of Appointment Guardian of Person (entitle under laws of North Carolina to have custody, care, and control of Resident #120) was assigned to the Guardian and signed by Clerk of Superior Court on 8/31/2021. Resident #120 was admitted to the facility on [DATE] with diagnoses including depression, agitation, and alcohol induced dementia. Resident #120's care plan that was updated on 7/24/2024 indicated he was confused and unaware of safety needs. The care plan also stated Resident #120 was a safe smoker and was allowed to go to the courtyard and could smoke unsupervised. A Psychiatry Progress Note by the Psychiatric Nurse Practitioner dated 10/21/2024 indicated Resident #120 was assessed for psychiatric medication follow-up and his current psychiatric medications included: trazodone 50 milligrams once a day (an antidepressant medication) and sertraline (an antidepressant medication) 50 milligrams once a day. The progress note further indicated he had no suicidal or homicidal ideation, he was calm and cooperative during the assessment, and his depression and insomnia were stable. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #120 was moderately cognitively impaired and had no behaviors. Resident #120 required supervision with transfers and toileting, was independent with ambulating in the facility, and did not require a mobility aid. A progress note dated 12/2/2024 at 5:20 pm written by Nurse #4 indicated Resident #120 went outside to the courtyard and climbed a tree to get on the roof at 4:30 pm, after a staff member told him he was transferring to the locked dementia (secured) unit. The Fire Department responded and assisted Resident #120 off the roof. The progress note further stated Resident #120 was put on hourly checks beginning at 6:00 pm. During the survey multiple attempts were made to contact Nurse #4 without success. Nurse Aide #5 was interviewed on 12/18/2025 at 1:37 pm. She stated she was in the activities room that led out to the smoking area on 12/2/2024 and saw Resident #120 moving the furniture in the smoking area. Nurse Aide #5 stated Resident #120 stepped up on a chair, and then stepped up on a table, and then swung himself onto the awning over the smoking area. Nurse Aide #5 stated she yelled out for help and immediately ran out to the courtyard, but Resident #120 had climbed to the top of the smoking area awning and then to the roof before she could get to him. Nurse Aide #5 stated Resident #120 was running across the roof toward the front hall of the facility. She stated Resident #120 went around the roof to above where the 100-hall exit door was (which was on the opposite side of the facility from where he initially got on the roof) and was sitting on the roof with his feet dangling over the side. The nurse aide explained from her vantage point she was able to witness the resident at all times when she was out in the courtyard, and she did not lose sight of him. Nurse Aide #5 stated other staff arrived in the courtyard and she returned to her assignment since she was not assigned to Resident #120. During a phone interview with Resident #120's court appointed Guardian on 12/18/2025 at 8:50 am she explained Resident #120 had a history of wandering the facility, but he had not attempted to leave the facility before the incident on 12/2/2024. The Guardian stated she had not been notified about the 12/2/2024 roof incident until a conversation with the Social Worker on 12/11/25. The Guardian stated when she saw Resident #120 at the hospital on [DATE] he told her he was not attempting to harm himself; he was trying to leave the facility when he climbed up on the roof from the courtyard. The Guardian stated the facility had asked her for Resident #120 to be placed on the secured unit before the incident on 12/2/2024 but it was because he was pushing other residents in their wheelchairs, not because he had attempted to elope, and she had refused to have him moved to the secured unit. The Guardian also stated she was no longer assigned to Resident #120 since he had moved to a secured unit at a facility in another county. Nurse Practitioner (NP) #1's progress note dated 12/5/2024 and timed 9:44 pm indicated Resident #120 was evaluated after he had climbed onto the roof of the facility on 12/2/2024. The progress note indicated Resident #120 had a history of alcohol dependence with acute withdrawal, illicit drug use, major depressive disorder, dementia, and chronic insomnia; and was confused. The progress note also stated Resident #120 denied suicidal ideation, was feeling well, and had no intentions or desires to get back on the roof. Nurse Practitioner #1 indicated an electronic wander guard transmitter should be put into place for Resident #120. NP #1's progress note dated 12/10/2024 and timed 6:28 pm by Nurse Practitioner #1 indicated Resident #120 was seen for a routine monthly follow-up assessment. At the time of the assessment the resident was confused, with diagnoses of major depressive disorder, dementia, chronic encephalopathy, and insomnia. The progress note stated supportive measures and redirection of behaviors should continue as needed. NP #1 was interviewed by phone on 12/18/2025 at 5:17 pm and stated she was present in the facility when Resident #2 had climbed onto the roof on 12/2/2024. NP #1 stated she saw Resident #120 on 12/2/2024 after the incident but did not document the visit until 12/5/2024 in a progress note. NP #1 stated she did not believe Resident #120 was suicidal and he stated he just wanted to leave the facility when she assessed him on 12/5/2024. She stated he had become agitated because he was told he was going to be moved to the secured unit. NP #1 stated Resident #120 was normally confused and would wander around the facility but had not tried to leave the facility until 12/2/2024. During a phone interview with the Psychiatric Nurse Practitioner on 12/29/2025 at 12:21 pm he stated he was not notified of the incident when Resident #120 climbed onto the roof of the facility on 12/2/2024. He stated he saw Resident #120 for depression and insomnia and reviewed his medications. The Psychiatric Nurse Practitioner stated when he assessed Resident #120 on 6/29/2024 and 7/16/2024 he was not suicidal but did have behaviors of wandering and definitely had cognitive impairment related to dementia. The Maintenance Director was interviewed on 12/18/2025 at 4:06 pm in conjunction with an observation made when he conducted measurements with a measuring tape. The Maintenance Director measured the distance from the ground to the top of the smoking area metal awning to be 96 inches (8 feet) and the distance from the top of the smoking area awning to the roof to be 60 inches (5 feet). The Maintenance Director stated he cut the tree limbs back around the smoking area awning and the roof after the 12/2/2024 incident when Resident #120 climbed up on the smoking area awning and then the roof. He explained it was reported to him that the resident had used the limbs to support himself as he had climbed. The Maintenance Director stated the top of the awning and roof were flat. Director of Nursing (DON) #2, the previous DON, who no longer worked for the facility, was interviewed by phone on 12/17/2025 at 3:27 pm. During the interview she stated she was present at the facility on 12/2/2024. She explained Resident #120 became upset because he told the DON he had been told by a staff member that he was going to be moved to the secured unit. DON #2 further stated Resident #2 climbed up on the awning over the smoking area in the courtyard and from there he climbed up on the roof of the facility. DON #2 stated the fire department was called and they removed him from the roof and he was on the roof for approximately 15 to 20 minutes. In a follow up phone interview on 12/19/2025 at 8:32 am DON #2 stated Resident #120 was not suicidal but tried to leave the facility when he climbed onto the roof on 12/2/2024. She stated Resident #120 was on every hour checks until Nurse Practitioner #1 saw him a few days after the 12/2/2024 incident and the resident stated had no intention of climbing on the roof again. On 12/19/2025 at 9:12 am Administrator #2, the former Administrator, was interviewed by phone and stated on 12/2/2024 Resident #120 had managed to stack furniture and used the limbs of a tree to climb up on the awning over the smoking area in the courtyard of the facility. Resident #120 then proceeded to climb up on the roof of the facility. The facility provided a statement that was undated and signed by the Social Worker that stated she met with Administrator #2, DON #2, and the Guardian on 12/1/2024, 12/2/2024 and 12/4/2024 and in the meetings they discussed moving Resident #120 to the secured dementia unit, but the Guardian had refused to move Resident #120. The Administrator was notified of the immediate jeopardy on 12/18/2025 at 4:15 PM. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #120 was a long-term resident who had documented cognitive impairment, agitation, impaired judgment, but no wandering behaviors prior to 12-2-2024. Resident#120 had a court-appointed guardian for the person. Resident#120 had a Brief Interview for Mental Status (BIMS) score of 9, indicating cognitive impairment on 10-22-2024 and was assessed as a safe smoker on 10-16-2024. Resident #120 had a documented history of mild agitation, impulsive behaviors, impaired decision-making and was care planned for those areas. Resident#120 was being seen by psychiatric services and was last seen on 10-21-2024 by a psychiatric Nurse Practitioner (NP). The notes from the psychiatric NP visit documented the resident's behaviors were stable and Resident#120 stated he got sad sometimes. Resident #120 was an active smoker, had been deemed a safe smoker, and did not require supervision. The smoking area was in the enclosed courtyard, and the resident was allowed to go out to the courtyard and smoke independently. Resident #120 ambulated independently without assistive device and gait was steady on even and uneven surfaces. He did not require supervision for ambulation due to gait. On 12-1-2024, the former Administrator and former Director of Nursing (DON) contacted Resident 120's court-appointed guardian to discuss concerns regarding Resident #120 including increased agitation and a decline in safety awareness all of which had been observed over several days prior to contacting the resident's guardian. During this call, the former Administrator and former DON reported Resident #120 had required frequent redirection, had been entering common areas without purpose, and had demonstrated poor judgment related to environmental safety including taking his roommate, who was not a smoker, out to the courtyard to smoke, and he became easily agitated with staff. The guardian was informed that the resident's behaviors appeared to be escalating and that additional supervision or a higher level of secured care might become necessary if the behaviors continued. No change in placement was approved by the guardian at the time of the call. In the days leading up to 12-2-2024, staff noted an increase in agitation and unsafe behaviors of Resident #120, which contributed to the escalation of behaviors, according to a note in the resident's chart dated 12-1-2024. The note documented the resident was trying to take his roommate outside to smoke. Resident #120's roommate was not a smoker. Resident#120 had been a safe smoker until 12-2-2024 when he was reassessed following his climbing onto the roof and his smoking status was changed to a supervised smoker. Resident#120 had made no prior attempts to elope and usually only went outside to smoke or to color. The reason for the resident's change in behavior was unknown. Resident#120 did not wear a wander guard up until the time of discharge. The former DON did attempt to place a wander guard on resident #120 on 12-2-2024 but according to an interview with the Assistant Director of Nursing (ADON) he would not wear the wander guard and ripped it off in seconds. On 12-2-2024, at approximately 5:00 PM, while Nursing Assistant (NA) #1 was in the Activities room which exits to the courtyard, and has windows with a view of the courtyard, and she observed Resident # 120 in the enclosed courtyard appearing restless, agitated, repositioning and climbing on courtyard furniture near the wall of the facility. NA #1 ran out to the courtyard, and the resident was observed to have climbed up onto the roof using a table and the branch of a tree. NA#1 called for assistance from other staff verbally as she was running out of building into the courtyard. By the time NA #1 got outside to the enclosed courtyard she observed resident #120 standing on the roof above the courtyard area, near the awning on the south side of the facility. The resident was alternating standing and pacing on the roof, demonstrating poor safety awareness and an inability to recognize the risk of serious injury. When other staff arrived in courtyard NA #1 stated she immediately notified the Unit manager, who contacted the former Director of Nursing and Unit 2 charge nurse who called the Fire Department. Staff maintained continuous visual observation from the courtyard below and did not access the roof due to safety concerns. The Fire Department assisted the resident off the roof using appropriate safety equipment which included a ladder and physical assistance. Two firemen went up to the roof to assist the resident in safely getting down from the roof and the resident was cooperative with redirection once emergency personnel arrived. Resident#120 was verbal but cognitively impaired, and when the fireman asked him why he climbed onto the roof, he stated he was trying to get outside, but was unable to provide further explanation. Resident #120 was assessed immediately upon removal from the roof by the former Director of Nursing, with a full head-to-toe assessment completed at approximately 5:30 PM, and no injuries were identified. Due to the resident's cognitive impairment, agitation, and the behavior of him climbing up to the roof, enhanced supervision of Resident #120 was initiated on 12-2-2024, at approximately 6:00 PM, which included frequent NA visual checks every 15 min and a nurse check hourly. Staff were instructed by the former DON to place the resident on 1:1 during periods of agitation. Resident did not require 1:1 monitoring. Resident#120 was then restricted from going out to the courtyard unsupervised and was placed on the supervised smoking list. This enhanced supervision was implemented at 6:00pm on 12-2-2024 per the medical record and was conducted by licensed nursing staff and direct care staff. The enhanced supervision remained in place until further care planning decisions were made. The facility determined the resident accessed the roof by climbing onto movable courtyard furniture, possibly also holding onto a tree branch, and stepping onto an awning, which provided access to the roofline. On 12-2-2024, immediately following the roof access incident, the former Administrator and former DON notified Resident 120's guardian of the event in which the resident gained access to the roof from the enclosed courtyard. The guardian was informed the resident had climbed furniture, accessed an awning, and stood on the roof. The resident had created a high risk for serious injury or death to himself due to impaired judgment and lack of safety awareness. During this conversation, the facility requested permission to transfer the resident to a secured unit within the facility, due to the unsafe climbing behavior, repeated wandering, inability to recognize danger, and escalating agitation. The former DON and the former Administrator explained that until placement could occur, the resident had been placed on enhanced supervision, had restricted access to the courtyard, and had been closely monitored by nursing and direct care staff. The guardian declined placement in the secured unit, stating a preference for the resident to remain in the current unit and attempting to manage behaviors in the resident's current environment, meaning out on the regular floor and not in the secured unit. The resident continued with periods of wandering and attempting to go to the courtyard from 12-2-2024 through 12-4-2024 according to interviews with the Unit Manager and the ADON. On 12-2-2024, Resident #120 was relocated to a room closer to the nurses' station, which allowed for increased frequency of staff observation, quicker response to agitation, and earlier intervention when wandering behaviors were noted. The resident had exhibited no further behaviors at that time, but administration team felt continued close supervision was needed for the resident for safety due to the 12-2-2024 incident. At the time of incident on 12-2-2024 Resident #120 had shown a cognitive decline and agitation but had not exhibited wandering behavior, attempted to exit seek, or display at risk behavior until 12-2-2024. On 12-4-2024, the former Administrator and Director of Nursing contacted the court-appointed guardian again to provide an update regarding Resident 120's safety risks. The guardian was informed that despite enhanced supervision, the resident continued to exhibit wandering behaviors, agitation, poor safety awareness, and the facility remained concerned about its ability to safely meet the resident's needs in a non-secured setting. The request for secured unit placement was reiterated due to continued risk of serious harm; however, the guardian again declined the request, citing a preference for continued care in the current environment. The guardian was advised about the resident's care plan had been updated on 12-2-2024, to include increased supervision, identification of wandering risk, environmental safety controls, and behavioral monitoring interventions, which remained in place. On 12-11-2024 at approximately 6:30 AM Resident #120 was observed by former Nurse #1 pacing and exhibiting increased agitation up and down hallway and charted the observation. Nurse #1 followed the resident into the courtyard and observed the resident moving around tables. The resident would not say what he was doing when asked but the resident was easily redirected back into the facility by former Nurse #1 and returned to his room without incident. The nursing station was across from resident's room, and he was monitored closely by staff until Involuntary commitment paperwork was obtained for psychiatric and medical evaluation due to the increased agitation and noted hallucinations (hearing a television (TV) that was not there or on and yelling for it to be turned off). The resident was transported to the hospital by the local police department and was to have a psychiatric evaluation as part of an involuntary commitment (IVC) for his agitation. The resident was admitted to the hospital. The resident's guardian felt the resident would become increasingly agitated in secured unit and would not allow admission into the secured unit. The facility was unable to safely meet the residents' needs due to guardian's continued refusal of placement into the secured unit. The former Administrator informed the hospital Resident #120 could return but it would need to be on the secured unit for safety, the resident's guardian declined, and alternate placement was arranged by the hospital. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All Residents with cognitive deficits and physical capabilities have the potential to be affected. At the time of incident on 12-2-2024 all residents who had wandering behaviors resided on the secured unit. As of 5-1-2025 all newly admitted residents have been assessed for wandering on admission as part of the admission assessment. All residents will be assessed for wandering quarterly and with any significant change in condition. All residents were assessed for wandering, change in behavior, increased agitation, and subsequent elevation of problematic/inappropriate behaviors on 10-24-2025 by ADON, who was acting as the DON. Wander guard transmitters were placed on all residents who had the ability to wander by the Unit Manager and ADON, who was acting as the DON. Any residents who were identified with a change in behavior, increased agitation, and subsequent elevation of problematic/inappropriate behaviors were reviewed by the ADON, who was acting as the DON, and referrals were made to the resident's physician and psychiatric service as needed. There were no residents assessed being at risk for injury in need of 1:1 due to behaviors on 10-24-2025. The Interdisciplinary Team (IDT) which included the Former Administrator, ADON, acting as DON, Social Worker#1, Admissions Coordinator, Unit Manager #1, Unit manager #2 Maintenance Director and Activity Director met on 10-24-2025. During the meeting the IDT reviewed all residents in the facility to identify residents who had wandering or exit seeking behavior. As of 10-24-2025 all residents who had wandering behavior or exit seeking had wander guards. As of 10-24-2025 there have been 2 staff members who were in the dedicated role of wandering resident monitors on duty 24 hours a day, 7 days a week. The 2 assigned staff members monitor wandering residents and points of egress. This system will remain in place for safety as long as facility has wanderers who can access points of egress in the facility or until a safer alternative is identified. Hall monitors are on the facilities staffing template for staffing coordinator to schedule every shift in the same manner she schedules nurses and NAs. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. During an all staff meeting on 12-14-2024, staff received in-service training regarding the expectations of supervision of wandering residents by the former DON. The training included education regarding continuous observation of residents exhibiting unsafe behaviors, immediate escalation of concerns, and proactive identification of environmental risks. All staff were educated and acknowledged they attended and attested to understanding of expectations, by signing education attendance log. Staff were instructed to relocate any resident who was displaying exit seeking behavior or was wandering to the secure unit and notify the former DON. The former DON would then evaluate if long-term placement to the secured unit was needed. On 5-1-2025 all employees in the facility were re-hired by new ownership and have received training on dementia, as well as caring for wandering residents and residents with behavior by Human Resources and the DON. All employees had to complete training module on caring for residents with Dementia and behaviors to be eligible for rehire by new administration by 5-1-2025. All newly hired staff receive training on dementia, as well as caring for wandering residents and residents with behavior by ADON and HR Director. The training is repeated annually after hire. On 10-24-2025 to alter the process and prevent recurrence, the facility implemented changes to supervision, environmental monitoring, and risk identification practices. These actions included restricting unsupervised courtyard access for residents with wandering or unsafe behaviors, implementing designated staff monitoring of the courtyard during resident use, completing routine environmental rounds focused on elevated surfaces and climb risks, and incorporating behavioral escalation triggers into care planning. These actions were completed and fully implemented by 10-24-2025 by ADON, acting as interim DON and the Maintenance Director. All Staff were educated on the systematic change on 10-24-2025. Staff that were not available were educated prior to returning to work. All new hires will be educated during orientation. On 10-24-2025 to alter the process and prevent recurrence, the facility implemented changes to supervision, environmental monitoring, and risk identification practices. These actions included restricting unsupervised courtyard access for residents with wandering or unsafe behaviors, implementing designated staff monitoring of the courtyard during resident use, completing routine environmental rounds focused on elevated surfaces and climbing risks. These actions were completed and fully implemented, with education completed by 10-24-2025 by the ADON, acting as interim DON, and the Maintenance Director to all staff. Education Included that a nurse manager be notified immediately for any new agitation, pacing, wandering or exit seeking behavior, a wandering assessment to be completed and a wander guard placed on resident, Medical Director or provider to also be notified of change in behavior as well as the Residents Responsible party to also be notified of change in behavior and interventions. On 10-24-2025 all employees were educated by the ADON on facility processes for residents with Increased agitation, pacing, exit seeking or wandering behavior and a review of the education will continue annually. All new hires will be educated on facility processes for residents with wandering behavior as part of the orientation process. All residents will be assessed for wandering and exit seeking quarterly and with any significant change in condition. Two staff members have been put into place to monitor wandering and exit seeking residents. The 2 staff members have been in place 24 hours a day, 7 days a week, since 10-24-2025. The 2 assigned staff members monitor residents with exit seeking behaviors, agitation and wandering residents and points of egress. This system will remain in place for safety as long as facility has wanderers who can access points of egress in the facility or until a safer alternative is identified. The wandering resident monitors have been on the facilities staffing template for staffing coordinator to schedule every shift in the same manner she schedules nurses and NAs. Residents with new behaviors of wandering and exit seeking behaviors are discussed Monday thru Friday in Morning clinical meetings by the Administrator, the DON, the ADON, the unit managers, the Social Worker, and the Rehab Director. The DON has been tasked with being responsible for checking the charts to ensure a wandering assessment was completed, Medical Director and the resident's responsible party was notified, a wander guard was initiated, and the care plan was updated with resident specific interventions. A list of exit seeking wandering residents will be updated immediately when a resident becomes newly identified as being at risk for wandering and the list of exit seeking wandering residents will be reviewed weekly by DON and Social Worker for accuracy. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Resident wandering assessments and nursing documentation will be audited by the DON and/or the ADON to identify residents who display an increase in agitated behaviors and/or exit seeking/wandering behavior. Audits will include that all residents with increased agitation, exit seeking, and wandering behaviors have wander guards in place and are care planned for appropriate interventions related to the identified behavior. Results of audits will be discussed weekly at the clinical At-Risk IDT Meeting. Audits were initiated on 10-24-2025 by the ADON, acting as the DON, and will continue weekly for 3 months, and then monthly for 3 months to ensure compliance. Results of audits will be presented monthly by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee, consisting of the Director of Nursing, the Assistant Director of Nursing, the Administrator, the MDS Nurse, the Social Worker, Business Office Manager, Maintenance Director, Housekeeping Director, Dietary Manager, Admissions Coordinator, Activities Director, Rehab Director, Unit Manager, and Medical Director for discussion and revisions will be made as needed. The facility's QAPI team met on 10-24-2025 and reviewed interventions put into place to address wandering, elopement, change in behavior, increased agitation, and subsequent elevation of problematic/inappropriate behaviors. Alleged date of compliance: 10-25-25. The facility's corrective action plan was validated on-site on 12/23/25 by record reviews, observations, and staff interviews. Review of audits showed the facility completed new wandering/elopement assessments on all residents. Individual interviews of multiple current staff members working all reported to have completed dementia and behavior de-escalation training since new ownership on 5/1/25. Record review of the in-service documents dated 12/12/24 and 10/24/25 noted the ADON, the previous DON and the Staff Development Coordinator completed the in-person trainings. Signed staff rosters were reviewed with no issues or concerns. Interviews conducted with multiple staff members revealed they had received training about dementia, behaviors, and the elopement monitoring process, and were able to identify what processes to put into place in the event a resident begins showing increased agitation and wandering. Observations revealed two hall monitors on

Based on record review and staff interviews, the facility failed to submit a 5-day investigation report to the State Agency for Resident #22 and Resident #6 for misappropriation of narcotic medication. In addition, the facility failed to report Resident #6's missing narcotics to Adult Protective Services or submit an initial allegation report to the State Agency. The deficient practice occurred for 2 of 3 residents reviewed for abuse, neglect, and misappropriation (Resident #22 and Resident #6). Findings included:The facility's Abuse Policy dated 10/20/2022 stated the facility would report allegations of misappropriation to the State Agency, Adult Protective Services, and Law Enforcement agencies within 24 hours if the event that caused the suspicion did not result in bodily harm. The facility's Diversion of Medications Policy dated 5/2022 indicated the facility would report to any agencies required by state regulation.1. Resident #22 was admitted to the facility on [DATE] with diagnoses of immobility and contractures.A review of Resident #22's physician's orders indicated he should receive oxycodone (a narcotic pain medication) 5 milligrams two times a day which was ordered on 10/22/2025.A Packing Slip Proof of Delivery form provided by the facility from the facility's contracted pharmacy was provided for review. The form was not signed by the receiving nurse but indicated Resident #22 had 2 medication cards of 30 tablets each of Oxycodone 5 milligrams delivered to the facility on [DATE]. The packing slip was printed at the pharmacy when the medications cards were transported to the facility on [DATE] at 2:27 pm.During an interview with Medication Aide (MA) #1 on 12/18/2025 at 10:52 am she stated she arrived for her shift on 11/6/2025 at 2:00 pm and was counting the narcotics on the medication cart with Nurse #2 when she realized Resident #22 should have had two medication cards of Oxycodone 5 milligrams because the cards were numbered 1 of 2 and 2 of 2, but Resident #22 only had (1) card and it was numbered 1 of 2. Medication Aide #1 stated she reported the missing narcotic medication card to DON #1 immediately on 11/6/2025.An interview was conducted with DON #1 on 12/17/2025 at 9:30 am and she stated they discovered Resident #22 had a card of 30 tablets of oxycodone 5 milligrams tablets missing on 11/6/2025 when MA #2 realized the card was missing from the locked narcotic drawer on the medication cart. DON #1 stated she completed a 24-hour report to the State Agency and sent it in on 11/7/2025. DON #1 stated she had also reported the 30 missing oxycodone 5 milligrams tablets to the police department, but they did not open a police report, Adult Protective Services, and to the facility's contracted pharmacist. DON #1 stated she had not reported the 30 missing oxycodone 5 milligrams to the Drug Enforcement Administration (DEA) because she had only been at the facility for a week and thought the contracted pharmacist would notify the DEA. DON #1 stated she thought she had sent the 5-day investigation report to the state agency but was unable to provide a copy of the report or the validation it was faxed to the State Agency, and the report was not received by the State Agency.2. Resident #6 was admitted to the facility on [DATE] with diagnoses of osteoporosis and chronic pain.A Physician's Order dated 9/16/2025 indicated Resident #6 received hospice services.On 10/2/2025 a Physician's Order stated Resident #6 should receive Oxycodone 5 milligrams every 6 hours as needed for moderate pain.A Packing Slip Proof of Delivery form indicated Resident #6 had 30 Oxycodone 5 milligrams tablets on 10/2/2025 at 5 pm.A Physician's Order dated 10/15/2025 indicated Resident #6 should receive Morphine Sulfate (a narcotic pain medication) 20 milligrams/milliliters at 0.5 milliliters by mouth four times a day. A Packing Slip Proof of Delivery form indicated Resident #6 had 30 Oxycodone 5 milligrams tablets on 11/13/2025 at 8 am.On 12/18/2025 at 10:42 am MA #1 stated she was assigned to Resident #6 on 11/10/2025 and was asked to count Resident #6's narcotics by the Hospice Nurse that was visiting. She stated she remembered Resident #6 had 28 oxycodone 5 milligram tablets in the locked narcotic drawer of the medication cart on the when she worked on 11/3/2025, but the oxycodone was not in the locked narcotics box on the medication cart. MA #1 stated Resident #6 had not been taking the oxycodone 5 milligrams tablets because they were as needed and she was also receiving Morphine Sulfate (a narcotic pain medication) and it relieved her pain. MA #1 stated she notified DON #1 immediately of the missing narcotics. DON #1 was interviewed on 12/18/2025 at 10:34 am and she stated MA #1 and the Hospice Nurse discovered a medication card with 28 tablets of Oxycodone was missing from the locked narcotics drawer of the medication cart on 11/10/2025 and they notified her immediately. DON #1 stated she had not initiated a 24-hour report or 5- day report to the State Agency for the 28 tablets of oxycodone, and she did not report to the police, Adult Protective Services, or DEA that the 28 tablets of oxycodone were missing. DON #1 stated she thought that she did not need to report Resident #6's missing oxycodone since she had already investigated Resident #22's missing oxycodone. Administrator #1 was interviewed on 12/19/2025 at 12:57 pm and he stated DON #1 should have ensured the State Agency, Adult Protective Service, and Drug Enforcement Agency were notified of the missing narcotics that belonged to Resident #22 and Resident #6.

Based on observations and staff interviews, the facility failed to remove expired leftover and unopened food items stored for use in 1 of 1 walk-in cooler, 1 of 1 dry goods storage room, and 2 of 2 nourishment rooms (100 and 200 Hall nourishment rooms), and failed to remove dented cans stored for use in the dry goods storage room. These practices had the potential to affect food served to residents.Findings included: 1a. An observation and interview with the Dietary Manager of the dry goods storage room was conducted on 12/15/25 at 10:20 AM. There were products that were expired and unlabeled. The expired products included:- thirteen thickened orange juice cups with a manufacturer's expiration date of 11/21/25.- one case of one hundred-fifty packages of animal crackers with a manufacturer's expiration date of 9/21/25.- one and a half cases of twelve-cup ground coffee packets with a manufacturer's expiration date of 11/20/24.- three containers of vegetable soup base with a manufacturer's expiration date of 11/8/25.- dozens of single use creamy French dressing packets in a storage bin that was labeled with a sticker for Italian dressing with 11/24/25 as the date the Italian dressing package was opened, hundreds of 1000 island single use dressing packets in an unlabeled storage bin without any date for when it was opened. The Dietary Manager stated the individual dressing packets had no expiration date printed on them and the expiration dates would have been on the original box, which was previously discarded, so the Dietary Manager was unsure of their expiration date.There was one case of dented cans of vegetables that were stored for use on the shelf with other canned goods and were not stored in the designated space for dented items. The signage on the designated space directed staff not to use dented items and to store them there for return and/or credit from their supplier. The Dietary Manager indicated the case needed to be removed and then placed it on the shelf next to the door which was designated for dented cans. The Dietary Manager revealed he was responsible for inspecting the storage areas and for checking for expired items and had no designated schedule for the checks.b. An observation and interview with the Dietary Manager of the walk-in cooler was conducted on 12/15/25 at 10:40 AM and revealed expired items which included two full 5-pound containers of chicken salad with a manufacturer's expiration date of 12/12/25 and one half full 5-pound container of chicken salad with a manufacturer's expiration date of 11/26/25. The three containers of chicken salad were removed by the Dietary Manager and placed on a shelf in the walk-in cooler that was designated for returns and credit from their supplier. The Dietary Manager stated his standard practice was to put any expired cold foods in the garbage.2a. An observation with the Dietary Manager and Regional Dietary Manager of the 200-hall nourishment room was conducted on 12/15/25 at 11:00 AM. In the 200-hall nourishment room there were two opened and partially used 32-ounce containers of nutritional supplement, one opened and partially used gallon of sweet tea, and three opened and partially used 32-ounce containers of thickened orange juice that were not labeled with a date the package was opened for use because manufacturer's directions stated the product was shelf stable for a predetermined number of days once opened. Manufacturer guidelines stated the sweet tea must be consumed within 5 to 7 days after opening, if stored refrigerated and the thickened drink products and nutritional supplement must be used within 4 days of opening, when refrigerated after opening. There were three personal individual food packages not labeled: one medium to-go paper container of partially eaten food, one partially eaten baked good wrapped in plastic packaging, and one fast food bag with items in it with the top folded down.b. An observation with the Dietary Manager of the 100-hall nourishment room was conducted on 12/15/25 at 11:08 AM and revealed there was one opened and partially used 32-ounce container of thickened lemonade and one opened and partially used 32-ounce container of nutritional supplement that was not labeled with the date the packages were opened. Manufacturer guidelines stated the thickened drink products must be used within 4 days of opening, when refrigerated after opening. There were two personal individual food packages which were not labeled: one partially eaten cake in a disposable plastic container and one medium size bag from a fast-food restaurant. An interview conducted with Dietary Manager on 12/15/25 at 11:10 AM. The Dietary Manager reported he was responsible for checking the nourishment refrigerators for expired items and had no designated schedule for the checks. The Dietary Manager stated that nursing staff were responsible for checking the nourishment rooms for any expired items. The Dietary Manager stated it was the responsibility of any staff that placed residents' personal food in the refrigerator to label it with the residents' name and date they place it in the fridge or freezer.An interview conducted with the Regional Dietary Manager on 12/15/25 at 11:20 AM revealed his company's food service contract began 6 weeks ago. The Regional Dietary Manager stated he expected food items to be stored and labeled with resident's name and date of when the item was received for storage, and for expired items to be removed from circulation. An interview was conducted on 12/18/25 at 9:45 AM with Unit Manager #2 on the 200 Hall. The Unit Manager #2 stated two staff who were assigned to the nourishment room task were responsible for removing outdated, mislabeled, or unlabeled items at the end of the shift. The Unit Manager was aware there were items not labeled and stored in the refrigerator which were removed by the Dietary Manager on 12/15/25 and stated the policy for food storage and labeling was posted in the nourishment rooms, but she also gave verbal reminders in her daily huddle.

Based on staff interviews and record reviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for residents previously determined to have a Level I status for a PASRR after a new serious mental disorder was identified for 4 of 5 residents reviewed for PASRR (Resident #14, Resident #83, Resident #107 and Resident #9). The findings included: 1. Review of Resident #14's medical record revealed a PASSR Level I was completed on 1/18/13 prior to admission with a recommendation to resubmit paperwork for PASSR Level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident # 14 was admitted to the facility on [DATE]. The electronic medical record revealed Resident #14 was diagnosed with dementia with behavioral disturbance on 02/23/24, schizophrenia on 8/21/24, and anxiety on 10/09/24. Review of the medical record revealed there was no documented evidence a request for an evaluation for a Level II PASRR was made. Review of the Nurse Practitioner's 8/1/25 progress note revealed schizophrenia was a diagnosis listed in the assessment and plan with olanzapine prescribed twice daily. Review of the psychiatric nurse practitioner's 10/14/25 progress note for consideration of a gradual dose reduction of olanzapine for schizophrenia revealed that it was contraindicated because the resident was stable and would continue to see and reassess the resident every 4 weeks for a gradual dose reduction of psychiatric medications for his schizophrenia and anxiety. During an interview on 12/17/25 at 3:45 PM with the Minimum Data Set (MDS) Nurse, she communicated it was her understanding that if a resident had a change in condition along with a new mental health diagnosis, then she was required to notify the Social Work Director the resident should be referred for evaluation for a Level II PASSR. The MDS Nurse stated she provided a copy of her handwritten list of 25 residents who had new mental health diagnoses that required a referral for a PASSR Level II evaluation to the Directors of Social Work and Nursing. Resident #14's name was on the handwritten list she shared. During an interview on 12/17/25 at 3:30 PM with the Social Work Director, she stated she initiated a PASSR Level I or Level II request for an evaluation if the Minimum Dat Set Nurse notified her that a resident had a significant change or a new mental health diagnosis. The Social Work Director stated Resident #14 was on an August 2025 list of names from an audit the MDS Nurse provided to the Social Work Director that still needed to be submitted for a PASSR Level II evaluation. The Social Work Director shared the list of 25 residents that needed to be submitted for PASSR Level I or II evaluation due to a mental health diagnosis and stated she crossed off resident names when she submitted them for a PASSR Level II evaluation. Resident #14's name did not have a line through it. The Social Work Director was unable to provide a date when the submission would be completed. During an interview on 12/18/25 at 3:00 PM with the Director of Nursing, she communicated her understanding that a request for an evaluation for a Level II PASRR should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. The Director of Nursing stated she has been in the position less than one month and was aware the MDS nurse and Social Work Director were updating their list of residents who still needed to be referred. The Director of Nursing stated she needed to review the performance improvement plan developed by the MDS Nurse and Social Work Director to address the staff's knowledge gap and lack of a process to identify residents who needed a referral for a PASSR Level I or II evaluation. The Director of Nursing stated she was not aware of any details or the residents' names on the list of 25. 2. Review of Resident #83's medical record revealed a PASRR Level I was completed on 3/8/17 prior to admission to the facility with a recommendation to resubmit paperwork for PASSR Level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The resident was admitted to the facility on [DATE] with diagnoses including schizophrenia. The electronic medical record revealed Resident #83 was diagnosed with severe depression on 3/8/23, dementia on 9/3/24, and bipolar disorder on 9/3/24. Review of the Psychiatric Nurse Practitioner's 9/11/25 progress note revealed that the resident was stable on current regiment and would be seen routinely for her schizophrenia, depression, and bipolar disorder. Review of the medical record revealed there was no documented evidence a request for an evaluation for a Level II PASRR was made. During an interview on 12/17/25 at 3:45 PM with the Minimum Data Set (MDS) Nurse, she communicated it was her understanding that if a resident had a change in condition along with a new mental health diagnosis, then she was required to notify the Social Work Director the resident should be referred for evaluation for a Level II PASSR. The MDS Nurse stated she provided a copy of her handwritten list of 25 residents who had new mental health diagnoses that required a referral for a PASSR Level II evaluation to the Directors of Social Work and Nursing. Resident #14's name was on the handwritten list she shared. During an interview on 12/17/25 at 3:30 PM with the Social Work Director, she stated she initiated a PASSR Level I or Level II request for an evaluation if the Minimum Dat Set Nurse notified her that a resident had a significant change or a new mental health diagnosis. The Social Work Director stated Resident #14 was on an August 2025 list of names from an audit the MDS Nurse provided to the Social Work Director that still needed to be submitted for a PASSR Level II evaluation. The Social Work Director shared the list of 25 residents that needed to be submitted for PASSR Level I or II evaluation due to a mental health diagnosis and stated she crossed off resident names when she submitted them for a PASSR Level II evaluation. Resident #83's name did not have a line through it. The Social Work Director was unable to provide a date when the submission would be completed. During an interview on 12/18/25 at 3:00 PM with the Director of Nursing, she communicated her understanding that a request for an evaluation for a Level II PASRR should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. The Director of Nursing stated she has been in the position less than one month and was aware the MDS nurse and Social Work Director were updating their list of residents who still needed to be referred. The Director of Nursing stated she needed to review the performance improvement plan developed by the MDS Nurse and Social Work Director to address the staff's knowledge gap and lack of a process to identify residents who needed a referral for a PASSR Level I or II evaluation. The Director of Nursing stated she was not aware of any details or the residents' names on the list of 25. 3. Review of Resident #107's medical record revealed a PASSR Level I was completed 3/22/18 prior to admission to the facility with a recommendation to resubmit paperwork for a PASSR Level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The resident was admitted to the facility on [DATE] with readmission on [DATE]. The electronic medical record revealed Resident #107 was diagnosed with psychosis on 9/11/24, dementia on 9/11/24, bipolar disorder on 9/11/24, anxiety on 9/11/24, and schizophrenia on 6/10/25. Review of the Psychiatric Nurse Practitioner's 6/10/25 progress note revealed the resident had a diagnosis of schizophrenia listed in their assessment and plan for Resident #103. Resident #107 would be seen every 4 weeks for psychiatric follow-up and assessment for a gradual dose reduction of psychiatric medications prescribed for her bipolar disorder, schizophrenia, and anxiety. Review of the medical record revealed there was no documented evidence a request for an evaluation for a Level II PASRR determination was made. During an interview on 12/17/25 at 3:45 PM with the Minimum Data Set (MDS) Nurse, she communicated it was her understanding that if a resident had a change in condition along with a new mental health diagnosis, then she was required to notify the Social Work Director the resident should be referred for evaluation for a Level II PASSR. The MDS Nurse stated she provided a copy of her handwritten list of 25 residents who had new mental health diagnoses that required a referral for a PASSR Level II evaluation to the Directors of Social Work and Nursing. Resident #14's name was on the handwritten list she shared. During an interview on 12/17/25 at 3:30 PM with the Social Work Director, she stated she initiated a PASSR Level I or Level II request for an evaluation if the Minimum Dat Set Nurse notified her that a resident had a significant change or a new mental health diagnosis. The Social Work Director stated Resident #14 was on an August 2025 list of names from an audit the MDS Nurse provided to the Social Work Director that still needed to be submitted for a PASSR Level II evaluation. The Social Work Director shared the list of 25 residents that needed to be submitted for PASSR Level I or II evaluation due to a mental health diagnosis and stated she crossed off resident names when she submitted them for a PASSR Level II evaluation. Resident #107's name did not have a line through it. The Social Work Director was unable to provide a date when the submission would be completed. During an interview on 12/18/25 at 3:00 PM with the Director of Nursing, she communicated her understanding that a request for an evaluation for a Level II PASRR should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. The Director of Nursing stated she has been in the position less than one month and was aware the MDS nurse and Social Work Director were updating their list of residents who still needed to be referred. The Director of Nursing stated she needed to review the performance improvement plan developed by the MDS Nurse and Social Work Director to address the staff's knowledge gap and lack of a process to identify residents who needed a referral for a PASSR Level I or II evaluation. The Director of Nursing stated she was not aware of any details or the residents' names on the list of 25. 4. Resident #9 electronic medical record included a pre-admission document dated 8/21/23 entitled FL-2. An FL-2 form is a medical assessment form which details a resident's diagnoses, medications, and care needed for admission to a long-term care facility. The FL-2 form reported Resident #9 was determined to have a PASRR Level I status. A PASRR Level I status indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition. The resident was admitted to the facility on [DATE]. His diagnoses included a history of a stroke. Resident #9's electronic medical record (EMR) reported under the Diagnosis tab that additional diagnoses were added for this resident on 8/7/24. These included dementia with psychotic disorder, bipolar disorder, and unspecified psychosis not due to a substance or known physiological condition. Resident #9's most recent comprehensive Minimum Data Set (MDS) assessment was a significant change in condition MDS dated [DATE]. The Identification Information section of this MDS reported Resident #9 was not determined to have a PASRR Level II status. A PASRR Level II status would be indicative of serious mental illness and/or intellectual disability or related condition. The resident's EMR included a Care Area Assessment (CAA) worksheet for Functional Abilities dated 6/18/25. The Nature of the problem/condition read, in part, The resident's medical history includes.a diagnosis of bipolar disorder, which was made after admission to the facility. As a result of this new diagnosis, a significant change in status assessment has been completed. An interview was conducted on 12/18/25 at 8:32 AM with the facility's Director of Social Services. During the interview, the Director was asked if Resident #9 was referred to the state authority for a PASRR evaluation and determination at any point in time due to the identification of a possible mental illness after his admission to the facility. The Director reported Resident #9 was one of the residents she had on a list (provided by the facility's MDS nurse) as needing to be referred for a PASRR evaluation. She stated, I'm still working on it. When asked if the referral had been initiated, she clarified that it had not. An interview was conducted on 12/18/25 at 8:56 AM with MDS Nurse #1. During the interview, the MDS Nurse reported that the facility's prior administration did an audit. The results of the audit indicated that all current residents needed to be reviewed for changes in his/her diagnoses in order to identify those who had a significant change and whose PASRR status should be re-evaluated. The nurse reported that once she completed a resident's significant change MDS, she would refer that resident to Social Services so they could request a PASRR referral, as needed. The facility provided a Performance Improvement Plan (PIP) entitled, Missed PASRR Level Screening After Psychiatric Diagnosis Change. The initial plan provided for review indicated the facility's date of compliance was 8/25/25 with a goal compliance of greater than or equal to 95% by 3/31/26. The initial date of compliance was not met. Also, the date of the facility's compliance goal (3/31/26) was not acceptable due to the extended time frame. An interview was conducted on 12/18/25 at 11:15 AM with the facility's Director of Nursing (DON) #1. The DON indicated she has only worked at the facility for a few weeks but understood a PIP had been previously started related to PASRR screenings. During the interview, the DON was informed that the facility's plan could not be accepted for past non-compliance. The DON stated that she understood this issue continued to be a concern.

Based on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of narcotic medication for 2 of 3 residents reviewed for misappropriation of resident property (Resident #22 and #6). On 11/6/2025 the facility discovered Resident #22 had a medication card of 30 Oxycodone (a narcotic pain medication) 5 milligram tablets missing from the medication cart's locked narcotic box and on 11/10/2025 the facility discovered Resident #6 had a medication card of 28 Oxycodone 5 milligram tablets missing from the medication cart's locked narcotic box. Findings included:The facility's abuse policy which was revised on 10/20/2022 was reviewed and the policy stated misappropriation was the deliberate misplacement, exploitation or wrongful use of the resident's money or belongings. The abuse policy further stated the resident has the right to be free of misappropriation of their property.a. A review of Resident #22's electronic medical record (EMR) revealed his physician's orders included oxycodone 5 milligrams two times a day which was ordered on10/22/2025.A Packing Slip Proof of Delivery form from the facility's contracted pharmacy was provided for review by the facility. The form was not signed by a receiving nurse but indicated 2 medication cards of 30 tablets each of Oxycodone 5 milligrams was delivered to the facility on [DATE]. The packing slip was printed at the pharmacy on 10/22/2025 at 2:27 pm. Resident #22's Medication Administration Record for 10/2025 indicated he had not complained of pain when he was assessed each shift, and he received his Oxycodone 5 milligrams twice a day at 8:00 am and 8:00 pm.Resident #22's Medication Administration Record for 11/2025 indicated he had not had any pain, and he received his Oxycodone 5 milligrams twice a day at 8:00 am and 8:00 pm.Review of Resident #22's Medication Administration Record for 12/2025 revealed he did not complain of pain during his pain observations each shift, and he received the prescribed dose of Oxycodone 5 milligrams twice a day at 8:00 am and 8:00 pm.An interview was conducted with Medication Aide (MA) #1 on 12/18/2025 at 10:52 am, and she stated she arrived for her shift on 11/6/2025 at 2:00 pm and was counting the narcotics on the medication cart with Nurse #2 when she realized Resident #22 should have two medication cards of Oxycodone 5 milligrams because the cards were numbered 1 of 2 and 2 of 2, and Resident #22 only had (1) card which was numbered 1 of 2. MA #1 indicated she notified Director of Nursing (DON) #1 immediately of the discrepancy. Attempted three calls and a text message to Nurse #2 for an interview and left telephone voice messages but she did not return the telephone messages.During an interview with DON #1 on 12/17/2025 at 9:30 am she stated they discovered the missing Oxycodone 5 milligram Medication Card of 30 tablets when Medication Aide (MA) #1 reported to her by MA #1 that Resident #22 had 2 medication cards of 30 tablets of Oxycodone 5 milligrams and one of the cards was missing when she counted the cards with Nurse #2 on 11/6/2025 at the beginning of MA #1's 2:00 pm to 10:00 pm shift. b. A Physician's Order dated 10/2/2025 indicated Resident #6 should receive Oxycodone 5 milligrams every 6 hours as needed (PRN) for moderate pain.A Packing Slip Proof of Delivery form dated 10/2/2025 and timed at 5:00 pm indicated Resident #6 had 30 tablets of Oxycodone 5 milligrams delivered to the facility.On 11/13/2025 at 8:00 am Resident #6's Packing Slip Proof of Delivery indicated 30 tablets of Oxycodone 5 milligrams was delivered to the facility.Resident #6's Medication Administration Record for 12/2025 indicated she was not administered any doses of her PRN oxycodone 5 milligrams. On 12/18/2025 at 10:42 am Medication Aide (MA) #1 stated she had been assigned to Resident #6 on Monday, 11/3/2025, and was asked to count Resident #6's narcotics by the Hospice Nurse. She stated she remembered Resident #6 had 28 oxycodone 5 milligram tablets in the locked narcotic drawer of the medication cart. MA #1 stated Resident #6 had not been taking the oxycodone 5 milligram tables that were ordered as needed and she knew she would not have taken 28 tablets in just 5 days. She stated she notified DON #1 immediately.The Hospice Nurse was interviewed by telephone on 12/18/2025 at 2:41 pm and stated she visited Resident #6 on 11/10/2025 and counted Resident #6's oxycodone tablets with Medication Aide (MA) #1. The Hospice Nurse stated she had also visited Resident #6 on 11/5/2025 and she had 28 tablets but on 11/10/2025 she did not have any Oxycodone. The Hospice Nurse stated Resident #6 did not usually take the Oxycodone because she had an order for another narcotic pain medication (Morphine Sulfate) which was liquid and easier for her to swallow. The Hospice Nurse stated she and Medication Aide #1 reported Resident #6's missing Oxycodone to DON #1 immediately. DON #1 was interviewed on 12/18/2025 at 10:34 am and she stated the 28 tablets of missing oxycodone 5 milligrams for Resident #6 was discovered by MA #1 when she was counting Resident #6's narcotics with the Hospice Nurse. She stated MA #1 notified her immediately of the missing narcotic medication. DON #1 stated neither MA #1 nor Nurse #2 were suspended during the investigation and neither were asked to provide a drug test. DON #1 stated the facility did not drug test staff unless they showed signs of impairment due to drug use.The Pharmacist, from the facility's contracted dispensing pharmacy, was interviewed by telephone on 12/18/2025 at 12:10 pm and she stated the pharmacy did not receive communication that either Resident #22 or Resident #6 had narcotic medications that were missing. The Pharmacist stated the facility would be responsible for investigating and reporting missing medication to the authorities.DON #1 was interviewed on 12/18/2025 at 10:34 am and she stated she began an investigation and submitted a 24 hour report for the 30 tablets of oxycodone to the state agency, police and adult protective service, did an audit of all other resident's narcotic medication cards; educated the nurses and medication aide on counting of narcotics at the beginning of each shift and counting the number of narcotic medication cards in the cart; and she initiated a new policy that she and the Assistant Director of Nursing (ADON) were the only staff that could remove narcotics that were to be returned to the pharmacy. DON #1stated she had a locked safe installed in her office closet and the closet had a lock for holding medications that should be returned to the pharmacy. DON #1 stated the staff had not been counting the number of cards when they did a narcotic count and when she reviewed the form where the cards should be counted when completing the narcotic count there were days that the count of how many cards should be in the cart had not been done. DON #1 stated she could not determine who had taken the narcotic medication cards that belonged to Resident #22 and Resident #6. DON #1 stated she began a plan of correction for the misappropriation of narcotic medications after Resident #22's narcotics were reported missing and Resident #6's narcotics were reported during the investigation.Administrator #1 was interviewed on 12/19/2025 at 12:57 pm and stated the nursing staff should have counted the narcotics following the facility's policy and ensured there was no missing narcotic medications.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) status for 1 of 5 residents (Resident #15) reviewed for PASRR.The findings included: Resident #15 was admitted to the facility on [DATE] with cumulative diagnoses which included non-Alzheimer's dementia; anxiety disorder; bipolar disorder; and psychotic disorder. A PASRR Level II Determination Notification letter for Resident #15 (dated 11/14/23) was reviewed. This letter noted Resident #15 had a PASRR number ending with the letter H, which indicated a halted PASRR Level II determination was made due to the resident having a primary diagnosis of dementia. The results of the evaluation, including the determination of a PASRR Level II status, are used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care. Resident #15's most recent comprehensive MDS was a significant change assessment dated [DATE]. The Identification Information section of this MDS reported Resident #15 was not determined to have a PASRR Level II status. An interview was conducted on 12/18/25 at 8:56 AM with MDS Nurse #1 related to the PASRR determination reported on Resident #15's significant change MDS assessment dated [DATE]. Upon review of this MDS assessment, MDS Nurse #1 confirmed the assessment was incorrect and that it should have indicated Resident #15 was a PASRR Level II resident. On 12/18/25 at 11:15 AM, an interview was conducted with the facility's Director of Nursing (DON) #1. At that time, the DON reported she would expect the residents' MDS assessments to be accurate.

Based on record review, and resident and staff interviews, the facility failed to allow a resident who was assessed as safe to smoke without supervision the choice to smoke at preferred times for 1 of 3 residents reviewed for choices (Resident #50).The findings included:Resident #50 was admitted to the facility on [DATE].Review of Resident #50's admission Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and was coded for tobacco use.Review of Resident #50's care plan created on 08/16/25 revealed the resident preferred to smoke. The goal was Resident #50 would smoke safely through the review period. Interventions included Resident #50 could smoke unsupervised.Review of Resident #50's smoking assessments revealed a smoking assessment was completed on 10/08/25. The assessment further revealed Resident #50 was safe to smoke without supervision.An interview with Resident #50 on 12/17/25 at 1:00 PM revealed she was an independent smoker and was able to smoke anytime from 7:00 AM until 8:00 PM. Resident #50 further revealed she would like to be able to smoke after 8:00 PM, but nursing staff would lock the doors going to the smoking area and was unable to smoke. Resident #50 stated she had reported to staff she wanted to be able to smoke after 8:00 PM.An interview with Nurse Aide (NA) #3 on 12/17/25 at 1:15 PM revealed she worked both the 7:00 AM to 3:00 PM shift and 11:00 PM to 7:00 AM shift, and Resident #50 had complained that she was unable to go out after 8:00 PM and smoke. NA #3 further revealed she had been educated by department heads that no residents were allowed outside to smoke after 8:00 PM. NA #3 indicated Resident #50 was a safe independent smoker and had no prior incidents that she was aware of.An interview with the Director of Nursing (DON) on 12/23/25 at 11:38 AM revealed the owner of the building was uncomfortable with residents going outside to smoke after 8:00 PM due to the cold weather. The DON further revealed independent smokers should be allowed to go out to smoke when they preferred. An interview with the Administrator on 12/23/25 at 9:30 AM revealed supervised smokers stopped smoking at 8:00 PM due to lack of staff being available and concerns of cold temperatures. The Administrator stated he was unaware that independent smokers were not allowed outside after 8:00 PM to smoke. The Administrator indicated it must have been carried over by the previous administration, and it would be corrected immediately that independent smokers could smoke after 8:00 PM if they preferred.

Based on observation and staff and resident interviews, the facility failed to place survey results in a location readily accessible to residents and visitors and available to review without asking.The findings included:A Resident Council group meeting was conducted on 12/15/25 at 3:00 PM. During the meeting, Resident #13, Resident #18, Resident #25, Resident #30, and Resident #99 indicated they did not know where the survey results were located. An observation conducted on 12/18/25 at 12:20 PM revealed a sign was located on the receptionist desk that stated, Survey Binder Is Located at Front Desk. The survey results book was located behind the reception desk in the lobby area near the facility entrance. The area where the survey results book was located was in a small room that was restricted by walls and a desk that was closed off to residents and visitors. The survey results book was observed to be visible behind Receptionist #1 but was not in reach from the front of the desk. An interview with Receptionist #1 on 12/18/25 at 1:35 PM revealed she had worked in the facility for three years and the survey results book had always been located behind the desk. Receptionist #1 stated the location of the survey results book was considered a restricted area that visitors and residents were not allowed to access. Receptionist #1 indicated residents or visitors would have to ask to be able to review the survey book results. Receptionist #1 revealed she worked Monday through Friday from 8:00 AM until 2:00 PM and she was educated to allow residents or visitors to review the survey results book if they had asked.An interview with Receptionist #2 on 12/18/25 at 2:20 PM revealed she had worked in the facility for a year, and the survey results book had always been behind the receptionist desk. Receptionist #2 indicated visitors and residents were not allowed in the area behind the desk and would have to request to see the survey results notebook. Receptionist #2 indicated she worked Monday through Friday and every other weekend from 2:00 PM until 8:00 PM. An interview with the Assistant Director of Nursing (ADON) on 12/18/25 at 4:30 PM revealed she had not noticed the survey results book had not been in a public area and was aware it needed to always be available to residents and visitors. The ADON indicated she understood that residents or visitors should not have to ask to see survey results.An interview with the Administrator on 12/18/25 at 6:00 PM revealed the survey results book had previously been placed in front of the receptionist desk, but residents had taken the book and misplaced it. The Administrator indicated he had tried to prevent the survey results book from going missing. The Administrator indicated he decided to move the survey results book to the current location a couple weeks ago. The Administrator stated he was aware the survey results book needed to always be available for residents and visitors. The interview further revealed the Administrator understood that residents or visitors should not have to ask to see the survey results.

Based on observations, record reviews, and interviews with the facility staff, rehabilitation (rehab) therapy staff, and Medical Director, the facility failed to identify a reclining Broda wheelchair (a specialized type of seating that allows for tilt-in-space positioning) as a restraint that was reclined in a position that prohibited the resident from rising independently and without medical justification for its use in this manner. This occurred for 1 of 3 residents (Resident #119) reviewed for restraints. The findings included: Resident #119 was initially admitted to the facility on [DATE]. She was discharged home with a family member on 11/12/25. The resident had a second admission to the facility on [DATE]. Her cumulative diagnoses included emphysema, a history of a cerebral infarction (a type of stroke) and repeated falls. Resident #119's electronic medical record (EMR) included a Nursing re-admission Assessment Tool completed by Nurse #3 and dated 12/13/25. This document contained information on the resident's mental and physical health. The resident was described as cognitively impaired, oriented to person only, and confused. The re-admission Assessment Tool also included a Device Assessment and Restraint Identification. These sections were not completed on the document. Resident #119's EMR did not include a physician order for the use of any device that would restrict the resident's movements. There was no documentation identified in Resident #119's medical record regarding the identification, assessment, or use of a restraint for this resident. An observation was conducted on 12/15/25 at 12:20 PM of Resident #119 as she was sitting near the 100 Hall Nursing Station in a reclining Broda wheelchair with the back of the chair reclined approximately 130 degrees. The resident appeared to be trying to sit up or stand up by pulling her upper body forward and away from the back of the chair. Another observation was made on 12/15/25 at 12:52 PM of Resident #119 as she was sitting in the reclining Broda wheelchair in her room. The back of the chair remained reclined at an angle of approximately 130 degrees. The resident was not leaning forward in the chair at the time of this observation. An observation was made on 12/16/25 at 10:28 AM as the resident was sitting in a reclined Broda wheelchair watching a television in her room. The back of the reclining chair was reclined slightly at approximately 110 degrees. Resident #119 appeared to be comfortable in the chair and was not attempting to sit up further or get up out of the chair. A second observation was conducted on 12/16/25 at 12:07 PM as the resident sat in her room with her lunch meal tray placed on a bedside tray table in front of her. The reclined Broda wheelchair she was sitting in remained slightly reclined with the back of the chair reclined approximately 110 degrees. The resident appeared to be content as she began to feed herself. A third observation was conducted on 12/16/25 at 3:59 PM as Resident #119 was sitting in a reclined Broda wheelchair in a common hallway of the facility. The chair back was reclined back approximately 130 degrees. The resident was observed to be grabbing the hallway's handrail and appeared to be trying to sit upright as she leaned forward. The resident was being supervised by staff member at the time of this observation. An observation was conducted on 12/17/25 at 11:45 AM as Resident #119 was observed to sitting in a Broda wheelchair at a table with three other residents in the dining room. The back of the chair was slightly reclined (approximately 110 degrees). The resident appeared comfortable at the time of the observation. An interview was conducted on 12/17/25 at 1:25 PM with the facility's Rehabilitation (Rehab) Therapy Manager. During the interview, the Manager was asked who was responsible for deciding what type of wheelchair would be used for a newly admitted resident. He stated that the Rehabilitation Therapy Department would evaluate a resident to help determine the type of wheelchair for a resident. When asked, the Manager stated a specific form was not used to document that a wheelchair assessment was completed for a resident. On 12/17/25 at 1:27 PM, an observation was conducted of Resident #119 as she was sitting in a reclined Broda wheelchair in her room with the television on. The back of the chair was observed to be reclined at approximately 130 degrees. The resident appeared to be attempting to raise her upper body from the back of the chair by placing her hands on the arm rests of the chair and pulling herself forward. Two nurse aides (NAs) were in the hallway in front of Resident #119's room at the time of the observation made on 12/17/25 at 1:27 PM. NA #1 identified herself as being assigned to care for Resident #119. NA #2 was assigned to another area but stated she was familiar with the resident. An interview was conducted with NA #1 and NA #2. When the NAs were asked why the resident's chair was reclined back as far as it was (approximately 130 degrees), NA #1 stated, She's a high risk for falls. When asked if reclining the back of the wheelchair that far was intended to prevent her from falling, they both agreed that it was. The NAs added that when Resident #119 was in an activity with someone close by, the back of the wheelchair could be reclined less. An interview was conducted on 12/17/25 at 4:10 PM with the second shift nurse (Nurse #2) assigned to Resident #119's hall. At that time, Nurse #2 reported that during the resident's first admission to the facility, she was in the same type of reclined wheelchair. She stated the resident had a history of multiple falls and seemed to do better with a roommate (which she had during this admission) and/or when there were people around her like when she was in an activity or in the dining room. The nurse was then asked if the resident would be able to get out of the wheelchair if the back of the chair was up and in a normal sitting position. The nurse stated, Yes, that's how she falls. An interview was conducted on 12/18/25 at 9:35 AM with the facility's Rehab Therapy Manager. Resident #119 was in the Rehab Therapy Department participating in therapy at the time of the interview. The back of the resident's reclining Broda wheelchair was observed to be upright while she was engaged in her therapeutic exercise. During the discussion of the resident's positioning in her reclining wheelchair, the Manager demonstrated the possible positions of the reclining back by using levers placed on the back of the chair (not accessible to the resident). As the Manager adjusted the reclining wheelchair's positions, he estimated the angles to range from 90 degrees (upright), 110 degrees, 130 degrees, and then a fully reclined position (not observed in use for this resident). He reported the 130-degree reclined position and fully reclined position were not typically used unless the resident wanted to rest. When informed of both the observations made of Resident #119 and staff interviews conducted, the Manager reported he would not want to use the reclining wheelchair at an angle greater than 110 degrees due to it becoming a restraint. He explained further by stating, For us, our thing is what device and seating system allows the greatest mobility and tolerance so they can increase strength, endurance and transition potentially to another device or seating system. He reported the reclining Broda wheelchair needed to be used as intended or they would need to remove it. He added, We've got to in-service on the correct way to use the chair. A follow-up telephone interview was conducted on 12/22/25 at 11:17 AM with the Rehab Therapy Manager. At that time, information was requested on the manufacturer's specifications for the precise measurement of the positioning angles achieved when the back of Resident #119's wheelchair was reclined. This information was not found on the manufacturer's website nor was it available from the Rehab Therapy Department as of 12/23/25. An interview was conducted on 12/18/25 at 11:15 AM with the facility's Director of Nursing (DON) #1. During the interview, the DON reported she understood how a reclined wheelchair (at 130 degrees) would be considered a restraint. She stated, The Broda chair is never to be used as a restraint. The DON agreed with the Rehab Therapy Manager that the facility needed to work on communication between the Therapy Department and nursing staff to be sure all staff knew how to adjust the reclining wheelchair appropriately for the resident. The DON stated she was certain the Rehab Therapy Manager never intended the reclining Broda wheelchair to be used as a restraint. A telephone interview was conducted on 12/22/25 at 10:45 AM with the facility's Medical Director. During the interview, the concern related to the observations of Resident #119 sitting in a wheelchair reclined at approximately 130 degrees was discussed. When asked, the MD stated he was not aware of any medical symptoms that may warrant the use of a 130-degree reclined wheelchair for this resident. He added that he certainly did not recommend restricting a resident's movements or restraining a resident and would suggest staff attempt other measures such as re-direction be utilized instead.

Based on record review and staff, Nurse Practitioner, and Guardian interviews, the facility failed to allow 1 of 3 residents reviewed for discharge to return to the facility after transfer to the hospital (Resident #120). Findings included:Resident #120 was admitted to the facility on [DATE] with diagnoses of alcohol abuse and dementia.A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #120 was severely cognitively impaired.A discharge return anticipated Minimum Data Set assessment was dated 12/11/2024.On 12/11/2024 at 1:59 pm the Social Worker's Note indicated the Guardian was notified of Resident #120 being issued a 30-day discharge notice for behaviors the facility was unable to manage and the facility was going to proceed with involuntary committal as they were no longer able to keep Resident #120 safe.A Progress Note dated 12/11/2024 at 7:15 pm written by Nurse #7 indicated Resident #120 was transferred to the hospital for evaluation after aggressive behavior and extreme exit seeking. The progress note further stated Resident #120 was transferred with two police officers and was calm at the time of discharge.A Nursing Home Notice of Transfer/Discharge signed by Administrator #2 dated 12/11/2024 indicated Resident #120 was transferred to the hospital due to the safety of individuals in this facility is endangered due to the clinical or behavioral status of the resident. The notice further stated the Guardian was notified of the transfer to the hospital.The Social Worker was interviewed on 12/17/2025 at 3:46 pm and she stated the Guardian was contacted on 12/11/2024 and told the facility could no longer handle Resident #120's behaviors and he was sent to the hospital for evaluation after he attempted to get on the facility's roof a second time on 12/11/2024. The Social Worker stated Resident #120 had climbed onto the roof of the facility on 12/2/2024.A telephone interview was conducted with the Guardian on 12/18/2025 at 9:10 am and she stated it was reported to her on 12/11/2024 Resident #120 was sent to the hospital because he was suicidal by the Social Worker. The Guardian stated she had not been made aware of Resident #120 climbing on the roof on 12/2/2024. She stated she had been notified Resident #120 was pushing other residents in their wheelchairs before 12/2/2025, and the facility wanted to move him to the secured dementia unit and she had refused. The Guardian stated on 12/11/2024 she was told he had attempted to jump off the roof of the facility by the Social Worker. The Guardian stated when she spoke with Resident #120 at the hospital, he stated he was not suicidal he just wanted to leave the facility. The Guardian stated she was also told during the conversation with the Social Worker the facility refused to accept him back to the facility on the grounds that they were unable to keep him from harming himself. Nurse #7 was interviewed by phone on 12/22/2025 at 1:02 pm she stated she had not worked on 12/2/2024 when Resident #120 had climbed on the roof of the facility but had heard about the incident. Nurse #7 stated she did not remember if Resident #120 was on 1-hour checks, or if he had an electronic wander guard transmitter on when he was found in the courtyard stacking lawn furniture to attempt to get up on the roof on the morning of 12/11/2024. Nurse #7 stated Resident #7 had always walked around the facility but had never attempted to leave until 12/2/2024 when he was told he was being moved to the secured dementia unit that was locked. She stated he became more agitated, and she was afraid he would hurt someone after the 12/2/2024 incident but he was not suicidal. Nurse #7 stated Resident #120 needed a one-to-one sitter or to go to the secured dementia unit, but the facility did not have someone to sit with him one-to-one. A Hospital Discharge Summary Note dated 1/16/2024 indicated Resident #120 was presented to the hospital from the facility on 12/11/2024 with aggressiveness towards staff and had climbed up on the facility's roof. Resident #120 was transported by the police to the hospital with an involuntary committal order. The discharge summary further stated Resident #120 was medically stable and behavioral health evaluated him on 12/11/2024 and he had not met the criteria for inpatient psychological services in the emergency department and after 7 days in the emergency department he was admitted to an inpatient room until placement could be found in a secured dementia unit. The note further indicated Resident #120's hospitalization had been prolonged due to his original facility declining his return. The hospital case management had secured placement for Resident #120 at another facility with a secured dementia unit on and he was discharged to that facility on 1/16/2025.On 12/19/2025 at 8:32 am Director of Nursing (DON) #2, who was the previous DON, stated when Resident #120 climbed on the roof of the facility on 12/2/2024 he was upset because he thought he was going to be moved to the 300-hall secured dementia unit, but there was not a plan to move him to the secured dementia unit. DON #2 stated he was not suicidal but was exit seeking. She stated no matter how much they reassured him he was afraid the facility was going to place him in the secured dementia unit. She stated he attempted to climb on the roof again on 12/11/2024 and they sent him to the hospital for evaluation and refused to take him back because he would not agree to placement on the secured dementia unit or wear an electronic wander guard bracelet. DON #2 stated he got more aggressive between 12/2/2024 and 12/11/2024 and the Guardian told them to send him to the hospital for evaluation. DON #2 stated before 12/2/2024 he was very mild mannered and he was not suicidal.On 12/19/2025 at 9:12 am Administrator #2, who was the facility's previous administrator, stated he did not refuse to take Resident #120 back from the hospital. Administrator #2 stated the Social Worker, DON #2, and he met with the Guardian to come up with a safe plan for Resident #120 before he was sent out on 12/11/2024 but the Guardian refused to allow him to be moved to the 300-hall dementia unit and the Guardian stated she felt it would be better for him to be moved to another facility. Administrator #2 stated the Guardian also suggested Resident #120 be sent to the hospital on [DATE] when he attempted to climb on the roof the second time.

Based on staff interviews and record review, the facility failed to submit a request for an evaluation for a level II Preadmission Screening and Resident Review (PASRR) for a resident previously determined to have a Level II PASRR status after a significant change in physical and/or mental status was identified. This occurred for 1 of 5 residents (Resident #15) reviewed for PASRR.The findings included:Resident #15 was admitted to the facility on [DATE] with cumulative diagnoses which included non-Alzheimer's dementia; anxiety disorder; bipolar disorder; and psychotic disorder. A PASRR Level II Determination Notification letter dated 11/14/23 for Resident #15 was reviewed. This letter noted Resident #15 had a PASRR number ending with the letter H, which indicated a halted PASRR Level II determination was made due to the resident having a primary diagnosis of dementia. The results of the evaluation, including the determination of a PASRR Level II status, are used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care.The resident's electronic medical record (EMR) census reported Resident #15 was hospitalized from [DATE] to 7/23/25.Resident #15's most recent comprehensive MDS was a significant change assessment dated [DATE]. The MDS section on Special Treatments, Procedures, and Programs indicated the resident received Hospice Care. The resident's EMR included her Care Area Assessment (CAA) worksheet for Cognitive Loss/Dementia dated 7/29/25. The nature of the problem/condition reported that Resident #15 was now under the care of Hospice.Upon request, the facility provided a current list of PASRR Level II residents on 12/16/25. This list reported Resident #15 was determined to have a PASRR Level II status. An interview was conducted with MDS Nurse #1 on 12/18/25 at 8:56 AM. During the interview, the MDS nurse reported she was aware that Resident #15 was a PASRR Level II resident and should have been referred for a PASRR re-evaluation when the significant change MDS was completed. The nurse stated this resident was on the original list for needing a PASRR referral. However, she did not know whether Social Services had made the referral.An interview was conducted on 12/18/25 at 9:28 AM with the facility's Director of Social Services. Upon inquiry, the Director reported she did not make a referral for Resident #15 to have a PASRR re-evaluation based on the resident having a significant change MDS dated [DATE]. She stated that because the resident already had a PASRR Level II status, she did not think a referral was necessary.

Based on staff interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for 1 of 11 newly admitted residents reviewed (Resident #119).The findings included: Resident #119 was initially admitted to the facility on [DATE]. She was discharged home with a family member on 11/12/25. The resident had a second admission to the facility on [DATE]. Her cumulative diagnoses included emphysema, a history of a cerebral infarction (a type of stroke) and repeated falls. Resident #119's electronic medical record (EMR) included a Nursing re-admission Assessment Tool completed by Nurse #3 and dated 12/13/25. This document included information on the resident's mental and physical health, a pain tool, Braden Scale, Patient Record of Tuberculosis Screening, Fall Risk/Medication, Smoking Safety Screen, Device / Air Mattress Safety Observation, and an Elopement Evaluation. Further review of Resident #119's EMR revealed there was no baseline care plan completed for this resident. A comprehensive care plan was initiated on 12/16/25 for Resident #119. As of the date of the review on 12/18/25, this care plan included only one area of focus (related to her nutritional status). An interview was conducted on 12/18/25 at 11:15 AM with the facility's Director of Nursing (DON) #1. During the interview, the DON was asked if a baseline care plan was completed for Resident #119 after her 12/12/25 admission. Upon review of the resident EMR, the DON reported she did not see where a baseline care plan was completed. She reported that normally a baseline care plan would be done by the resident's admitting nurse within 24 hours of admission. An interview was conducted on 12/18/25 at 2:31 AM with Unit Manager #1. Upon inquiry, Unit Manager #1 reported the admitting nurse was responsible to complete a baseline care plan for a newly admitted resident using the admission Nursing Collection Tool form. Upon review of Resident #119's EMR, the Unit Manager reported that Nurse #3 had admitted the resident to the facility on [DATE]. She stated the nurse completed a re-admission assessment form instead of the required admission assessment when the resident was admitted to the facility. However, she reported the re-assessment form was missing the baseline care plan component (which included focus areas, goals, and interventions). Completing the wrong form resulted in a failure to complete a baseline care plan for Resident #119. A telephone interview was conducted on 12/18/25 at 3:58 PM with Nurse #3. Nurse #3 was identified as the nurse who admitted Resident #119 to the facility on [DATE]. When asked, the nurse reported that as the admission nurse, she was responsible to complete the admission packet forms for a newly admitted resident. She reported the admission packet consistent of several required forms that were auto populated by the facility's electronic software as needing to be completed. Nurse #3 stated, I did what was there for me to do. The nurse stated that these forms included the re-admission assessment form, so she filled it out. Nurse #3 reported she did not know the admission Nursing Collection Tool form needed to be completed in order for the resident to have a baseline care plan.

Based on observations, staff interviews and record review, the facility failed to obtain a provider's diet order for a resident after her admission to the facility. This occurred for 1 of 11 newly admitted residents reviewed (Resident #119).The findings included: Resident #119 was initially admitted to the facility on [DATE]. The resident's diet order (dated 10/15/25) was a Regular diet with mechanical soft textures and regular, thin liquids. On 10/22/25, Med Pass 2.0 (a high calorie, high protein nutritional supplement) was added to her diet order as 120 milliliters (ml) to be given at bedtime daily. Resident #119 was discharged to her home with a family member on 11/12/25. Resident #119 was hospitalized from [DATE] to 12/12/25. Her hospital Inpatient Discharge summary dated [DATE] included Diet and Nourishment Orders for a pureed diet with thin liquids. The resident was admitted a second time to the facility on [DATE]. Her cumulative diagnoses included emphysema, a history of cerebral infarction (a type of stroke) and repeated falls. Resident #119's electronic medical record (EMR) included a Nursing re-admission Assessment Tool completed by Nurse #3 and dated 12/13/25. This document included information on the resident's mental and physical health. Resident #119 was described as cognitively impaired, oriented to person only, and confused. A short section on nutrition noted her usual food intake pattern was Probably Inadequate. It also reported that the resident had some or all natural teeth and required partial to moderate assistance for eating. An observation was conducted on 12/16/25 at 8:42 AM as a nurse aide removed Resident #119's breakfast meal tray from her room. The meal ticket and observation of the food remaining on Resident #119's tray indicated she was served a regular, pureed diet. The resident consumed approximately 25% of the meal. A review of the resident's electronic medical record (EMR) conducted on 12/16/25 at 10:23 AM revealed Resident #119 did not have a provider's diet order. On 12/16/25 at 12:07 PM, Resident #119 was observed sitting in a reclining wheelchair (reclined at approximately 110 degrees) in her room as she was served a lunch meal tray by the nurse aide. The meal ticket and observation of the resident's meal tray indicated the resident received a regular diet with pureed foods. Resident #119 was observed as she picked up her silverware and began to feed herself. An interview was conducted on 12/16/25 at 2:14 PM with the facility's Dietary Manager in the presence of the Regional Dietary Manager. Upon review of Resident #119's EMR, the Dietary Manager confirmed the resident did not have a provider's diet order. The Dietary Manager located a Communication Form regarding Resident #119 (from Nursing to Dietary) that he had found on his desk. This Communication Form indicated the resident was to receive a regular diet with pureed textures and thin liquids. Unit Manager #1 was identified by her signature as having completed the Communication Form (not dated). When asked about a provider's diet order for the resident, both the Dietary Manager and Regional Dietary Manager confirmed that a diet order was still needed. An interview was conducted with Unit Manager #1 on 12/16/25 at 3:09 PM. During the interview, the Unit Manager confirmed she put Resident #119's diet order into her EMR this afternoon after she was alerted that the order was missing. Upon inquiry, Unit Manager #1 reported an order for a newly admitted resident would typically be put into his/her EMR upon admission to the facility. She recalled filling out a Communication Form for this resident after she was admitted on [DATE] and bringing it to the Dietary Department so she wouldn't miss any meals. The Unit Manager reported the diet written on this Communication Form was based on Resident #1's hospital discharge information from 12/12/25, which recommended a regular pureed diet with thin liquids. However, when asked, Unit Manager #1 confirmed there should have been a diet order put into Resident #119's EMR upon admission to the facility. An interview was conducted with the facility's Director of Nursing (DON) #1 on 12/18/25 at 11:15 AM. During the interview, the DON was asked what her thoughts were regarding the failure to have a provider's order for Resident #119's diet in her EMR after admission to the facility. The DON stated, That's a huge problem. She reported the diet order should have been put into the EMR and then the Communication Form sent from Nursing to the Dietary Department upon the resident's admission.

Based on observations, record review, and staff interviews, the facility failed to maintain a urinary catheter drainage bag off the floor to prevent the risk of infection for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #8). The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder. Review of Resident #8's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #8's cognition was severely impaired and was totally dependent for most activities of daily living (ADL). The MDS further revealed Resident #8 was coded for having an indwelling urinary catheter.Review of Resident #8's physician orders revealed an order dated 12/09/25 for an indwelling urinary catheter for neurogenic bladder with urinary retention.Review of Resident #8's care plan revised on 12/16/25 revealed the resident was readmitted to the facility from the hospital with a catheter for neurogenic bladder with urinary retention. The goal was Resident #8 would not have any complications. Interventions included the catheter tubing are to be free of any kinks or obstruction and drainage bag in proper location.An observation conducted on 12/17/25 at 9:55 AM revealed Resident #8 was in bed with the bed in a low position and urinary catheter drainage bag was lying flat on the floor.An observation and interview with Nurse Aide (NA) #8 on 12/17/25 at 11:50 AM revealed Resident #8's urinary catheter drainage bag was on the floor. NA #8 stated she was in the resident's room about an hour ago and did not recall seeing Resident #8's catheter bag lying flat on the floor. NA #8 stated she had been educated to hang the bag at the side of the bed on the metal bed frame, but it often fell off due to the resident's bed being in low position and slipping off the bed frame.An observation and interview with Unit Manager (UM) #1 on 12/17/25 at 12:00 PM revealed the urinary catheter drainage bag was on the floor beside Resident #8's bed. UM #1 hung the urinary catheter drainage bag on the side of the resident's bed frame, and the urinary catheter drainage bag still touched the floor. UM #1 indicated the resident's bed needed to be raised some to ensure the bag did not touch the ground. UM #1 revealed Resident #8's catheter bag should never touch the ground due to possible contamination and germs.An interview with the Assistant Director of Nursing (ADON) on 12/18/25 at 4:30 PM revealed she had completed training with nursing staff a month ago about catheter care. It was further revealed it was never acceptable for a urinary catheter drainage bag to touch the ground due to contamination.An interview conducted with the Director of Nursing on 12/18/25 at 6:00 PM revealed Resident #8's urinary catheter drainage bag was expected to be off the floor. The DON further revealed nursing staff had been educated on the importance of catheter care and urinary catheter drainage bags touching the ground was not acceptable.

Based on observations, record review, and interviews with staff, the facility failed to enter a physician's order for oxygen delivery for 1 of 1 resident reviewed for respiratory care (Resident #101).The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, tobacco use, and anemia. On 12/15/25 at 3:55 PM Resident #101 was observed asleep in bed and wearing oxygen via nasal cannula at 3 Liters/minute (L/min) connected to portable oxygen next to her bed. The resident did not show any signs of discomfort or difficulty breathing. Review of the nurse progress note date 12/15/25 2:52 PM progress note revealed Nurse #8 notified the provider that Resident #101 had abnormal vital signs: blood pressure 159/101, pulse 104, and oxygen saturation level of 64% on room air. A normal oxygen saturation level is at, or above, 90%. Nurse #8 documented she was ordered to start Resident #101 on 2L/min of oxygen. Nurse #8 wrote that she communicated with provider Resident #101's oxygen saturation level increased to 89% on the 2L/min and the oxygen was increased to 3L/min and Resident #101's oxygen saturation level went up to 91%. On 12/15/25 at 3:55 PM Resident #101 was observed asleep in bed and wearing oxygen via nasal cannula at 3 L/min connected to portable oxygen next to her bed. The resident did not show any signs of discomfort or difficulty breathing. On 12/15/2025 at 4:00 PM an attempt was made to interview Nurse #8 about the oxygen order, but Nurse #8's was not present at the facility and the attempt was unsuccessful. Review of orders in the electronic medical record on 12/15/25 at 3:00 PM revealed there was no order for oxygen use. On 12/16/25 at 9:18 AM Resident #101 was observed resting in bed and wearing oxygen via nasal cannula at 3 L/min connected to a portable oxygen next to her bed. Resident #101 was alert and oriented to self and did not show any signs of discomfort or difficulty breathing. Review of the provider progress note dated 12/16/25 12:00 PM revealed Resident #101 had upper respiratory infection symptoms with difficulty breathing and oxygen saturation level was 90% while on oxygen via nasal cannula at 3L/minute. Review of orders in the electronic medical record on 12/16/25 3:00 PM revealed there was no order for oxygen use. Review of the provider progress note dated 12/17/25 8:45 AM revealed Resident #101 had mild upper respiratory infection symptoms during the week of 12/15/25 through 12/17/25 and the oxygen saturation levels dipped below 90% so they started oxygen, antibiotics, and nebulizers; Resident #101 responded quickly and oxygen saturation levels returned to the low 90%'s on room air. Review of orders in the electronic medical record on 12/17/25 12:00 PM revealed there was no order for oxygen in the chart. An interview was conducted on 12/17/25 at 3:25 PM with Unit Manager #1. Unit Manager #1 reviewed Resident #101's medical record with the surveyor present and stated she found a note entered on 12/15/25 by Nurse #8 that stated Nurse #8 contacted the provider about Resident 101's low oxygen saturation levels and the provider gave an order for oxygen to be applied. Unit Manager #1 further revealed Nurse #8 failed to create an order in the electronic medical record which was required to be done at the time the order was received on 12/15/25 but still had not done so on 12/17/25. Unit Manager #1 indicated she was updating the orders at the end of the interview.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 6 residents (Resident #35 and Resident #105) observed during the medication administration. The findings included: 1. On [DATE] at 8:16 AM, Medication Aide (Med Aide) #1 was observed as she prepared and administered fifteen (15) medications to Resident #35. A review of Resident #35's current orders revealed a medication order was initiated on [DATE] for 200 - 25 micrograms (mcg) per actuation of Breo Ellipta aerosol powder to be given as one puff by mouth one time a day for shortness of breath / wheezing. Breo Ellipta is an inhaled medication used for the management of chronic obstructive pulmonary disease (COPD) and/or asthma. Resident #35's Breo Ellipta was scheduled for administration at 8:00 AM once daily in accordance with the physician's orders. This medication was not given to Resident #35 during the morning medication administration observation conducted on [DATE]. An interview was conducted on [DATE] at 9:12 AM with Med Aide #1, who was joined by Unit Manager #1. When asked about the omission of Resident #35's Breo Ellipta inhaler during the morning medication pass, Med Aide #1 reported this inhaler was not available on the medication cart. Unit Manager #1 added that the Breo Ellipta inhaler was identified as expired and removed from the medication cart on [DATE]. The Unit Manager reported another inhaler was ordered from the pharmacy, but that it had not yet been delivered. An interview was conducted on [DATE] at 11:15 AM with the facility's Director of Nursing (DON) to discuss the results of the medication administration observation. At that time, the DON reported she would have expected Resident #35's Breo Ellipta inhaler to have been ordered before it was out or expired so it would have been available for administration as scheduled. 2. The manufacturer's Full Prescribing Information for the Insulin Lispro prefilled insulin pen included Instructions for Use. These instructions indicated the insulin pen needed to be primed with 2 units of insulin prior to each injection. Priming ensures the insulin pen is ready to dose and removes air that may collect in the cartridge during normal use. If the pen is not primed before each injection, too much or too little insulin may be delivered. On [DATE] at 11:05 AM, Nurse #1 was observed as she prepared to administer insulin to Resident #105. The nurse withdrew an Insulin Lispro prefilled insulin pen from the medication cart, placed a needle on the pen, and turned the dose selector to select 15 units of insulin in preparation for the injection. The nurse did not prime the insulin pen. Nurse #1 was accompanied as she brought the insulin pen down the hallway to the resident's room. Upon reaching Resident #105's door (before entering the room), the nurse was asked to stop. At that time, Nurse #1 was asked if she had primed the insulin pen. She stated No. Upon further inquiry, the nurse was asked if she was supposed to prime the insulin pen before each injection. She responded, Yes and was then observed as she primed the insulin pen. After priming the insulin pen and re-setting the dose selector to select 15 units of insulin, Nurse #1 was observed as she administered the insulin to Resident #105 in accordance with the physician's orders. An interview was conducted on [DATE] at 11:15 AM with the facility's Director of Nursing (DON). During the interview, the DON confirmed that the Insulin Lispro pen needed to be primed with 2 units of insulin prior to each use. The DON further stated that she would expect nursing staff to follow the clinical guidelines for each medication they are administering.

Based on observation, record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 6 of 7 days reviewed (12/11/25, 12/12/15, 12/13/25, 12/14/25, 12/15/25, and 12/17/25).The findings included:Review of the facility's daily nurse staffing sheet revealed underneath the facility's name was a space to specify the date and resident census along with columns to specify the number of staff and hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medicine Aides (CMAs), and Certified Nursing Assistants (CNAs) for each 8-hour shift, 7:00 AM to 3:00 PM (first shift), 3:00 PM to 11:00 PM (second shift) and 11:00 PM to 7:00 AM (third shift).a. The nursing staff schedule dated 12/11/25 revealed on the1st shift (6:00 AM to 2:00 PM) there were 5 LPN's and 11 CNAs. On the 2nd shift there was one (1) LPN, 8 CNAs, and 3 CMAs. Review of the daily nurse staffing sheet dated 12/11/25 revealed that for the 1st shift, the facility had 4 LPNs and 9 CNAs. On the 2nd shift (2:00 PM to 10:00 PM) the daily nurse staffing sheet indicated the facility had 2 LPNs, 9 CNAs, and One (1) CMA.b. The nursing staff schedule dated 12/12/25 revealed on 1st shift there were 4 LPNs. Review of the daily nurse staffing sheet for 12/12/25 revealed the1st shift had 3 LPNs.c. The nursing staff schedule dated 12/13/25 revealed on the 1st shift there were 4 LPNs and one (1) CMA. Review of the 12/13/25 daily nurse staffing sheet revealed the 1st shift had 3 LPN's and 2 CMAs.d. The nursing staff schedule dated 12/14/25 revealed on 3rd shift (10:00 PM to 6:00 AM) there were 7 CNAs. Review of the daily nurse staffing sheet dated 12/14/25 indicated there were 6 CNAs on the 3rd shift. e. Review of the nursing staff schedule dated 12/15/25 revealed on the 1st shift there were 5 LPNs. Review of the daily nurse staffing sheet for 12/14/25, revealed the 1st shift had 4 LPNs.f. Review of the nursing staff schedule dated 12/17/25 revealed on the 3rd shift there was one (1) RN. Review of the daily nurse staffing sheet dated 12/17/25 revealed there were 3 RNs on the 3rd shift. An interview with the Staff Coordinator on 12/18/25 at 1:10 PM revealed she and Receptionist #1 and Receptionist #2 were responsible for posting the daily staffing sheets and usually posted them first thing in the morning for all three shifts. The Staff Coordinator stated she and Receptionist #1 and Receptionist #2 were responsible for updating the daily staffing sheets to reflect callouts and/or staff schedule changes. The Staff Coordinator was not aware the daily staffing sheets had not been updated on 12/11/25, 12/12/15, 12/13/25, 12/14/25, 12/15/25, and 12/17/25. The Staff Coordinator indicated she worked Monday through Friday and on the weekends and after 5:00 PM assigned nurses were responsible for making revisions.An interview with the Receptionist #1 on 12/18/25 at 1:35 PM revealed she assisted the Staff Coordinator with posting the staffing sheet. Receptionist #1 indicated that she, the Staffing Coordinator, and nursing staff were responsible for revising the staff posting if needed. Receptionist #1 stated nursing staff had sometimes failed to communicate changes if staff called out of work. An interview with Receptionist #2 on 12/18/25 at 2:20 PM revealed she never made revisions and had not been educated to revise daily posted staffing sheets. Receptionist #2 indicated she had never been told it was her responsibility to revise the daily posted staffing sheets.An interview with the Administrator on 12/18/25 at 6:00 PM revealed the Staffing Coordinate was responsible for posting and updating the daily nurse staffing sheets. The Administrator stated he would expect for daily nursing staffing sheets to be updated as needed to reflect the correct number and hours of nursing staff that worked each shift. The Administrator indicated he assumed nursing staff had made revisions if the Staffing Coordinator was unable to.

Based on record review, observations, and staff, Resident, Pharmacy Consultant and Nurse Practitioner interviews, the facility failed to administer pain medication as ordered for 1 of 3 residents (Resident #2) reviewed for pain management. Findings included: Review of Resident #2's hospital record indicated she had a right ankle Computed Tomography (CT) Scan on 12/23/2024 which showed a new minimally displaced fracture involving the right ankle and a knee x-ray that showed a mildly displaced fracture involving the distal femur which forms the knee joint. The hospital record also indicated Resident #2 had surgical repair of the right ankle on 1/25/2025. Resident #2 was admitted to the facility on [DATE] with fractures to her left knee and right ankle. An admission Minimum Data Set assessment dated [DATE] indicated Resident #2 was cognitively intact and had moderate pain frequently. A Physician's Order dated 1/8/2025 at 8:00 pm indicated Resident #2 should receive Oxycodone Hydrochloride (a narcotic pain medication) 10 milligrams two times a day for pain beginning 1/8/2026 and would be discontinued on 1/10/2025. Resident #2's Medication Administration Record for 1/2025 indicated Resident #2 did not receive Oxycodone HCI 10 milligrams on 1/8/2025 at 8:00 pm or 1/9/2025 at 8:00 am. The Medication Administration Record for 1/2025 indicated Resident #2 received Acetaminophen 1000 milligrams as needed for pain on 1/9/2025 at 7:22 am and on 1/13/2025 at 10:45 am. Further review of Resident #2's Medication Administration Record for 1/2025 indicated she rated her pain at a 0 on a scale of 1 to 10 (with 1 being the least amount of pain and 10 being the worst amount of pain) on 1/8/2025 and 1/9/2025. On 1/29/2025 at 1:35 pm Resident #2 was interviewed and stated she was admitted on [DATE] and did not receive the narcotic pain medication she needed for pain from fractures in both legs until the next day. Resident #2 stated the nurses did give her Acetaminophen which did not relieve her pain, and she rated her pain at an 8 or 9 (on a scale of 1 to 10) from the time she was admitted until she received the ordered medication on the evening of 1/9/2025. Nurse Aide #2 stated she worked 7:00 am to 3:00 pm shift on 1/8/2025 and was assigned to Resident #2 when she was admitted . Nurse Aide #2 stated Resident #2 did complain of pain when she arrived, and she notified the Unit Manager of Resident #2's pain in both legs. An interview was conducted with Unit Manager #1 on 1/29/2025 at 1:15 pm and she stated Resident #2 admitted around 3:00 pm on 1/8/2025 and when she came from the hospital, they did not send a prescription with her for the Oxycodone Hydrochloride (a narcotic pain medication). Unit Manager #1 stated she did get an order for Acetaminophen 1000 milligrams every 6 hours as needed for pain. Unit Manager #1 stated Resident #2 rated her pain at a 7 on a scale of 1 to 10 (one being the least amount of pain and 10 being the worst pain) and she gave her the Acetaminophen and she later rated her pain at a 3 about an hour later. During an interview with Nurse Aide #3 on 1/29/2025 at 2:15 pm she stated she worked on the 3:00 pm to 11:00 pm shift on 1/8/2025 and Resident #2 did not complain of pain to her during her shift. Nurse Aide #3 stated she checked on her every 2 hours and when she turned her call light on. Nurse Aide #3 stated Nurse #1 did give her pain medication that night, but she did not know what she was given. Nurse #1 was interviewed on 1/29/2025 at 2:05 pm and stated she cared for Resident #2 on 1/8/2025 on the 7:00 pm to 7:00 am shift and she gave her Acetaminophen that evening and checked on her an hour later and she said her pain was a 2 on a scale of 1 to 10. Nurse #1 stated she must have forgotten to document the Acetaminophen she gave Resident #2 on the Medication Administration Record. The Pharmacy Consultant was interviewed by phone on 1/30/2025 at 2:30 pm and stated Resident #2 would need narcotic pain medications as ordered for fractures in both legs. She stated the ordered narcotic would have been beneficial in managing Resident #2's pain. The Pharmacy Consultant stated the facility should have obtained a prescription, signed by the provider, and faxed it to the pharmacy and then the pharmacy would have released Resident #2's narcotic pain medication when she was admitted to the facility. The Director of Nursing was interviewed on 1/29/2025 at 3:53 pm and she stated Unit Manager #1 was not able to get a prescription for Resident #2's pain medication on the evening she was admitted to the facility. She stated Unit Manager #1 did get an order for Acetaminophen and Resident #2 was documented by Unit Manager #1 and Nurse #1 as not having pain during the evening or night. The Director of Nursing stated the on-call service the facility contracts will not give a prescription for a narcotic if the prescription is not sent from the hospital. The Director of Nursing stated when the prescription is faxed to the pharmacy the medication is released from the electronic back-up medication system. During an interview with the Administrator on 1/29/2025 at 4:01 pm he stated the nursing staff should have reached out to the Physician or Nurse Practitioner to obtain a prescription for Resident #2's ordered pain medications so the medication could be dispensed from the facility's back-up medication system to ensure Resident #2 was comfortable.

Based on record review, observations and resident, staff, Police Officer, Nurse Practitioner and Medical Doctor interviews, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 3 residents investigated for abuse (Resident #7). Resident #7 reported to the facility that Nurse Aide (NA)#1 had punched her in her right eye. Resident #7 revealed that Nurse Aide #2 was present during this incident and witnessed the allegation. After this incident Resident #7 had a circular reddish, purple bruise below her right eye and reported she felt angry and upset at the time of the incident. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, dementia, cerebellar stroke syndrome, glaucoma, and peripheral vascular disease. The quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #7's cognition was moderately impaired and she required extensive to total assistance with activities of daily living. The assessment indicated the resident did not receive anticoagulants during the 7-day look back period. Behavioral symptoms and rejection of care were not observed. A review of Resident #7's care plan revised on 12/28/23 indicated that Resident was resistive to care due to dementia: refused showers, medication, and activities of daily living (ADL). The goal was the Resident would cooperate with care. The intervention included staff would allow the resident to make decisions about treatment regime, provide sense of control, and educate regarding consequences regarding refusals. A review of the 24-hour initial report dated 1/13/24 revealed on 1/13/24 at 11:13 am, the facility was made aware of the employee to resident abuse. Law enforcement was notified on 1/13/24 at 12:00 pm. The Original Allegation Details read in part, Resident Reported that Nursing Aide (NA) #1 hit her in the eye during ADL care. Resident was assessed for injury with no injury reported. Responsible Party (RP) and Medical Doctor (MD) notified. NA #1 was sent home, and the staffing agency was notified that NA will not be allowed to work pending outcome of the investigation. Resident's Brief Mental Status (BIMS) 12. A review of a statement dated 1/13/24 from NA #1 read in part, I went into room [ROOM NUMBER] to assist bed 109A with patient care me and another NA (NA #2) as we approached the bed to tell her what we was about to do I grabbed the remote to her bed and the remote was beside her head I grabbed the remote she started yelling saying that the remote hit her in the head and it never touched her. I explained to her that it never touched her but, in her mind, she just kept saying that she was hit by the remote. I proceeded with care trying to redirect her and she just kept yelling, scratching, grabbing, and kicking me repeatedly I was still trying to redirect her that I only was trying to clean her up and she was swinging so wild that she hit herself in the face I walked out the room while NA #2 still in room and went to notify nurse what was going on and when the nurse came in the she said I'm going to get her fired and the nurse started asking her what was going on and me and NA #2 walked out the room we was asked after to write statements I never touched the resident she was repeatedly fighting me for no reason at all. Attempts to contact NA #1 on the 1/18/24 and 1/19/24 were not successful. An interview was conducted with Nursing Aide (NA) #2 on 1/18/24 at 2:16 pm and he stated on 1/13/24 NA #1 asked him to assist her with Resident #7. NA #2 stated both NA # 1 and himself assisted Resident #7's roommate first, and then NA #1 went to start on Resident #7 while I finished lowering roommate's bed. He stated he walked around the privacy curtain to assist with Resident #7, and Resident was kicking and swinging at NA #1, and the resident was saying you hit my head, you hit my head and something about a remote, NA #1 was saying no she didn't to Resident and Resident #7 took another swing at NA #1, and then NA #1 took one of her hands and held Resident #7's hands to her chest and with her other hand, closed her fist and hit Resident in her right eye. NA #2 stated Resident #7 said to NA #1 you're done, and asked NA#2 if he had seen that. NA #1 told me to go get the nurse and I told NA #1 to go and get the nurse. He stated Nurse #2 came in the room and asked what happened and Resident #7 pointed to NA #1 and the Resident said she hit me. NA #2 stated both NA #1 and he left the room and was told to write a statement of what happened. An interview was conducted with Nurse #2 at 2:16 pm on 1/18/24. She indicated she was the Nurse on duty on 1/13/24 and she saw NA #1 come out of Resident #7's room, and overheard NA #1 report to NA# 4, that Resident was refusing care. Nurse #2 indicated she went into Resident #7's room and observed Resident with some discoloration under her right eye. Nurse #2 indicated, NA #2 was in the room and NA #1 re-entered the room. She stated she asked Resident #7 what happened, and Resident #7 pointed to NA #1 and stated that woman hit me. Nurse #2 stated she then asked NA #1 to leave Resident's room. Nurse #2 indicated that NA #1 was asked to go home and provide a statement about what happened. Nurse #2 stated she did a skin assessment and no other bruising to Resident's body except for the bruising to corner of right eye that was possibly light purple in color. She indicated she reported the incident to the Unit Manager that was working in the facility that day. A second interview with Nurse #2 was conducted at 3:45 pm on 1/18/24 and she described Resident #7's right eye as being discolored with little purplish dots under the eye that weren't connected. No bruising/discoloration was observed anywhere else on Resident's body. A review of the Nurse Practitioner (NP) note dated 01/15/23 indicated patient (Resident #7) reported to the NP that Resident #7 was involved in an altercation with a staff member and sustained facial bruising after being hit in the face. Resident #7 indicated that NA #1 came in to change her and she had a very nasty attitude and was being rude and forceful. Resident #7 indicated that she did not want to be changed and NA #1 started to change her anyway and she asked her to stop, Resident #7 indicated that NA #1 balled up her fist and hit me in my face, NP ordered a facial X-ray. Review of the facial x-ray results dated 1/15/24 revealed negative for fracture. Review of the 5-day investigation report dated 1/18/24 revealed the incident occurred on 1/13/24 during the AM care for Resident #7. The report read in part, Resident #7 alleged she was physically abused when NA #1 hit her in the eye during ADL care. Resident #7 was interviewed by the Director of Nursing and law enforcement and the Resident reported NA #1 hit her in the eye during ADL care. The incident was witnessed by another staff member, and he confirmed the allegation. A skin assessment was completed on the resident and no concerns noted. Pain assessment completed with no concerns identified. Resident RP and MD were notified. Resident was assessed by the Nurse Practitioner (NP). Resident declined to press charges against NA #1. Staff continued to observe the Resident for changes in mood and/or behavior and will follow up as needed. Corrective Actions following Incident read in part, The facility indicated NA #1 will not be allowed to work in the facility and had been reported to the health care personnel registry. Additional assigned resident skin checks revealed no concerns. Staff will be reeducated on Abuse and Neglect. The facility substantiated the allegation, and the accused individual was terminated from the facility on 1/13/2024. An interview was conducted on 1/18/24 at 1:33 pm with Resident # 7 and she stated she had made an abuse allegation regarding NA #1 who hit her in the eye. Resident #7 indicated that it hurt. Resident #7 further stated she felt fine now, and she was not scared now. Resident #7 also indicated when the incident happened, she felt angry and upset, but was fine now and she felt safe. An observation was made on 1/18/24 at 1:36 pm of Resident #7's right eye with a circular reddish, purple bruise about the size of two fingers wide below her right eye. On 1/18/24 at 2:25 pm an interview was conducted with Nurse #1, and she indicated she had received a report from Nurse #2 on 1/13/24 that Resident #7 alleged NA #1 hit her in the face. She stated she went into Resident #7's room and observed Resident to have a discoloration below right eye and she reported NA #1 had hit her in the eye. Nurse #1 indicated she called the Director of Nursing (DON) and the Administrator and did a 24-hour report to the State. A phone interview was conducted with the NP on 1/18/24 at 4:05pm. She indicated she assessed Resident #7, on 1/15/24 due to facial bruising. NP indicated Resident #7 told her a staff member had a nasty attitude and was trying to change her and she didn't want to be changed, however she still proceeded to change her. She stated the staff member balled her fist up and hit her in the face. NP indicated she had facial bruising, however her orbital eye cavity was uninjured. She stated the Resident stated it hurt when it happened, but it now only hurts to touch, however Resident refused ice or pain medication. The NP stated Resident #7 had no visual changes, no closed head injury, no head trauma, she bruised significantly, she was intact neurologically. No orbital edema, it was superficial bruising, no head trauma and should fully recover with no negative outcome. She stated during the examination, Resident's demeanor was fine, she was a little tearful. A telephone interview was conducted with the facility Medical Doctor (MD) on 1/18/24 at 4:13 pm and she indicated she immediately ordered an orbital x-ray, and the facility did neurological checks. The MD stated the building acted appropriately, and there were no negative outcomes other than superficial bruising. They did a facial x-ray just to be safe. She stated the x-ray was good, no fractures. During an interview with the DON on 1/18/24 at 4:30 PM, she indicated Resident #7 had some bruising to her right eye. The DON stated NA #1 was suspended at the time of investigation and she initially denied the incident and a statement was received from her. She indicated attempts were made to contact NA #1 for further interview, however, was unable to contact her. A telephone interview was conducted on 1/19/24 at 11:09 am with the Salisbury Police Officer and he indicated he responded to a call at Salisbury Rehab and Nursing Center on 1/15/24. He stated he looked back on his call history and verified that the facility called to report the incident before Monday, January 15, 2024. He stated the facility indicated Resident #7 had been assaulted by an agency staff person (NA #1) by hitting Resident in the right eye. He stated he gathered all the details of the investigation and charges would be filed for assault on an elderly person and there will be a warrant for NA #1's arrest by the end of the weekend. He stated he was still working on the police report and indicated it would be ready by the end of the weekend. During an interview on 01/19/24 at 1:30 PM, the Administrator stated the facility has a zero tolerance of abuse. The Administrator further stated NA #1 was terminated from the facility. He expected all residents to be free from abuse and neglect and free from any retaliation. The Administrator indicated that the abuse allegation was substantiated.

Based on hospital record review, facility record review, observation, and staff, Nurse Practitioner and Physician interviews the facility failed to provide supervision to prevent 1 of 1 residents, Resident #1, with a history of eating items from the trash, from ingesting an unidentified object. The facility also failed to assess Resident #1 for symptoms of potentially life-threatening diseases since the unidentified object was alleged to be a mouse. Immediate Jeopardy began on 8/9/2021, when Resident # 1 ingested an unidentifiable object and the facility failed to immediately and effectively respond to the situation. The Immediate Jeopardy was removed on 8/14/2021 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of G (actual harm that is not immediate jeopardy) due to the second example. Based on hospital record review, facility record review, observation, resident, nurse practitioner, and staff interviews, the facility failed to provide supervision and effective interventions to prevent further altercations involving Resident #5 with other residents after the initial altercation on 8/16/21. As a result of one of the altercations, Resident #4 was sent to the emergency room (ER) where she received a [CONDITION(S)] shot and was prescribed two separate oral antibiotics, which was determined to be a level G (actual harm that is not immediate jeopardy) deficient practice. Resident #5 was placed on one-to-one supervision during the investigation. Findings included: 1. Resident #1 admitted to the facility on [DATE] and resided in a secure unit. His diagnoses included dementia and [CONDITION(S)]. There was not a care plan for Resident #1 ' s behavior of eating from the trash or putting non-edible items in his mouth. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired; ambulated with supervision only; and did not have any behaviors. The Director of Nursing (DON) was interviewed on 8/12/2021 at 7:15 pm and stated she was on the unit where Resident #1 resides on the evening of 8/9/2021. She stated she exited a room and Resident #1 walked by with a styrofoam food container from the trash in his hand and a 2-inch-long dark colored string hanging from his mouth. The DON stated before she could stop Resident #1, he swallowed the string. The DON stated she inspected his mouth and there was nothing in his mouth. The DON stated she left the unit and when she returned about 20 minutes later Nurse #1 told her Resident #1 had vomited or spit up. The DON stated she did not look at what Resident #1 had spit up. The Director of Nursing stated she reported the incident to the Administrator at that time and to the Physician the next morning, 8/10/2021. The DON stated the Physician did not give orders for follow up for Resident #1. The Social Worker was interviewed on 8/13/2021 at 10:24 am and stated he was making his rounds on the 300-hall unit when he noticed Resident #1 had a styrofoam food container in on hand and something else in his other hand. The Social Worker stated Resident #1 turned his back to him and put something in his mouth. The Social Worker stated Resident #1 turned back towards him and he had what looked like a black string hanging from his mouth that was approximately 3 to 4 inches long. The Social Worker stated he could not tell what Resident #1 put in his mouth. The Social Worker stated he did not report what he saw to the Physician or the Family Member. A telephone interview was conducted with Nurse #1 on 8/13/2021 at 9:30 am. Nurse #1 stated on the evening of 8/9/2021 she was at the Nurses ' Station when Resident #1 walked up the hall with a Styrofoam food container in his hand and the DON screamed out and stated she thought she was going to be sick. Nurse #1 stated the DON said she saw Resident #1 pick a food tray out of the trash and something was moving in his hand and before she could stop him, he put something that looked like a mouse in his mouth. Nurse #1 stated Resident #1 would not open his mouth. Nurse #1 stated the DON left the unit. Nurse #1 stated she felt sick and went into the bathroom and when she came out Nurse Aide #1 yelled out and came to the nurses ' station. Nurse #1 stated Nurse Aide #1 told her Resident #1 spit up something that looked like [NAME] and a tail. Nurse #1 stated she could not look at what Resident #1 had spit up because she was so sick, and she stated the DON did not look at what Resident #1 had spit up. Nurse #1 stated the DON notified the Administrator of the incident and she thought she was going to notify the Physician and document the incident. An interview by phone was conducted with Nurse Aide #1 on 8/12/2021 at 7:05 pm and she stated on 8/9/2021 Resident #1 arrived in the dining room at supper and he spit out a greyish-brown ball of fur with a piece of [NAME] in it. Nurse Aide #1 stated she picked up what was spit out in a glove and put it in the trash and then had Resident #1 open his mouth. Nurse Aide #1 stated there was greyish-brown fur on Resident #1 ' s tongue. Nurse Aide #1 stated she notified Nurse #1 immediately. During an interview with the Administrator on 8/12/2021 at 6:39 pm she stated it was reported by Nurse Aide #1 on 8/9/2021 Resident #1 had fur in his mouth and [NAME] that may have been a mouse tail. The Administrator stated the facility reported the incident to the Physician on 8/10/2021 when he arrived at the facility. The Administrator stated she had the facility ' s pest control provider check for any signs of mice on 8/11/2021 and the facility also had an education on what they should do if they saw pests in the facility 8/11/2021. During an interview with Nurse Aide #2 on 8/13/2021 at 11:36 am she stated she did not witness the incident on 8/9/2021 when Resident #1 put something in his mouth, but she has observed him digging through the trash and getting other resident ' s food before, and she redirected him when he has the behavior. Physician was interviewed on 8/13/2021 at 1:55 pm and he stated he was notified on the morning after the incident, 8/10/2021, that Resident #1 may have swallowed a mouse. The Physician stated he did not assess Resident #1, write orders, or call Poison Control because he thought the Nurse Practitioner would be seeing Resident #1. During an interview with the Representative from the facility ' s pest control company on 8/13/2021 at 4:20 pm he stated he had been coming to the facility for the past 4 months and he treated the building every month for bug control but had not seen signs of mice. He stated he had set traps outside the facility to keep mice from coming inside on 7/21/2021 during a routine pest control visit and he had inspected the facility on 8/11/2021 for any signs of mice and cockroaches inside the facility. The facility ' s pest control company report dated 8/11/2021 stated the facility was inspected for rodent and cockroach activity and no activity was found. The report further stated exterior rodent [NAME] traps were applied. A Progress Note with a date of service of 8/12/2021 by the Nurse Practitioner stated she saw Resident #1 after staff reported he ingested a rodent. The Progress Note further stated the Nurse Practitioner called Poison Control and they suggested Resident #1 be monitored for fever, bleeding, and vomiting. An interview by phone with the Nurse Practitioner on 8/13/2021 at 12:00 pm revealed she was told by the DON on 8/12/2021 Resident #1 may have ingested a mouse on Monday 8/9/2021. The Nurse Practitioner stated she learned about the incident from the DON when she was in the facility to see resident but had not been called in to see Resident #1. The Nurse Practitioner stated she had examined Resident #1 for any bite marks on his lips and mouth and did not see any. The Nurse Practitioner stated she was also concerned if Resident #1 had ingested a mouse he may have also ingested poison from the mouse and she also worried about what disease the mouse may carry. The Nurse Practitioner stated she called the NC Poison Control and was told Resident #1 should be monitored for fever, bleeding, and bloody diarrhea. The Nurse Practitioner did not write orders for monitoring for Resident #1. During a follow up interview with the DON on 8/13/2021 at 3:26 pm she stated she had updated Resident #1 ' s care plan yesterday, 8/12/2021, to include his history of eating from the garbage after she reported to the Family Member, he may have ingested something unknown from the garbage on 8/9/2021. The DON stated the Family Member had stated he had a history of eating from the garbage and putting inedible items in his mouth. The DON also stated Nurse #1 should have documented the incident that occurred on 8/9/2021 in the medical record. An interview and observation with Nurse Aide #5 on 8/13/2021 at 5:12 pm revealed she cared for Resident #1 frequently. Nurse Aide #5 stated Resident #1 wanders and gets into trash and other resident ' s food. Nurse Aide #5 stated Resident #1 had to be watched constantly and redirected. During the interview with Nurse Aide #5 on 8/13/2021 at 5:14 pm Resident #1 entered the dining room and was opening the cabinet doors and going through items in the cabinets. Nurse Aide #5 redirected Resident #1 to the table. Nurse Aide #6 was interviewed on 8/13/2021 at 6:52 pm and he stated he was not told the signs and symptoms to monitor for if Resident #1 did ingest a mouse. During an interview with Nurse #2 on 8/13/2021 at 6:53 pm she stated was not told what signs and symptoms Resident #1 should be observed for after the incident when he allegedly ingested a mouse. Nurse #2 stated Resident #1 wanders and has rummaged in the trash and she stated she redirects him Nurse #4 was interviewed on 8/13/2021 at 7:01 pm and she stated she did not receive any instruction regarding what symptoms she should observe Resident #1 for after the possible ingestion of a mouse. Nurse Aide #7 was interviewed on 8/13/2021 at 7:04 pm and stated she had not told what signs and symptoms to look after Resident #1 ' s incident where he may have swallowed a mouse. On 8/13/2021 at 8:12 pm the Administrator was notified of Immediate Jeopardy. On 8/14/2021 the facility provided a Credible Allegation of Immediate Jeopardy Removal: Credible Allegation of Compliance F689. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8.9.21, resident #1 was seen by DON and social worker with a string like object hanging from his mouth. DON and SW immediately approached resident and checked resident ' s oral cavity for any foreign objects but found none. On 8.9.21 after incident DON failed to document and complete incident report, notify MD, notify RP, and update care plan. On 8.9.21, DON and/or Nurse #1 failed to document assessment of resident after incident. On 8.9.21, twenty minutes after incident, nurse #1 alerted DON that resident had spit up an unidentified item. Nurse #1 failed to document findings and incident. On 8.9.21, DON/and or nurse #1 failed to notify poison control for guidance on unidentified potentially harmful item. On 8.9.21 DON/ and or nurse #1 failed to document attempts to notify RP. All residents with identified behavior of placing items in mouth are at risk. Facility failed to initiate a care plan for the potential of placing non-food related items in mouth upon admission for resident #1 to address the prior history of the exhibited behavior. DON initiated a care plan on 8.12.21 for the exhibited behavior of placing potentially harmful items in mouth. All staff educated on care plan on 8.13.21 and 8.14.21 by Administrator and DON. All residents are at risk for incident and/or accident. On 8.9.21 Nurse failed to document incident or notify resident physician or responsible party per facility policy. Resident ' s RP was notified via cell phone by DON on 8.12.21. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. M.D. was notified on 8.10.21 by DON and RP was notified on 8.12.21 by DON. On 8.10.21 immediately upon noticing string like object hanging from resident #1 ' s mouth, DON states she swept resident ' s mouth for any signs of foreign objects. She found none. Director of nursing called poison control on 8.12.21 with recommendations to monitor for fever, vomiting or bleeding. The FNP completed assessment of resident #1 on 8/12/21 at 4:00 pm related to incident of ingesting potential harmful item in his mouth. FNP also notified poison control on 8.12.21 with same recommendations. Director of Nursing completed additional assessment of resident #1 on 8.13.21. Resident #1 will be monitored by licensed nurse for any change in condition to include fever, vomiting or bleeding as recommended by poison control. DON entered order to monitor for changes in condition for resident #1 on 8.13.21. Licensed and Registered Nurses were educated on 8.13.21 and 8.14.21 by Administrator and DON. On 8.13.21 Regional Director of Operations and Regional Clinical Director met with Administrator and Director of Nursing to review process for assessment and Care plan. Regional Director of Operations and Regional Clinical Nurse provided remediation education on policies for resident assessment and care plans on 8.13.21. MDS nurse will be educated by Administrator when MDS Coordinator returns from vacation. On 8.13.21 Regional Clinical Nurse met with the Director of Nursing and reviewed the facility ' s policy on documentation and notification of physician and resident representative. Regional Clinical Nurse provided remediation education to the Director of Nursing on facility policy for incident and accidents including notification of physician and family notification as of 8.13.21. On 8/13/21 Director of Nursing begin education to all Nurses on facility policy for incident and accidents which included documentation of incident/accident, assessment of incident/accident, and notification to physician and representative. Director of Nursing will conclude education of all licensed Nursing staff on 8.14.21. As of 8.14.21 no licensed will be allowed to work prior to receiving education on incident and accident documentation. Starting 8.14.21 any agency or new licensed staff will be educated by the Director of Nursing or designee, on facility documentation and notification related to incident/accident prior to starting shift. Sign in sheets will be audited by DON or designee daily to ensure all new staff have signed. Beginning on 8.13.21 Administrator and or Director of Nursing educated all staff on residents with behaviors of putting or ingesting something harmful in their mouth. Starting on 8.14.21 all new staff or agency staff will be educated on residents with behaviors related to potential for putting potential harmful things in mouth and/or digging in trash prior to working. Education to be completed by Administrator and DON, with Administrator and DON or designee educating any new staff to the facility. Daily schedule will be reviewed by Administrator, DON, or designee to ensure new staff educated as they come in, starting on 8.14.21. On 8.13.21, DON initiated order for monitoring resident for signs and symptoms of ingesting potentially harmful items. Care plan was updated on 8.12.21 for behaviors of potentially ingesting potentially harmful items and digging in trash. On 8.14.21, all staff have been educated on monitoring for residents putting potentially harmful items in mouth and digging in trash. On 8.14.21, IDT team was in-service by Administrator related to care planning of behaviors of residents putting potentially harmful items in mouth or digging in trash. Administrator will be responsible for making sure IJ removal plan is carried out and completed. Facility alleges IJ removal as of 8.14.21. Credible Allegation IJ removal On 8/17/2021 a review was conducted of the plan to ensure those affected by the deficient practice. The facility updated Resident #1 ' s Care Plan to include a history of eating items out of the trash and putting non-edible items in his mouth on 8/12/2021. The Nurse Practitioner assessed Resident #1 and called Poison Control on 8/12/2021. A review of Resident #1 ' s medical record revealed there was a Nursing Progress Note each shift beginning 8/12/2021 to document signs of nausea, vomiting, diarrhea, and bloody stools. The Administrator was interviewed and stated the facility had reviewed all residents who scored as cognitively impaired on the BIMs (Brief Interview for Mental Status) and had evaluated them for the possibility of placing non-edible food items in their mouths on 8/14/2021. During the validation three other residents that were cognitively impaired were reviewed and two had care plans for potential to place non-edible objects in their mouths. Both residents were ambulatory and had behaviors like putting objects in their mouths. The other resident was bed bound and was at no risk of placing non-edible items in their mouth. The facility did in-service education with the Nursing Department which included care planning any resident that had behaviors of putting non-edible objects in their mouth on 8/14/2021. The education for the Nursing Department also included reporting of any change in condition or accident to the Physician and Responsible Party immediately. The in-service education included notifying Poison Control if needed and Emergency services if needed and then documenting what had happened and what was done for the resident in the resident ' s record. The facility also included education with all other staff (housekeeping, dietary, and maintenance) to report any time a resident is attempting to put something in their mouth or has put something non-edible in their mouth. Interviews were conducted with multiple staff members from each shift and different disciplines, and they were able to verbalize the correct information. The facility has included the in-service education in the new employee education and education for agency staffing beginning 8/14/2021. 2. Resident #5 was admitted to the facility on [DATE] and her cumulative diagnoses included stroke, dementia with behavioral disturbance, and generalized weakness. A review of Resident #5 ' s Minimum Data Set (MDS) assessment revealed a quarterly assessment with an Assessment Reference Date (ARD) of 8/2/21. The resident was coded as having severe cognitive loss. For Activities of Daily Living (ADLs) the resident was coded as having required supervision with the support of one person for bed mobility, transfer (such as into and out of bed to a wheelchair), walking in the room, walking in the corridor, and moving about the unit. The resident was coded for having displayed verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others). Resident #5 ' s care plan, documented the resident had a focus area for the resident having impaired cognitive function/dementia or impaired thought processes related to Alzheimer ' s, but the goals nor the interventions addressed the resident ' s behaviors. On 8/13/21 the resident was seen for a psychiatry initial visit by a Geriatric Nurse Practitioner-Board Certified (GNP-BC). The GNP-BC recommended adding [MEDICATION(S)] (an anticonvulsant medication which is also used to treat the manic phase of [CONDITION(S)] (manic-depressive illness) Delayed Release (DR) 250 milligram (mg) twice a day and to continue the other [CONDITION(S)] medications the resident was on. a. Resident #6 was admitted to the facility on [DATE]. The resident ' s cumulative diagnoses included: Dementia with behaviors, delusional disorders, psychoses, [CONDITION(S)], [CONDITION(S)] disorder, anxiety, and depression. A review of Resident #6 ' s Minimum Data Set (MDS) assessment revealed an annual comprehensive assessment with an Assessment Reference Date (ARD) of 8/11/21. The resident was coded as having severe cognitive impairment. For Activities of Daily Living (ADLs) the resident was coded as having required limited assistance of 1 person for bed mobility, transfer (such is into and out of the bed to and from a wheelchair), locomotion both on and off of the unit. The resident was not coded for any behaviors during the assessment period. Resident #6 ' s care plan included the following focus areas related to behavior: Verbally aggressive (yelling at other residents, accusing them of stealing her belongings), potential to be physically aggressive striking other residents related to dementia, impaired cognitive function/dementia related to dementia, delusional, [CONDITION(S)], dementia in other diseases classified elsewhere with behavioral disturbance, other specified problems related to psychosocial circumstances, and level II Pre Admission Screening and Resident Review (PASRR). The resident ' s care plan was revised on 8/14/21. An incident report dated 8/16/21 and timed 3:40 PM, which was completed by Nurse #5, was reviewed. The incident report detailed Resident #5 wandered into Resident #6 ' s room and Resident #6 asked Resident #5 to leave her room. Resident #5 walked over to Resident #6 and hit her across her face as was reported by Resident #6. Resident #6 provided further information that she then hit Resident #5 across her face. No injuries were observed and neither resident had any complaints of pain. Both residents were separated. There was no information in the incident report regarding further monitoring of either resident. During an interview conducted on 8/24/21 at 12:14 PM with Nurse #5 she stated Resident #5 could be pleasant, but lately she had been getting riled up and was more agitated. She said the resident could get up and move around the dementia unit independently. The nurse further explained, recently, the resident had been getting into more verbal altercations with residents. b. Resident #7 was admitted to the facility on [DATE]. The resident ' s cumulative diagnoses included: Dementia, [CONDITION(S)], generalized weakness, and anxiety. A review of Resident #7 ' s MDS assessment revealed a quarterly assessment with an ARD of 8/11/21. The resident was coded as having severe cognitive impairment. For ADLs the resident was coded as having required supervision and setup help only for bed mobility, transfer (such is into and out of the bed to and from a wheelchair), walk in the room, walk in the corridor, locomotion both on and off of the unit. The resident was not coded for any behaviors during the assessment period. Resident #7 ' s care plan included the following focus areas related to behavior: Elopement risk/wanderer related to dementia and the resident had a history of wandering aimlessly. There was also a focus area for the resident having the potential to be physically aggressive to staff and residents related to dementia. The resident ' s care plan was revised on 8/14/21. An incident report dated 8/18/21 and timed 8:15 AM, which was completed by Nurse #6, was reviewed. The incident report detailed Resident #7 wandered into Resident #5 ' s room, Resident #5 asked Resident #7 to leave her room, and Resident #7 would not leave the room. The two residents then got into an altercation where they scratched each other. The information was documented as having been provided by a Nursing Assistant (NA) who had witnessed the altercation. The nurse documented the altercation resulted in Resident #7 receiving an abrasion to her upper chest area which was cleansed with wound cleanser and ointment was applied. There was no documentation regarding further monitoring or either residents for behaviors. An additional incident report dated 8/18/21 and timed 8:15 AM, which was completed by Nurse #6, was also reviewed. The incident report detailed Resident #7 wandered into Resident #5 ' s room, Resident #5 asked Resident #7 to leave her room, and Resident #7 would not leave the room. The two residents then got into an altercation where they scratched each other. The two residents were separated by an NA. The information was documented as having been provided by a NA who had witnessed the altercation. The nurse documented the altercation resulted in Resident #5 receiving two skin tears to her right lower arm which resulted in a scant amount of blood observed. which was cleansed with wound cleanser, ointment, and a dressing was applied. There was no documentation regarding further monitoring of either residents for behaviors. Review of a psychotherapy comprehensive clinical assessment dated [DATE] by a Doctor of Philosophy (PhD) psychologist. Resident #5 was seen for initial assessment of cognitive status, [CONDITION(S)], and dementia behaviors. The PhD documented the resident was seen by the GNP-BC and recommended adding [MEDICATION(S)] DR 250 mg BID. She further documented the resident was not appropriate for psychotherapy but encourages staff to have patient come out of room even if for brief periods at a time to either connect with other peers or maybe an activity, and to encourage to connect with resident to reduce isolation. The resident was determined to not be appropriate for psychotherapy and advised social work. During an interview conducted on 8/25/21 at 11:24 AM with NA #8 he stated he had seen Resident #5 and Resident #7 get into an altercation and he had also seen Resident #5 get into altercations with other residents. He said Resident #7 had grabbed Resident #5 and they were both trying to grab each other in Resident #7 ' s room. He said Resident #5 had also grabbed Resident #7 ' s shirt. He said he hadn ' t seen the whole altercation because he had just happened to have been passing by Resident #7 ' s room when the altercation was already underway. He said he had seen where Resident #7 had scratched at Resident #5 ' s chest. He said he had passed the room earlier and everything looked OK with both residents in the room earlier. He explained Resident #5 was all over the dementia unit and did not know where her room was. He said Resident #5 liked attention and if you gave her a lot of attention, she wouldn ' t do anything. He said once Resident #5 was with him and he was giving her attention, she was no problem for the rest of the day. NA #5 stated during an interview conducted on 8/25/21 at 11:43 AM Resident #5 had been in several altercations with different residents. She stated there had been one day when Resident #5 was just fighting everyone. The NA stated she was also a medication aide and she had observed a pattern with Resident #5. She explained the resident would get up in the morning, eat her breakfast, take her medications, then take a nap, and when she would wake up from her nap she would be agitated. She further stated it was common for her to wander into other resident ' s rooms, sometimes it helped to redirect her, and sometimes it did not. She said when Resident #5 had an altercation with Resident #7 on 8/18/21, Resident # 5 had a scratch on her neck and Resident #7 had scratches on her arm. She said she had alerted Nurse #6 who came over to check on the residents. She said after the altercation with the two residents they had kept Resident #5 close to them, but she did not know if there was someone assigned to be with Resident #5. The NA said if there was a serious altercation, then a resident would have one to one. She said there was nothing specific set up for Resident #5. She said it helped with the resident if someone were to spend time with her and give her attention, but most of the altercations come when she goes into other resident ' s rooms and argues with them that it is her room. An interview was conducted on 8/25/21 at 10:16 AM with Nurse #6. She stated she was told by NA #8 and NA #5, Resident #7 had gone into Resident #5 ' s room and she wouldn ' t leave, and the two residents had gotten into it, this had happened on 8/18/21. She explained when she arrived on the dementia unit both residents had scratches and both residents had required treatment for the scratches. Resident #5 had scratches to her chest and Resident #7 had scratches on her arm. She said both residents were upset, excited, and agitated a little bit over what had happened. An observation conducted of Resident #7 on 8/25/21 at 12:00 PM revealed the resident had two separate dry and intact abrasions on her right arm. One skin tear was approximately 1 centimeter (cm) long and was L shaped. The other skin tear was approximately 5 millimeters (mm) long and was crescent shaped. c. Resident #8 was admitted to the facility on [DATE]. The resident ' s cumulative diagnoses included: dementia with behavioral disturbance, depression, anxiety, generalized weakness, [CONDITION(S)], and [CONDITION(S)]. A review of Resident #8 ' s MDS assessment revealed a quarterly assessment an with ARD of 8/11/21. The resident was coded as having severe cognitive impairment. For ADLs the resident was coded as having required supervision or setup help of 1 person for bed mobility, transfer (such is into and out of the bed to and from a wheelchair), walking in the room, walking in the corridor, locomotion both on and off of the unit. The resident was coded for behavioral symptoms not directed towards others during the assessment period. Resident #8 ' s care plan included the following focus areas related to behavior: Elopement risk/wanderer related to resident wanders aimlessly, dementia, Alzheimer ' s. Behavior problem related to Alzheimer ' s dementia-there were multiple dated entries with behaviors including attempted elopement, pulling fire alarm, verbally aggressive to staff, wandering into other resident ' s rooms, refusing medications, combative towards staff, ripped air conditioning cover off, attempted to take another resident ' s walker, physical altercation with other resident, and threw lunch tray. The resident ' s care plan was revised on 8/14/21. A pharmacist review note dated 8/20/21 and timed 9:36 AM documented Resident #5 had altercations with other residents on 8/16/21 and 8/18/21. The resident had other behaviors which included cussing and screaming at other residents while walking down the hall, will calm down, and then start back crying or screaming. The resident ' s [CONDITION(S)] medications included [MEDICATION(S)] 1 milligram (mg) three times a day and [MEDICATION(S)] 50 mg each evening at bedtime. There were no recommendations regarding the resident ' s medication at the time of the review. An incident report dated 8/20/21 and timed 7:23 PM, which was completed by Nurse #7, was reviewed. The incident report detailed Resident #8 was hit in the center of the back by Resident #5. The description included Resident #8 was walking by Resident #5 when the Resident #8 caused the aggressive behavior by Resident #5. There were no identified injuries for Resident #8. There was no information in the incident report regarding further monitoring of either resident. A second incident report dated 8/20/21 and timed 7:39 PM, which was completed by Nurse #7, was also reviewed. The incident report detailed according to staff Resident #5 hit Resident #8 in the center of the back. The description included Resident #5 had very aggressive behaviors. There were no identified injuries for Resident #5+. There was no information in the incident report regarding further monitoring of either resident. A phone interview was conducted on 8/25/21 at 2:54 PM with Nurse #7. The nurse stated Resident #5 was agitated all of the time since 7/4/21 and she had documented the resident ' s agitation. The nurse stated she believed Resident #5 was a threat to other residents. She explained on 8/20/21 Resident #5 had hit Resident #8. d. Resident #4 was admitted to the facility on [DATE]. The resident ' s cumulative diagnoses included: stroke, dementia with behaviors, ge [TRUNCATED]

Based on record review, family, Nurse Practitioner and staff interviews, the facility failed to assess and treat 1 of 3 residents, Resident # 2, for skin breakdown which was discovered when Resident #2 was admitted to the hospital with increased blood glucose level and a bloodstream infection. Findings included: Review of Resident #2's Medical Record revealed she was admitted to the facility on [DATE] and discharged to the hospital on 7/4/2021. Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse that completed Resident #2's Admission Assessment was not available for interview. Resident #2's Medical Record further revealed she did not have a skin assessment completed after her initial Admission Assessment. A Care Plan dated 6/14/2021 stated Resident #2 had skin breakdown, a blistered area to her right shoulder and was at risk for further skin breakdown. The Care plan indicated the goal was for Resident #2 to have intact skin. Interventions to prevent skin breakdown included weekly skin audits and treatments to affected areas were an intervention. An Admission Minimum Data Set assessment dated [DATE] revealed Resident #2 was severely cognitively impaired, required extensive assistance with bed mobility and total assistance with toileting and did not have pressure ulcers. Nurse Aide #3 was interviewed on 8/25/2021 at 1:11 pm and stated she cared for Resident #2 on 7/1/2021 and 7/2/2021. Nurse Aide #3 stated she had changed Resident #2 because she was incontinent of bowel and bladder and she did not remember Resident #2 having any skin breakdown. Nurse #1 was interviewed on 8/24/2021 at 3:57 pm and stated she had reported a blister on Resident #2's right shoulder to the Wound Nurse but had not been aware of any pressure ulcers to her sacrum or buttocks. Nurse #1 stated she had not done a skin assessment when the blistered area was found to Resident #2's right shoulder. It had been reported to her during a report from another Nurse. Nurse #1 stated she did not remember doing any skin assessments for Resident #2. Nurse #1 stated the skin assessments are done weekly and they are on the electronic Medication Administrator Record (MAR). Nurse #1 stated the MAR would automatically show that the skin assessment needed to be signed off. During an interview with Nurse #5 on 8/25/2021 at 4:00 pm she stated she cared for Resident #2 on 7/4/2021 when she was sent to the hospital. Nurse #5 stated she did not assess Resident #2's skin and she did not remember doing a skin assessment on Resident #2 when she cared for her. Nurse #5 stated skin assessments should be done weekly and are recorded on the Medication Administration Record. During an interview with Resident #2's Family Member on 8/25/2021 at 11:42 am she stated the facility had not notified her of the wound to Resident #2's sacrum but had called her on 7/4/2021 after 6:00 pm to tell her Resident #2 was being sent to the hospital. The Family Member stated when she arrived at the emergency room she was shown the wound to Resident #2's sacrum and it was as long as her hand and it was very deep with what she thought was bone showing. A Wound Care note dated 7/5/2021 at 1:40 pm from the hospital records stated Resident #2 had an 11-centimeter by 4.2-centimeter unstageable ulcer to Resident #2's sacrum and extended to the right buttock. The note further stated the ulcer would benefit from surgical debridement. During an interview with the Director of Nursing (DON) on 8/24/2021 at 4:36 pm she stated she did not find any skin assessments completed for Resident #2 during the time she was at the facility. The DON stated she felt the skin assessments were not added to the Medication Administration Record when Resident #2 was admitted , and this was the reason they had been missed. The DON stated the assessments should have been activated when Resident #2 was admitted to the facility. An interview was conducted with the Wound Care Nurse Practitioner on 8/25/2021 at 1:32 pm. The Wound Care Nurse Practitioner stated she saw Resident #2 for small blisters to her left posterior shoulder, but no other wounds were reported to her. The Wound Care Nurse Practitioner stated the Nurses should do weekly wound assessments and report any skin breakdown. The Administrator was interviewed on 8/27/2021 at 10:38 am and stated the Nursing staff should have completed a skin assessment for Resident #2 weekly from her admission to her discharge. The Administrator stated she thought the admission was not entered into the electronic system correctly and the skin assessment did not trigger for the nurses to complete them. On 9/3/2021 at 12:23 pm a follow-up interview was conducted with the Wound Care Nurse Practitioner and she stated Resident #2 would have been high risk for skin breakdown due to weakness and incontinence. The Wound Care Nurse Practitioner stated she may have had a deep tissue injury before going to the emergency room and depending on how long she was in the emergency room it could have contributed to her having an unstageable deep tissue injury.

Based on observation of recorded facility video, resident interview, staff interview, observation, and record review the facility failed to protect two of three residents reviewed for physical abuse (Resident #16 and Resident #17) from Resident #2. During a physical altercation on 9/17/20 Resident #2 struck Resident #16 with a closed right fist to the head and body repeatedly causing Resident #16 to experience a swollen lip. A staff member observed Resident #2 hit Resident #17 in the head with the open canopy of an umbrella, and then proceeded to hit Resident #17 in the leg with the closed umbrella. The facility also neglected to supervise Resident #2 to prevent him from providing a supervised smoker (Resident #16) with cigarettes. Resident #16 was at risk for injury due to unsafe smoking behaviors and required supervision while smoking. Resident #16 was observed smoking unsupervised on the patio on recorded video footage. Immediate jeopardy began on 9/17/20 when Resident #2 was observed on facility security camera footage to have engaged in altercation with Resident #16 where Resident #2 was observed to have repeatedly punched Resident #16 numerous times to the face with a closed right fist. The punches delivered by Resident #2 to Resident #16 resulted in Resident #2 experiencing a swollen lip. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 11/4/20. The immediate jeopardy was removed on 11/5/20. The facility will remain out of compliance at a scope and severity level of E (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The Findings Included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's care plan dated 7/14/20 revealed focus area titled, the resident has limited physical mobility related to Chronic Obstructive [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]) disease process and weakness. There was a sub-title which documented the resident had a motorized wheelchair and often unsafe: speeding, bumping into other residents, allowing or encouraging others to hang on and ride behind him. The goal was for the resident to demonstrate appropriate use of the motorized wheelchair to increase mobility through the review date. The listed interventions included; safety education and reminders related to motorized wheelchair use to be provided to resident as needed (slow speed, monitoring for other residents, and negotiating safely around them, not allowing other residents to hold on to back of his wheelchair for a free ride. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the following regarding Resident #2: He was cognitively intact; he was independent or required supervision with setup help or one person physical assist for all activities of daily living. He had no impairment to his upper or lower extremities. The resident was documented as having weighed 337 pounds. a. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 ' s care plan revealed a focus area most recently reviewed on 7/17/20 regarding the resident having had a [MEDICAL CONDITION] disorder related to a past head injury. Further review revealed focus areas including: [MEDICAL CONDITION]/[MEDICAL CONDITION] related to head injury, the resident was deemed to be an unsafe smoker as of 6/16/20 due to the resident dozing off with a lit cigarette posing danger to himself and others, the resident had an Activity of Daily Living deficit related to left side [MEDICAL CONDITION], impaired cognitive function/dementia or impaired decision making in that the resident had lost money several times and was unable to recall what he did with the money, the resident received [MEDICAL CONDITION] medications related to [MEDICAL CONDITION] and delusional disorder, anti-anxiety medications related to an anxiety disorder, and antidepressant medication related to depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the following regarding Resident #16: He was cognitively intact; he required limited assistance of one person for bed mobility, transfer (such as from a bed to a wheelchair), and locomotion off of the unit (how the resident moves to and returns from off unit locations). He had impairment to one side of his upper or lower extremities. The resident was documented as having weighed 179 pounds. Review of a 24-hour report dated 9/18/20 revealed an allegation Resident #2 had punched Resident #16 in the face while the two of them were in the smoking area on 9/17/20. The facility alleged they did not become aware of the altercation until 9/18/20 at 12:50 PM. The 24 hour report was signed by Administrator #1 on 9/18/20. The allegation type was classified as resident abuse and the local police department was documented as having been notified. A review was completed of the 5-working day investigation report dated 9/25/20. The review revealed the allegation of resident abuse when Resident #2 punched Resident #16 in the face on 9/17/20 was investigated, substantiated, and had caused harm to Resident #16, as evidenced by his lip being swollen. The summary of the investigation documented Resident #2 hit Resident #16 in the mouth while the two were at the smoking area. Resident #2 accused Resident #16 of taking two of his cigarettes, however Resident #16 denied the accusation. The report further documented due to Resident #2 ' s aggressive behavior, orders were received to send him to the hospital to be evaluated, and he refused to go. The local police department was contacted the officer instructed the facility to involuntary commitment papers for Resident #2. The officer was informed the resident was alert and oriented, and the officer directed the facility to press charges against Resident #2. Resident #16 went to the magistrate and pressed charges against Resident #2 and a warrant was issued for Resident #2. Resident #2 was placed on every 15 minute checks. An officer from the police department came to the facility to serve the warrant on 9/21/20 and the officer did not come into the facility and Resident #2 refused to meet the officer at the entrance. The officer returned on 9/22/20 and served the resident with a summons to appear in court on 10/25/20. The resident was documented to remain on every 15 minute checks. The report was signed by Administrator #1 on 9/25/20. An observation of facility security camera footage from 9/17/20 and timed 3:33 PM was conducted in conjunction with an interview with the Maintenance Director (MD) and the Maintenance Assistant (MA) on 10/28/20 at 2:33 PM. The video did not have audio and was black and white video. Resident #2 was in his electric wheelchair and Resident #16 was in a manual wheelchair with an ash tray on his lap. Resident #2 rolled up to Resident #16 ' s right side and got within inches Resident #16 and leaned toward Resident #2. Resident #2 then propelled his electric wheelchair to the point where he had to spread his knees apart to get even closer to Resident #16 then reached with his left hand and pulled a cigarette shaped object from behind Resident #16 ' s right ear. Resident #2 then tried to roll away and Resident #16 grabbed Resident #2 ' s left hand with his right hand. Resident #16 continued to hang onto Resident #2 ' s left hand as Resident #2 backed away from him. Resident #2 then started to use his right hand to punch Resident #16 in the face. Resident #16 then backed up and Resident #2 propelled at him with his hands held up in a boxing type position, Resident #16 took the ash tray with his right hand and attempted to strike Resident #2 as he propelled toward him. Resident #2 got within an arm ' s length of Resident #16, grabbed Resident #16 ' s right arm, attempted to make several punches with his right arm as he attempted to hold Resident #16 ' s right arm with his left hand, the ash tray fell to cement patio, Resident #16 attempted to strike at Resident #2 as Resident #2 continued to use both of his arms in an attempt to grab Resident #16 ' s right arm while he punched Resident #16 in the head. Eventually Resident #2 succeeded in holding Resident #16 ' s right arm and proceeded to make 5-6 direct punches to Resident #16 ' s head and knocked the hat off Resident #16 ' s head. Resident #2 then used his electric wheelchair to move away from Resident #16. Resident #16 then moved toward Resident #2 slightly and attempted, unsuccessfully to strike at Resident #2. Resident #2 then again propelled toward Resident #16 within arm ' s length, and again used his left hand to grab Resident #16 ' s right arm, and then delivered punches too numerous to count to his head. Resident #2 then backed up again, repositioned himself in his electric wheelchair, and again got within arm ' s length of Resident #16, again grabbed his Resident #16 ' s right arm with his left hand and proceeded to deliver punches to Resident #16 ' s head too numerous to count with his right fist. Resident #2 backed away from Resident #16 again, repositioned himself in his wheelchair, and repeated the same maneuver again where he rolled up to within arm ' s length of Resident #16, used his left hand to hold Resident #16 ' s non-affected arm, which was his right arm, and then proceeded to punch Resident #16 in the face several more times. Resident #2 backed away from Resident #16 again and repositioned himself in his wheelchair. It appeared as Resident #2 said something to Resident #16 and then Resident #16 rolled toward Resident #2 and attempted to kick him with his right leg. Again, Resident #2 repeated rolling up to Resident #16 within arm ' s length, grabbed Resident #16 ' s right arm with his left hand, and this time pulled his upper body toward him and started to repeatedly punch Resident #16 to the head while twisting Resident #2 ' s right arm. Resident #2 backed his wheelchair up and repositioned himself in the chair. Resident #2 then uses his electric wheelchair to go around the smoking area and then returns inside of the building. The first strike from Resident #2 to Resident #16 occurred at video mark 3:33:30 PM and the last strike from Resident #2 to Resident #16 was at video mark 3:36:29 PM. Additionally observed in the video, Resident #19 was observed to have witnessed the entire altercation. At the conclusion of the video the Maintenance Director stated he was the only one who had access to the facility video surveillance system, and he stated neither he nor anyone else had observed the just viewed video footage prior to that viewing. During an interview with Resident #16 conducted on 10/29/20 at 2:46 PM he stated Resident #2 had accused him of stealing two cigarettes, he punched me in the lip, and we got into it, he ' s bigger than me, he has two arms and I only have one. The resident continued and stated they kept swinging at each other, he kept hitting me in the head, and then he tried to use his one good hand to punch him in the stomach. Resident #16 explained Resident #2 had punched him first and he had just been sitting there when Resident #2 had come up to him and started accusing him of having stolen cigarettes. Resident #16 stated during the altercation Resident #2 had taken two cigarettes from him. He said Resident #2 kept punching him in the head and he had a busted and swollen lip from being punched in the face. He said he was trying to defend himself with his right hand but Resident #2 was holding it because he knew he couldn ' t use his left arm to defend himself. He stated it upset him a lot that Resident #2 had held his one good hand and continued to punch him knowing he couldn ' t use his left hand. He said he felt like Resident #2 was continuing to try to intimidate him because just last night when he was in the day room, Resident #2 went past him and with his electric wheelchair hit the anti-tip bars on the back of his wheelchair and it had upset him. He stated he felt like Resident #2 would hit him again An interview was conducted on 10/27/20 at 12:14 PM with Resident #2. During the interview the resident stated he was supposed to go to court because Resident #16 had placed a warrant out for his arrest due to an altercation he had with him. The resident stated the altercation was due to him having accused Resident #16 of having stolen his cigarettes. The resident stated he was unable to recall the date of the altercation. An interview was conducted with Resident #19 on 10/28/20 at 2:52 PM. He stated he remembered Resident #2 had sold two cigarettes to Resident #16 in the morning and then he stated Resident #2 accused Resident #16 of stealing two cigarettes from him. He stated he recalled that Resident #16 had tried to hit Resident #2, Resident #2 caught Resident #16 ' s hand and then hit him back. He said the two of them continued to argue and hit at each other. He said it was a scary situation. A phone interview on 10/30/20 at 2:19 PM was conducted with the Occupational Therapist (OT) who was working with Resident #16. She stated Resident #16 had asked her to pull down his mask on 9/18/20 to see if his lip was cut. She stated she asked the resident what had happened, and he replied Resident #2 had hit him and accused him of stealing two cigarettes, but he said he had not stolen the cigarettes. She stated the resident ' s lip was swollen and did have a cut on the inside of his mouth on his bottom lip. The OT said the resident did not complaint of pain anywhere else except for his lip and that it was sore. Review of the witness statement from the OT, which was an email dated 9/18/20 and timed 2:49 PM, Resident #16 also informed her Resident #2 had been in another fight on 9/18/20. She further stated she informed her supervisor of the information Resident #16 had shared with her. The resident had a physician ' s order dated 9/18/20 and timed 12:56 PM for Resident #2 to be sent to the ER via ambulance for evaluation with psych services for combative behaviors. A nursing progress note dated 9/18/20 and timed 2:36 PM by Nurse #1 documented it had been reported by Resident #16 that Resident #2 had hit him while they were both at the smoking area on 9/17/20. The note further documented orders were obtained to send Resident #2 to the emergency room (ER) for evaluation of aggressive behavior and the resident refused to go to the ER. An order was received for the Resident #2 to be placed on every 15 minute checks and those were initiated. Review of a progress note written by the Nurse Practitioner (NP) dated 9/23/20 and timed 11:45 AM revealed she had conducted a remote visit with the resident on 9/22/20. She documented she spoke with the resident about his aggressive behaviors and discussed the use of medication for feelings of depression or other symptoms of mood changes. The resident responded with a statement of, ' I ' m fine and I don ' t need nothing. The NP documented she further discussed an order for [REDACTED]. An NP noted dated 9/29/20 by the NP documented the facility staff stated the resident had displayed aggression and continued to misuse his electric wheelchair. The NP documented the resident at first declined a psychiatric referral, but then agreed to it, and signed the necessary paperwork. The psychiatric referral was to evaluate aggressive behaviors. The NP further documented the resident was provided education regarding the safe use of his electric wheelchair and if he was unable to use the electric wheelchair safely, the electric wheelchair would be taken. The resident was documented as agreeing to take Sodium Valproate for mood disorders until he was able to have the psychiatric referral completed due to his aggressive behaviors. The resident was documented as verbalizing understanding of safety precautions as related to the wheelchair, agreed to the psychiatric referral, and agreed to starting the new medications for his mood disorders. Review of a physician progress notes [REDACTED].#2 ' s physician documented the staff reported increasing aggression behaviors. A phone interview was conducted with the NP on 10/30/20 at 12:13 PM. She stated she had placed the resident on Sodium Valproate (a medication used to treat [MEDICAL CONDITION] disorder) to help control Resident #2 ' s mood. The NP said she had received reports the resident had become very aggressive both physically and verbally. She said she started the medication on 9/29/20 and added she had tried to start him on the medication earlier, but he had refused. The NP stated the resident was very manipulative and he would say one thing and then do another. The NP stated she believed the psychiatric consult, which she had ordered on [DATE], and the resident agreed to, needed to be completed as soon as the facility can get it done. During an interview conducted on 10/27/20 at 4:45 PM with Social Work (SW) #1 and SW #2 it was stated Resident #2 had inappropriate behaviors including resistive to care, and aggression towards other residents. The SWs stated the resident was cognitively intact, so he was re-educated on how to treat other residents and praised for following directions. Resident #2 was placed on every 15 minute checks after the altercation was discovered and he remains on the 15 minute checks. It was further stated the resident was referred to psychiatric services but due to the resident having had intact cognition, the resident refused, and the referral was cancelled. SW #1 stated Resident #16 was taken to the magistrate and he pressed charges against Resident #2 for the altercation which took place in September. The originally scheduled court date was 10/25/20, but that date was cancelled, and they are awaiting word from the DA about another scheduled court date. Review of an email from the psychiatric evaluation company dated 10/29/20 and timed 3:52 PM revealed communication the company had received the referral for Resident #2. The resident had yet to be picked up by their services, but he will be on the schedule to be seen at the next visit. During an interview with Resident #2 conducted on 10/30/20 at 11:20 AM Resident #2 stated Resident #16 had tried to bite him during the altercation on 9/17/20 regarding Resident #16 having allegedly stolen two of his cigarettes. Resident #2 further stated, smiling and laughing as he made the statement, he then helped his fist into Resident #16 ' s mouth for him a few times. Resident #2 stated he had never given cigarettes to Resident #16. During an interview with Administrator #1 conducted on 10/28/20 at 5:41 PM she stated she had not observed the video of the altercation from 9/17/20 involving Resident #2 and Resident #16. Administrator #1 further stated usually video footage was automatically deleted after 30 days and she was not aware of how long the video footage was saved for. During an interview with Smoking Aide (SA) #2 on 10/28/20 at 4:53 PM she stated Resident #2 would make derogatory and inappropriate comments to Resident #16; such as statements like, oh go tell your daddy, referring to Resident #17 as Resident #16 ' s father. During a phone interview with Administrator #2, who replaced Administrator #1 on 11/2/20, and the Regional Director of Operations (RDO) on 11/6/20 at 2:36 PM it was stated by Administrator #2 it was the expectation for administration to be notified promptly of all allegations of abuse and for the allegations to be investigated promptly. The Administrator further stated Resident #2 was placed on 15 minute checks as of 9/18/20 to monitor him for inappropriate behavior. She further stated Resident #2 was started on 1:1 supervision by a staff member as of 10/30/20 and remained on 1:1 supervision. During the period of 1:1 supervision he had not been observed to exhibit inappropriate behaviors. The Administrator said Resident #2 was moved from the 100 hall to the 200 hall and placed in a different room which she believed had also helped to alleviate inappropriate or aggressive behavior. Both the RDO and the administrator stated Resident #2 was completely alert and oriented which had made putting interventions in place challenging. b. Review of the facility policy titled Smoking Policy-Residents, which had an effective and last reviewed date of 2/1/20, revealed a safe smoking evaluation was to be conducted upon admission, quarterly, and as needed for all residents who smoked. The evaluation included disease/[DIAGNOSES REDACTED]. The policy documented no resident, regardless of designation, was permitted to possess smoking materials outside of the designated smoking area. The risk factors and interventions that were identified on the evaluation would be documented on the resident ' s care plan. Review of a Safe Smoking Assessment for Resident #16 dated 6/16/20 revealed the resident was deemed not to be a safe smoker due to exhibiting signs of confusion, inability to verbalize or demonstrate an understanding of the smoking policy, inability to verbalize or demonstrate an understanding of the smoking times and places to smoke, inability to remain alert during the course of smoking at all times, and the resident was documented as requiring supervision while smoking. There was an addendum to the smoking policy, with a revision date of 04/2020, which stated; All smokers, except Independent-Safe Smokers, are supervised while smoking. Review of Resident #2 ' s care plan, dated 7/14/20, revealed no focus area or intervention regarding him being a smoker. An observation of facility security camera footage from 9/17/20 and timed 11:33 AM was conducted in the presence of the MD and the MA on 10/28/20 at 2:33 PM. The video did not have audio and was black and white video. Resident #16 was observed to have received 2 cigarette shaped objects from Resident #2. Resident #16 was then observed to have smoked the cigarettes with no visible staff supervision. Later in the video, at 3:30 PM prior to the altercation with Resident #16, Resident #2 was observed to have been smoking and was holding an ash tray in his lap. During the altercation Resident #2 was observed to have removed a cigarette shaped object from Resident #16 ' s right ear. After the altercation, Resident #16 was observed to have withdrawn another cigarette and was holding it in his hand with no observed staff supervision. During an interview with Resident #16 on 10/27/20 at 4:24 PM he said he was waiting to go outside and smoke because he had to have someone watch him go out and smoke. There was a cigarette round shaped singed hole in the splint on his left hand and the resident stated he had burned it about a month ago. The resident stated he was an unsupervised smoker at the time when he had burned his splint. He stated the cigarettes he had during the altercation, on 9/17/20, were his, and he had not taken them from Resident #2. An interview was conducted with SA #1 on 10/30/20 at 11:15 AM. The SA stated Resident #2 handed out smoking supplies to other residents, including residents who were supervised smokers. She stated she had reported Resident #2 handing out smoking supplies to the nurse. Regarding Resident #16, she stated he tried to go outside and smoke frequently while unsupervised. She said he is a supervised smoker but will go outside and get cigarettes from other residents or even purchase cigarettes from other residents. She said she had caught him with cigarettes frequently and she had reported it to his nurse about him having cigarettes even though he was a supervised smoker. She further stated when she was not out there for supervised smoking times she would look to see if he was out in the smoking area when she happened to pass by the area. An observation of Resident #2 on 10/30/20 at 11:18 AM revealed him not being cooperative with storing smoking materials as per what SA #1 was asking him to return his smoking materials to her instead of keeping them on his person. Resident #2 proceeded to argue with SA #1 and attempted to stow cigarettes and other smoking materials in his shirt. During an interview with Resident #2 conducted on 10/30/20 at 11:20 AM Resident #2 stated he gave out cigarettes to other residents. During an interview conducted on 10/28/20 at 3:43 PM Nurse #3 stated Resident #2 was constantly giving out cigarettes to other residents. She said she had talked to him about his behaviors several times, but the resident would do what he wanted to despite being told of the rules. During a phone interview with Administrator #2 and the Regional Director of Operations (RDO) on 11/6/20 at 2:36 PM it was stated the expectation for administration to be notified promptly of all allegations of abuse and for the allegations to be investigated promptly. The Administrator further stated Resident #2 was placed on 15 minute checks to monitor him for inappropriate behavior. She further stated Resident #2 was currently on 1:1 supervision by a staff member and had not been observed to exhibit inappropriate behaviors. The Administrator said Resident #2 was moved from the 100 hall to the 200 hall and placed in a different room which she believed had also helped to alleviate inappropriate or aggressive behavior. The Administrator stated due to Resident #2 ' s non-adherence to the smoking policy, Resident #2 had been made a supervised smoker. Both the RDO and the administrator stated Resident #2 was completely alert and oriented which had made putting interventions in place challenging. c. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the following regarding Resident #17: He had severe cognitive impairment; he was independent and required no setup or physical help from staff for all ADL ' s except for personal hygiene which he required supervision and setup help and bathing which he was totally dependent for. He was coded for no behaviors. He had no impairment to his upper or lower extremities. The resident was documented as having weighed 195 pounds. Resident #17 ' s care plan, which was most recently reviewed on 8/26/20, had a focus are documenting Resident #17 had impaired cognitive function/dementia as well as delusional thinking. Further review revealed a focus area regarding the resident receiving antipsychotic medications related to behavior management. Review of a 24-hour report dated 9/18/20 revealed an allegation Resident #2 had hit Resident #17 in the chest and poked him with an umbrella on the 100 hallway on 9/18/20. The 24 hour report was signed by Administrator #1 on 9/18/20. The allegation type was classified as resident abuse and the local police department was documented as having been notified. A review was completed of the 5-working day investigation report dated 9/25/20. The review revealed the allegation of resident abuse when Resident #2 hit Resident #17 in the chest and poked him with an umbrella on 9/18/20 was investigated and substantiated. The summary of the investigation documented Resident #2 hit Resident #17 in chest and poked him with an umbrella. It was reported by another resident, Resident #17 had taken Resident #2 ' s umbrella. Resident #2 denied hitting or poking Resident #17 with his umbrella. Resident #17 was assessed and was found to have not experienced any visible injuries. Administrator 1 documented she contacted the local police department regarding a previous incident regarding Resident #2 and the officer instructed the Administrator to file involuntary commitment papers for Resident #2. The Administrator informed the officer that Resident #2 was alert and oriented and the officer responded the facility needed to press charges against Resident #2. It was further documented Resident #2 was placed on every 15 minute checks and the resident had displayed no inappropriate behaviors since the 15 minute checks were initiated. The administrator further documented the resident had a court date on 10/25/20 regarding a previous incident. During an interview with SA #2 on 10/28/20 at 4:53 PM she stated she had observed an incident between Resident #2 and Resident #17 in the morning on 9/18/20. She stated it was raining and Resident #2 had gone out on the sidewalk in the courtyard in his electric wheelchair and had an umbrella to protect him from the rain. She said when Resident #2 returned to the covered smoking area from the sidewalk, he still had his umbrella up, and purposefully went out of his way to run the canopy part of the umbrella into Resident #17 ' s face. She told Resident #2 that was inappropriate and not to do that and then Resident #2 proceeded to retract the umbrella, turned his electric wheelchair around, and returned to Resident #17 and proceeded to hit him on the leg with the closed umbrella. The SA said she was telling Resident #2 to stop and was saying his name and the resident responded to her by imitating and mocking her saying his name as if she were saying it. The SA stated she had reported it to Nurse #2. She said the nurse asked her for a written statement and had made a report. During an interview with Resident #16 conducted on 10/29/20 at 2:46 PM he stated he was out on the smoking patio the day Resident #2 and Resident #17 had an altercation. He recalled the day after he and Resident #2 were in an altercation, 9/17/20, which would have been 9/18/20, Resident #2 got into a fight with Resident #17 about an umbrella in the evening. He stated Resident #2 told Resident #17 to Leave his damn umbrella alone, you son of a b*tch. He said Resident #17 kept backing up and Resident #2 kept driving his electric chair towards him. He said he could not see what happened next because when Resident #17 was backing up and Resident #2 was going toward him they went far enough away where he was unable to see what happened. Resident #2 was interviewed on 10/30/20 at 11:15 AM and he stated Resident #17 had stolen his umbrella and so he swung at Resident #17. Resident #2 stated Resident #17 was not all there and acted inappropriately sometimes. Review of a nursing progress note in Resident #17 ' s electronic medical record (EMR) with an effective date of 9/18/20 and timed 4:30 PM, written by Nurse #2, revealed it was reported to the nurse Resident #17 had an altercation with Resident #2. It was reported Resident #17 picked up Resident #2 ' s umbrella, not knowing it belonged to Resident #2. It was further reported Resident #2 got the umbrella from Resident #17, hit Resident #17 with the umbrella, and then tried to dump Resident #17 out of his wheelchair. No injury was discovered on Resident #17. An interview was conducted on 10/28/20 at 4:00 PM with Nurse #2. The nurse stated it had been reported to her Resident #17 was trying to protect himself from Resident #2 on 9/18/20 but she thought it may have occurred during the evening of 9/17/20. The nurse stated someone from the other side had reported it and she did not know who had reported it. She said she did not believe there were any staff who had reported the altercation. The nurse stated it was reported to her that Resident #2 had hit Resident #17 with his umbrella, tried to dump Resident #17 out of his chair, and Resident #17 fell from his chair. She said she assessed Resident #17 on 9/18/20 and she did not discover any injuries. The nurse said Resident #2 was on the 100 hall at the time and they were trying to keep him a (TRUNCATED)

Based on record review, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to re-order [MEDICATION NAME] medication for a resident who had long-term use of [MEDICATION NAME] for pain management. The resident ' s last dose of [MEDICATION NAME] was on 10/25/20 during the 8:00 AM medication pass and the resident and the resident ' s Nurse Practitioner was not notified until 10/27/20 (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the following regarding Resident #2: He was cognitively intact; he was coded as having had pain for the past 5 days, received no as needed medications for pain, received no non-medication interventions for pain, had pain frequently, and he rated his pain at the highest level at 10 on a 0-10 scale. A review was completed of the medication monitoring control record (narcotics sheet) for Resident #2 ' s 30 milligram (mg) [MEDICATION NAME] sulfate tablets. The review revealed 30 [MEDICATION NAME] tables were received on one of two cards on 9/25/20; there were another 30 on a second card. The directions for the administration were one tablet orally every 12 hours for pain. The next available refill date was 10/20/20. Administration from the card was initiated on 10/10/20. The last dose give was by Medication Aide #1 on 10/25/20. Review of the Medication Administration Record [REDACTED]. Further review revealed the resident received the medication every 12 hours, at 8:00 AM and 8:00 PM, from 10/1/20 through the 8:00 AM dose on 10/25/20 at 8:00 AM. The following doses had a code for not being administered as other/see nurses notes, 10/25/20 at 8:00 PM, 10/26/20 at 8:00 AM, 10/27/20 at 8:00 AM, 10/27/20 at 8:00 PM, and 10/28/20 at 8:00 AM. There was one recorded dose as having been administered on 10/26/20 at 8:00 PM by MA #2. There was an order for [REDACTED]. The medication was discontinued on 10/28/20. On 10/29/20 there was a new entry for [MEDICATION NAME] tablet 30 mg, give one tablet orally every 12 hours for pain management. The medication was documented as having been administered at 8:00 AM on 10/29/20 and the resident had a pain level of 10 and at 8:00 PM on 10/29/20 and the resident had a pain level of 7. Further review did reveal the resident was additionally on [MEDICATION NAME]-[MEDICATION NAME] tablet 10/325 mg ordered, dated 7/8/20, one tablet every 8 hours for chronic pain. Review of the MAR indicated [REDACTED]. During an interview with Resident #2 conducted on 10/27/20 at 12:14 PM stated he had not had his [MEDICATION NAME] medication in 4 days and had only had his [MEDICATION NAME]. The resident was unable to identify how long he had been on [MEDICATION NAME] for pain relief but stated it had been a long time, well before he was admitted to the facility. The resident stated he had experienced pain at the highest level, a 10 on a 0-10 scale, since he last had his [MEDICATION NAME] pain medication. The resident pointed an area on his stomach which protruded and stated he had a hernia which caused him pain and discomfort. An interview was conducted with MA #2 on 10/28/20 at 11:13 AM. She stated the Nurse Practitioner (NP) #2 had ordered the [MEDICATION NAME] 20 mg abuse deterrent on 10/27/20 because Resident #2 continued to complain of pain and said that he hurt all of the time. The MA said she did not have any [MEDICATION NAME] in the cart for Resident #2 and that was why the [MEDICATION NAME] 20 mg abuse deterrent had been ordered. An interview was conducted on 10/28/20 at 11:33 AM with Nurse #2. During the interview the nurse stated the prescription for Resident #2 ' s [MEDICATION NAME] was sent to the pharmacy on 10/27/20. She said the resident was receiving his other pain medication, the [MEDICATION NAME]. The nurse reviewed the narcotics sheet for Resident #2 ' s [MEDICATION NAME] and stated the last dose of Resident #2 ' s [MEDICATION NAME] was administered on 10/25/20 and it was not re-ordered because a new prescription was needed, and they did not get the new prescription until 10/27/20. The nurse said the resident ' s [MEDICATION NAME] was supposed to come in from the pharmacy on the delivery expected the night of 10/28/20. A phone interview was conducted with NP #2 on 10/28/20 at 1:05 PM. The NP stated Resident #2 ' s [MEDICATION NAME] was on back order. The NP further stated it was his expectation for the [MEDICATION NAME] to have been ordered in advance so there would not be a lapse in administration. The NP said further adding to the problem with supplying the [MEDICATION NAME] for the resident was that the pharmacy had needed an actual prescription prior to sending the medication due to it being a narcotic. The NP stated it was not healthy for someone to abruptly stop taking [MEDICATION NAME] after having taken it for a long time. He said he did not know how long the resident had been taking the [MEDICATION NAME] but was pretty sure it was a long time. The NP stated Resident #2 had not received the prescribed [MEDICATION NAME] since 10/25/20 and he was fairly miserable by the time he had seen him on 10/27/20. The NP stated he had ordered the [MEDICATION NAME] 20 mg abuse deterrent medication to help the resident with his pain and discomfort until the [MEDICATION NAME] arrived. During an interview conducted on 10/29/20 at 3:14 PM with Nurse #1 she stated when Resident #1 was admitted in December of 2019 he arrived already having been on [MEDICATION NAME]. During a phone interview with NP #1 on 10/30/20 at 12:13 PM she stated it was her expectation for the facility to call her for prescriptions and refills for medications prior to the medication running out. She further stated it did not matter if it was during the week or the weekend about calling for refills and prescriptions and she had also she had also experienced problems with the pharmacy supplying ordered medications in a timely manner. Multiple attempts were made to interview MA #1, but all were unsuccessful. During a phone interview with the facility Nurse Consultant (NC) conducted on 11/17/20 at 1:08 PM she stated typically the process for re-ordering medications was when the supply was down to seven days, the provider would be contacted to see if there was a need to refill the medication or what do next. The NC stated the [MEDICATION NAME] for Resident #2 was on back order from the pharmacy and the pharmacy had not communicated to the facility regarding the back order. The NC stated NP #2 had ordered the [MEDICATION NAME] 20 mg abuse deterrent because the resident ' s [MEDICATION NAME] had run out. The NC stated when the MAs or the nurses became aware the [MEDICATION NAME] had not arrived from the pharmacy and there was none left at the facility for the resident the resident ' s provider (NP or doctor) should have been contacted to obtain an order to hold the medicine or to receive an order for [REDACTED].

Based on record review, staff interviews and observation, the facility failed to protect a resident's right to be free from physical abuse for one of three residents reviewed for abuse (Resident # 124). Resident # 124 was struck on the left cheek by a staff member which caused a red mark to the left cheek of Resident # 124. Findings included: Resident # 124 was readmitted to the facility on [DATE]. The Resident's admission [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident # 124 with severe cognitive impairment, disorganized thinking that did not fluctuate, had 1 to 3 days of physical behaviors toward others and 4 to 6 days of verbal behaviors toward others. Resident # 124 required extensive assist of 2 staff members with bed mobility, transfers, dressing and personal hygiene. Resident # 124 received scheduled pain medications and received antianxiety medication for 7 days of the review period and antidepressant medication for 2 days of the review period. A care plan originally dated [DATE] and updated most recently on [DATE] recorded that Resident # 124 exhibited behaviors that included yelling and screaming at staff, hitting and kicking at staff and spitting at staff. The care plan goal was that Resident # 124 would verbalize the need to control abusive behavior through the next review date. The care plan's interventions included the following: administer medications as ordered and to observed and document for side effects and effectiveness, assess coping skills and support system, assess Resident # 124's understanding of the situation and allow time for the Resident to express self and feelings toward the situation and to observe and document behavior and attempted interventions, provide positive feedback for good behavior and attempted interventions, psychiatric consult as needed and when Resident # 124 became agitated to intervene before agitation escalated by guiding away from source of distress, engage calmly in conversation and if response is aggressive the staff was to walk calmly away and approach later. On [DATE] at 2:42 PM, an observation was made of Resident # 124, Resident # 124 was quietly sitting in his wheelchair in the doorway of his room. There were no observed signs of redness or bruising to Resident # 124's face or arms. A written statement by Nursing Assistant (NA) #2 dated [DATE] at 11:17 PM revealed that she had been in Resident # 124's room with NA #1 and had turned her back to look for a gown when she heard NA #1 say to Resident # 124 not to hit her and NA #2 heard what she thought was a slap and NA #1 stated, you get what you give. NA #2 left the room and reported to Nurse # 1. On [DATE] at 12:05 PM an interview was conducted with NA #2. NA #2 revealed that she had been assigned to Resident # 124 and that she had asked NA # 1 to assist putting him to bed and Resident # 124 started to yell at them and when NA #2 turned her back to NA #1 and Resident # 124 to look for a gown, NA #2 heard a slap and when NA #2 turned back around a red mark was observed on the left side if Resident # 124's face. NA #2 revealed that she left the room immediately and reported to Nurse #1 what she had thought happened. Nurse #1 went to the Resident's room and told NA # 1 to leave the Resident's room and the Nurse #1 and NA #2 finished providing care. NA #2 revealed that all staff were aware that Resident # 124 could be aggressive during care and that sometimes he spit at staff, but that Resident # 124 had never slapped any staff member that she was aware of. NA #2 stated that she did not see NA #1 after the incident and that the Administrator and a police officer came to the facility and interviewed her. NA #2 added that Resident # 124 did not act scared of NA # 1 when they started to provide care to him. NA #2 stated that the NAs and the resident were Resident # 124's room and he had been sitting in his wheel chair when this happened. NA #2 also revealed that it was common for Resident # 124 to yell at staff during care. A nurse progress note dated [DATE] at 1:36 AM written by Nurse #1 revealed that Resident # 124 was involved in an altercation at 9:30 PM on [DATE]. A reddened area was noticed on Resident # 124's left cheek with no complaint of pain and no signs of distress observed. Resident # 124's vital signs were stable; the family of Resident # 124 was notified and the physician was notified. Resident # 124 was alert in bed and was listening to music. A review of a written statement by Nurse #1 dated [DATE]at 11:30 PM revealed that NA #2 reported to the nurse that NA #1 had hit resident # 124. Nurse #1 reported to the nurse supervisor (Nurse #3), excused NA #1 from the room of Resident # 124 and assessed Resident # 124 with redness to the left cheek, but no bruising. NA #2 had reported that her back was turned to NA #1 and Resident # 124 and that NA #2 heard a slap and NA # 1 stated to Resident # 124, you get what you give. During an interview with Nurse #1 on [DATE] at 7:46 AM Nurse # 1 revealed that NA # 2 had reported to her that she heard NA #1 slap Resident # 124 and that NA #1 had told Resident # 124 that you get what you give. Nurse #1 immediately removed NA #1 from the room of Resident # 124 and called the nurse supervisor (Nurse #3) and reported what had been reported by Na #2. A review of a written statement by Nurse #3 on [DATE] at 12:08 AM revealed that Nurse #1 had reported that NA #2 had heard NA #1 slap Resident # 124 and Nurse #3 called the administrator to inform him of what had been reported. Nurse #3 also assessed Resident # 124 and observed that the left cheek of Resident # 124 was more red than the right cheek. Nurse # 3 then called the facility administrator to explain what had happened and Nurse #3 had NA #2 show her exactly where NA #1 and Resident # 124 were when NA # 2 heard a slap. On [DATE] at 2:23 PM an interview was conducted with Nurse #3 which revealed that she was the nurse supervisor on [DATE] and that Nurse #1 had reported to her that NA #2 was very upset and had stated that NA #1 may have slapped Resident # 124 in the face when NA #1 and NA #2 were getting Resident # 124 ready for bed. Nurse #1 had removed NA #1 from the room of Resident # 124 and Nurse # 3 went to assess Resident # 124 and observed a red area to his left cheek and Nurse #3 had NA #2 re- enact what she (NA #2) had seen and heard when NA #1 and NA #2 were in the room of Resident # 124. Nurse # 3 called the administrator and was told to take NA #1 to the conference room and to remain there until the administrator came to the facility. Nurse # 3 took NA #1 to the conference room and remained there until the administrator and a police officer arrived at the facility. Nurse #3 revealed that she had begun all staff in-servicing for abuse and abuse prohibition as per the facility's policy as soon as the Administrator arrived at the facility. A review of a written statement by NA #1 dated [DATE] at 12:16 AM revealed that Resident # 124 had been yelling and hitting at staff. NA #1 placed her hand on the hand of Resident # 124 to try to calm him. NA #2 went to get a gown and when NA #1 removed Resident # 124's shirt, he spit at her and NA #1 covered his mouth so he would not spit and stated to Resident # 124, sometimes you get what you deserve. NA #1 revealed that she had covered Resident # 124's mouth to stop him from spitting again, but that NA #1 did not mean to be so forceful. On [DATE] at 10:38 AM an attempt was made to reach NA #1 for an interview and the telephone number was not accepting calls at that time and voice mail was unavailable. Review of Health Care Personnel Registry (HCPR) 24 Hour Initial Report dated [DATE] completed by the Administrator recorded that on [DATE] at 9:30 PM, NA #1 was reported to have slapped Resident # 124 in the face and that a report had been filed with the Police Department at 10:50 PM. Review of the Incident / Investigation Report completed by the Police Department dated [DATE] at 10:51 PM revealed the crime of Simple Physical Assault had been committed at the facility with no injury observed and further investigation to be completed. Witnesses included NA #2, Nurse #1 and Nurse #3. A review of a written statement by the facility Administrator dated [DATE] at 12:51 AM revealed that on [DATE] at approximately 9:30 PM, the Administrator had received a call from Nurse #3 that an allegation of abuse had been made by NA #2 that NA #1 had slapped a Resident. The Administrator instructed Nurse #3 to remove NA #1 from Resident care areas and to remain with NA #1 in the conference room until the Administrator arrived at the facility. The Administrator arrived at the facility at 10:50 PM and called 911 to have an officer dispatched to the facility and a 24 Hour Report was submitted to the State. A police officer arrived at approximately 11:10 AM and began interviewing all staff members involved which he concluded at approximately 12:30 AM. The officer stated no arrest would be made at that time, but that the information would be presented to the District Attorney on [DATE] and that the officer suspected that there was enough evidence for a misdemeanor assault on a handicap person charge. NA #1 was suspended pending further investigation. The police officer and Administrator escorted NA #1 out of the facility. After the officer exited the facility, Nurse #3 was instructed to begin all staff in-services and reeducation on abuse, neglect prohibition, non - violent behavior interventions and behavior management and that education would continue throughout the weekend and into the upcoming week until all staff was reeducated prior to working their next scheduled shift. Review of the HCPR 5 Working Day Report dated [DATE], completed by the Administrator reported that NA #1 was suspected of Resident abuse on [DATE] at 9:30 PM which resulted in physical injury/harm and that a report to the facility from the Police Department revealed that NA #1 was charged with Misdemeanor Assault on a handicap person. Na #1 had been terminated from employment from the facility on [DATE]. The facility Administrator provided all staff in- service documentation dated [DATE] through [DATE] that included a summary of the abuse allegation, types of abuse, a root cause analysis of staff burn out, review of the Storms of Life Employee Assistance Program, the HAND In Hand and patient centered care program and a review of signs of staff burn out. On [DATE] through [DATE] repeated in-servicing was provided to all staff to engage staff in topics of abuse and staff burn out. On [DATE], the facility interviewed cognitively intact residents for abuse and neglect concerns and interviewed family members of cognitively impaired residents for abuse and neglect concerns with no concerns identified. This was confirmed by review of audit forms supplied by the facility on [DATE] and [DATE]. On [DATE] at 10:44 AM an interview was conducted with the Director Of Nurses (DON) which revealed that all staff had been educated on [DATE] through [DATE] to attend Hand In Hand education to be presented to all staff on [DATE] through [DATE] and to walk away from any situation, even to stop providing care and to report to the nurse that they felt they needed a break and needed to deescalate a situation of concern for staff to resident interaction. When the DON stated that staff burn out was being addressed by the facility by changing staff assignments or allowing for time off from work if needed to address any concerns with staff burn out and new employees were also educated that the facility wanted to provide support and that any concerns could be discussed with a member of the management team in a private and confidential manner. The DON revealed that the expectation was that all staff be monitored for burn out or for possible personal life conflicts and that all staff provide support to one another to prevent a professional crisis from happening as it had in this specific instance. An interview conducted with the Administrator on 1 [DATE]at 2:23 PM revealed that and ad - hoc QA/PI (Quality Assurance/ Performance Improvement) had been added to the weekly QA meeting and that the facility expectation was to prevent resident abuse and to be more aware of staff burn out and how to provide assistance to staff members to deal with burn out and that it would be expected that the facility assist all staff members if they had concerns of burn out to prevent any future staff to resident altercations. The facility had not been aware that NA #1 had needed assist or had suffered from staff burn out, but the facility was now making an effort to make certain that all staff was aware of resources available for them to use if they felt they needed support from outside of the facility. The Administrator revealed that the root cause of the abuse allegation was determined to be from NA #1 having had multiple personal concerns that caused her to become frustrated with in her job description. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: F223 1.On [DATE] at approximately 9:30pm the second shift Supervisor contacted the Administrator via phone to report an allegation of physical abuse. NA #2 alleged that NA #1 slapped Resident # 124 while providing care. She went on to describe that Resident #124 spat at NA #1 while providing assistance with ADLs and NA #2 slapped Resident #124's face. NA #1 was immediately removed from Resident #124's Room by the Charge Nurse. The Administrator instructed the 2nd Shift Supervisor to escort NA #1 to the conference room and remain with NA #1 until the Administrator arrived at the facility. NA #1 received one on one monitoring by the 2nd Shift Supervisor until all interviews were completed and she left the facility. The Administrator arrived at the facility, contacted 911, and a Police Officer was dispatched to facility. The Police report was completed by the Officer. NA #1 was suspended by the Administrator pending further investigation. The Administrator completed and submitted a 24-hour report to NC Healthcare Personnel Registry on [DATE] at 10:01pm. A Nursing assessment was completed by the Charge Nurse and the Second Shift Supervisor for Resident #124 with no injuries identified. He was noted by the Charge Nurse to be sleeping quietly following the event. The Physician, Medical Director, and Responsible Party for Resident #124 were notified regarding the event by the Administrator on [DATE] at 10:30pm. Emotional support was provided to Resident #124 and his Responsible Party by the Administrator on [DATE] with ongoing follow up and support provided by Social Services. 2. Further investigation reveals the following regarding NA # 1. NA #1 began employment on [DATE].NA #1 had a completed background check on [DATE] which met criteria for employment. The associate attended general orientation on [DATE] with education received on abuse and neglect as well as resident rights. The NA completed education related to abuse, neglect, resident rights, dementia, and dealing with patients with behaviors on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Last abuse education prior to allegation for NA #1 was completed on0 [DATE] by the Nursing Supervisor. NA #1 had no previous allegations of abuse or corrective actions related to customer service or abuse in employee file. Residents assigned to NA #1 were interviewed verbally by the Administrator related to abuse allegations involving NA #1 with no concerns noted. This audit was completed by [DATE]. On0 [DATE] an ad-hoc QA/PI meeting was held to discuss the outcome of the investigation of this abuse allegation with the QA/PI Committee. On [DATE] additional abuse and neglect audits were completed with cognitively intact residents and families of cognitively impaired residents, by assistant administrator, social worker, and nurse manager. No new allegations were identified. On [DATE] an additional ad hoc QA/PI meeting was held to conduct further root cause analysis related to potential staff burnout and stress as a cause for resident abuse. 3. On [DATE] all facility staff including Nursing, Housekeeping, Dietary, Social Services, and Administration were re-educated by Nurse Supervisors regarding abuse prevention and dealing with behaviors. This was initiated immediately and continued until all staff were re-educated prior to returning to work. CMS ( Center for Medicare and Medicaid Services) Hand-In-Hand and staff burnout education was scheduled during the QA/PI meeting on [DATE] and completed with 6 sessions accommodating all shift on [DATE]-[DATE] for all facility staff related to preventing abuse, dealing with specific patient behaviors to include no retaliation against residents who exhibit behaviors, promoting person-centered care, alternative strategies to promote positive interactions with patients who are exhibiting behaviors (tag out, take a break, try later, step into their world, etc.) and associate burnout Additionally the education included group discussion about our specific patients and their specific behaviors. CMS Hand-In-Hand education and education about our specific patients and their specific behaviors is ongoing monthly for all staff and monthly associate meetings scheduled to discuss concerns with work environment or burnout. 10 random cognitively intact residents and the family members of cognitively impaired residents will be interviewed weekly regarding allegations of abuse by the Administrator, DON or Nursing Supervisors beginning on [DATE]. If any adverse outcomes are identified via the weekly audit, immediate action will be taken, to include reporting incident via 24-hour report. 4. The results of the weekly audits will be reported by the Administrator in the weekly Quality Assurance and Performance Improvement Committee meeting, recommendations will be made by the committee to maintain compliance. Compliance achieved [DATE]. The corrective action plan was validated on [DATE]. Validation included interviews with randomly chosen residents and resident family members which revealed there were no concerns of abuse to residents in the facility and to report abuse immediately to facility staff or management. Validation included interviews of 5 randomly chosen front line staff interviewed on [DATE] through [DATE] which included validation of recent in-service education for types of abuse, abuse prevention, reporting abuse and recognizing and reporting signs of staff burn out. Interviews conducted with 3 department managers was conducted on [DATE] through [DATE] which included validation of recent in-service education for types of abuse, abuse prevention, reporting abuse and recognizing and reporting signs of staff burn out. On [DATE] the facility had initiated random audits of interviews of 10 residents for abuse, abuse reporting and recognizing and reporting signs of staff burn out to the facility. Cognitively intact residents were audited and family members of cognitively impaired residents were audited. The facility had educated all staff to recognize and report any signs of staff burn out and the staff had been provided with materials of out sourced entities available to the staff to deal with staff burn out. The facility had also scheduled Hand In Hand mandatory education for all staff to begin on [DATE], [DATE],[DATE] and [DATE]. Town Hall meetings had been scheduled for the residents, families and community starting on [DATE],[DATE] and [DATE].

Based on observations, staff interview and record reviews, the administration failed to achieve and maintain compliance related to securing exit doors and maintaining the safety of its residents for 1 of 3 cognitively impaired residents (Resident #1.) The administration failed to have systems in place to ensure special projects which required the use of exit doors were systematically planned and implemented with resident safety and security concerns fully assessed and addressed. Immediate Jeopardy began 6/12/17 when Resident #1 exited the facility unattended by facility staff and was found outside, after a concerned neighbor reported seeing someone outside the building. Resident #1 had exited the building through an unlocked emergency exit door and the alarm for the door had been turned off. The facility did not have procedures in place to manage special projects, such as the use of the emergency exit door to remove unwanted storage items from the facility, in a manner that ensured the safety and security of residents. The Immediate Jeopardy was lifted on 6/17/17 when the facility ' s acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement new procedures. The findings included: The findings included: This citation is cross-referenced to: 1). F224 – Based on observation record review and staff interview the facility failed to maintain the safety of residents by leaving an emergency exit door unlocked and the door alarm disengaged resulting in the elopement of 1 of 3 residents with wandering behaviors (Resident #1). Resident #1 exited the emergency exit door near room [ROOM NUMBER] on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. 2). F323 – Based on observation, record review, and staff interview the facility failed to prevent 1 of 3 cognitively impaired residents from exiting a locked unit through an emergency exit door unnoticed, failed to keep an emergency exit door securely locked and failed to ensure the alarm for an emergency exit door was turned on. Resident #1 exited the emergency exit door near room [ROOM NUMBER] on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. Interview with the Administrator on 6/17/17 at 3:56 PM revealed that he had been aware the emergency exit door was going to be used to enable disposal of items into a dumpster outside the building, but he was not directly involved in planning how the task would be carried out. He also acknowledged that the Director of Nursing (DON) had not been consulted in regards to the project. The Administrator stated that there was a new procedure in place that would require the Interdisciplinary Management Team, including himself the Director of Nursing (DON) and the Maintenance Director to pre-plan special projects that could impact resident safety and security. Detailed plans would be developed and implemented as needed to ensure resident safety during and after the project and he (the Administrator) would have to inspect the completed project before the implemented safety strategies could be deemed no longer necessary and removed. In addition he indicated that the emergency exit doors would only be used for emergency situations effective immediately. The Administrator also stated that he had received additional education from District Director of Clinical Services #2 in regards to oversight for resident safety and security, neglect and quality assurance. On 6/16/17 the Administrator, Director of Nursing, District Director of Clinical Services #1 and District Director of Clinical Services #2 were notified of Immediate Jeopardy at 4:42 PM. The Administrator provided the following credible allegation of compliance on 6/17/17 at 4:00 PM. The credible allegation indicated: 06/12/17 10:30 pm the Housekeeping Supervisor (HSG) and Assistant discussed, with the Maintenance Director, a plan to remove unused furniture, etc. from the storage rooms at the end of the hallway closest to room [ROOM NUMBER]. The Maintenance Director instructed the HSG Supervisor on the importance of 2 staff persons being present to barricade the hallway with linen carts and furniture to prevent resident movement down the hallway, to monitor the exit doors at all time and to secure the door prior to completing the task and leaving the 300 Unit and to immediately report to the Maintenance Supervisor after the task is completed. 06/12/17 at approximately 11 am HSG staff proceeded to the 300 Unit and began their task. The door is an emergency exit door and has an alarm that can be turned off with a key that is kept by the Maintenance Director. The alarm was disengaged – the lock was still functioning but the Housekeeping staff used the keypad to unlock the door and go in and out – when the door was firmly shut it would lock automatically. 06/12/17 approximately 4:10 pm based on the investigation- Resident #1 exited through the exterior door closest to room [ROOM NUMBER]. Resident #1 last interacted with staff at 4:06 PM when she received Tylenol from the certified medication aide. At approximately 4:25 pm a resident from the apartments behind the facility came to the door and notified the staff that there was a resident sitting outside the facility. 2 Certified Nursing Assistants immediately went outside, assisted the resident back into the Facility at 4:30pm, the Charge Nurse completed an assessment which revealed no injuries, the resident ' s physician and family were notified. The resident was re-assessed at risk for elopement by the Nurse Manager, a Wanderguard was placed, and the care plan was updated. The Director of Nursing (DON) was first to assess the door after the resident was returned to the facility and found it not completely closed. The door appeared to be closed from hallway view until the DON actually pushed onto the door and realized the lock was not fully engaged. The Maintenance Director and Maintenance Assistant stayed at the door, investigated the door for proper function, engaged the alarm and stayed to monitor the door until the facility elopement process was implemented. The Second Shift Supervisor remained monitoring both exterior doors by viewing them throughout 2nd shift from the Nurses station until she was relieved by an assigned door monitor. A second door monitor was assigned to sit outside the 300 Unit Hall Unit to monitor this door. On 6/12/17 by 4:45 pm following the event, door monitors were placed at all 3 exit doors. The Administrator was notified of the incident immediately and went with the Maintenance Director to the 300 Hall Unit. The Maintenance Director said that when he got there the door was already securely closed and therefore locked and he used his key to re-engage the alarm. 06/12/17 5:00 pm, the interdisciplinary team (IDT) including the NHA and DON reviewed the unsupervised exit of Resident #1 from the 300 Unit exterior door. The Housekeeping employees involved were no longer in the facility, both were contacted and suspended pending investigation. The Administrator completed a 24 hour report to the Healthcare Personnel Investigation regarding this event. The 5 day investigation is due to be completed on 6/20/17. 06/12/17 5:15 pm the Nurse Managers completed a head count for all residents at risk for elopement throughout the entire facility. Residents with Wanderguards were assessed to validate placement and function of the Wanderguards by the Nurse Managers. Elopement assessments and care plans were reviewed and validated for all residents assessed at risk by the Nurse Managers. Elopement notebooks were reviewed and updated as needed by the Nurse Managers. 06/12/17 5:15 pm All exterior facility doors and interior Wanderguarded doors were checked by maintenance to validate proper function and engagement of alarms. 06/12/17 5:20 pm the Staff Development Coordinator (SDC) and Area Staff Development Coordinator (ASDC) initiated education with all facility staff present on 2nd shift, all staff received training on ensuring the doors are secure, fire exit doors are to only be used in case of a fire or permission of the Administrator, a complete review of the elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors and redirecting residents, reporting any observations of unsecure doors or windows or concerns related to all aspects of resident safety immediately and directly to the NHA and DON. The 2nd shift supervisor provided training to the 3rd shift and the NHA and DON were in the facility by 6:00am on 6/13/17 to assist the SDC with training 1st shift, no staff has been allowed to work since 2nd shift on 6/12/17 without receiving this training. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted education with all staff on Abuse and Neglect Prevention on June 16, 2017 including resident security and supervision. Beginning June 16th No staff will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide security and supervision can constitute resident neglect. The NHA and DON will have a no tolerance approach to any deviation from the policy. 06/12/17 5:30pm An investigation was initiated, the Administrator and Director of Nursing conducted interviews with 1st and 2nd shift staff on the 300 Hall Unit including Housekeeping staff. It was determined that Resident #1 exited the exterior door by room [ROOM NUMBER] after it was left unlocked due to human error following trash disposal. On 6/13/17 the Administrator and the Maintenance Director re-evaluated the Wanderguard System and security for all interior and exterior doors for the 300 Unit and throughout the facility. Based on the results of this review Wanderguard alarms will be added to the exterior doors of the 300 Unit. These system upgrades will be completed by 6/18/17. This system has been initiated to provide a back-up alert in the event human error occurs. Going forward all residents on the 300 Unit will have a Wanderguard in place and all exit doors will have Wanderguard alarms. These Wanderguards will be in place by 6/18/17. Going forward, residents with Wanderguard bracelets in place will activate a second alarm when they are beside the emergency exit and a louder alarm then sounds in the event the door is opened and will not stop alarming until it is reset by a staff member. The annunciator for the Wanderguard System is stationed on the wall across from the nurses ' station that is easily visible from the nurses ' station and heard throughout the unit. A door monitor was placed at all exit doors until upgrades completed. On 6/13/17 the IDT also implemented a new process for conducting special projects within the facility, including the 300 Unit. Going forward the IDT, to include the Administrator, Director of Nursing, Nurse Managers, Maintenance Director and Housekeeping Director, will discuss any project prior to initiating and ensure there is a plan for when the project will begin and end, who will be responsible for assigning staff for door or window monitoring required as a result of safety measures expected to be compromised while the project is being completed. The NHA, DON and Maintenance Director will be notified immediately upon completion of the project and monitoring will not be removed until approved by the NHA or DON. Only the Administrator may determine when the Door Monitor will be discontinued after discussion with the QAPI committee. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The 2 exterior doors for the 300 Unit and the Fire Exit doors on the 100 and 200 Hallways will always remain locked and will not be used for entry or exit at any time unless there is a fire or unless there is an emergency that the NHA (Nursing Home Administrator) determines use of these doors as necessary. Any deviation or adjustment to this plan will be reported to the QAPI committee. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17. The IDT was instructed on 6/14/17 of the upcoming leadership changes and expectations. On 6/15/17 the Assistant Administrator met with the staff on the 300 Unit to explain her new leadership role and her active participation with supervision on the Unit. 0n 6/15/17 the Director of Quality of Life Programs met with the IDT including leadership from the 300 Hall Unit. The Director of Clinical Services completed re-education of Administrator and Director of Nursing on 6/17/17. This education included facility policy for Abuse Prohibition and the facility policy for Elopement and the state and federal regulations governing long term care facilities with regards F323 Supervision to Prevent Accidents and F224 Abuse and Neglect Prohibition. On 6/17/17, the Administrator and DON were retrained on the Quality Assurance & Performance Improvement Program by the Division Vice President of Clinical Services. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director · Infection Preventionist The Administrator will lead the committee to complete weekly QAPI meetings with review of action plans and new areas of concern for Performance Improvement, with evidence of root cause analysis and action plans to address potential and actual concerns. District Director of Clinical Services will review weekly QAPI Minutes for 12 weeks and attend meetings as able. On 6/17/17, the Division Vice President of Clinical Services conducted re-education for the Administrator on the facility ' s policy and procedures for assembling a QAPI committee, collecting data and analyzing trends, and development and implementation of a plan to improve with ongoing monitoring to sustain compliance. The facility utilizes the Plan, Do, Study, Act method for Quality Assurance and Performance Improvement Program including scheduling, identification of Quality issues, trends or patterns, submission of data, and initiation of quality improvement plans related to identified areas of opportunity. The committee has met weekly in the past to monitor ongoing compliance with F323 Supervision to prevent Accidents and Elopement but will begin meeting 3 times per week on 6/17/17 to increase monitoring with F323 Supervision to prevent Accidents with a focus on the review of Window Checks and Door checks being conducted to correct and maintain the elopement management process and to evaluate systems for effectiveness of the facility ' s overall compliance with F323 Supervision to prevent Accidents and Elopements. F224 Abuse and Neglect Prohibition will be reviewed daily to validate monitoring and maintain the system for preventing and reporting abuse and neglect. The District Director of Clinical Services reeducated the IDT on 6/17/17 on Federal Regulation F 520 and the Facility QAPI Committee Policy regarding the expectations regarding maintaining an ongoing Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee consists of the Executive Director, Director of Clinical Services, Medical Director and at least 3 other members and meets at least monthly (Medical Director at least quarterly). Education also included the processes and procedures of implementing, reviewing and revising ongoing action plans for areas of deficiency that have been identified to attain and maintain substantial regulatory compliance and provide the highest level of care to residents. Newly hired IDT employees will be educated upon hire. The District Director of Clinical Services or the District Director of Operations will attend QAPI meetings at a minimum of quarterly to assure compliance with Federal Regulation F 520 to sustain and maintain compliance with Federal Regulation F 323-Resident Safety to include ongoing monitoring and revisions to the plan as necessary, and to maintain compliance with F224 the Prohibition of Abuse. The Director of Clinical Services completed re-education of Administrator and Director of Nursing on 6/17/17. This education included facility policy of Abuse and Neglect Prohibition and state and federal regulations governing long term care facilities with regards to the Prohibition of Abuse and Neglect. It is the responsibility of the Administrator to serve as the Abuse Coordinator for the facility and to ensure there is a zero tolerance for Abuse or Neglect by retraining current facility staff and by validating compliance with weekly interviews and observations completed by the Administrator, Assistant Administrator, Director of Nursing, Nurse Managers, Therapy Manager, and Social Services Director. A validation of the credible allegation was completed on 6/17/17 at 5:00 PM by the following: Review of the completed head count, review of the every 15 minute observation for Resident #1, review of door audits completed by the facility on 300 hall and throughout the facility, review of the in-service sign in sheets for 6/12/17 through 6/17/17 and the materials regarding the topics covered, interviews with multiple licensed and non-licensed nursing staff to verify their understanding of the information covered in the in-services, interview with the Maintenance Director to verify completion of the Wanderguard modification to the emergency exit doors, observation of the functioning of the emergency exit door near room [ROOM NUMBER], observation of the door monitors and review of the staff monitoring exit doors to 300 hall, and observation of residents on 300 hall and the placement and function of their Wanderguard bracelets including Resident #1. The Administrator and Director of Nursing were also interviewed regarding the education they received from the District Director of Clinical Services #2 in regards to oversight of special projects to ensure resident safety and security.

Based on observation, record review and staff interview the facility neglected cognitively impaired residents by leaving an emergency exit door unlocked and the door alarm disengaged, resulting in the elopement of 1 of 3 residents cognitively impaired residents with wandering behaviors (Resident #1). Resident #1 exited the emergency exit door near room [ROOM NUMBER] on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. Immediate Jeopardy began 6/12/17 when Resident #1 exited the facility through an unlocked emergency exit door that also had the alarm disabled. The resident was not with facility staff and was found outside, after a concerned neighbor reported seeing someone outside the building. The Immediate Jeopardy was lifted on 6/17/17 when the facility ' s acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement new procedures. The findings included: Resident #1 was admitted [DATE] and readmitted [DATE] to 300 hall (a locked unit) due to dementia with behavioral disturbance. Other [DIAGNOSES REDACTED]. Review of the 1/4/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 9.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired, did not have behaviors such as wandering, walked with supervision and did not use any mobility devices. Review of the Quarterly MDS dated [DATE] revealed Resident #1 was cognitively impaired had wandering behaviors on 4-6 days during the look back period, had physical and verbal behaviors towards others, walked with supervision and did not use any mobility devices. Review of the Care Plan updated 3/31/17 revealed a Plan of Care for impaired cognitive function and for psychosocial well-being problem with interventions including psychiatric consult and when conflict arises, remove residents to a calm and safe environment and allow to vent/share feelings. Review of the 4/7/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 2.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. Review of the 5/8/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 9.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. The Medication Administration Record [REDACTED]. An SBAR (Situation, Background, Assessment and Recommendation) Note dated 6/12/17 revealed the exit door was left open by the housekeeping staff and resident walked outside. Was notified that resident was outside. Sent (Nursing Assistants) out to get res (resident) and this nurse went out to the side door. Res brought onto 300 hall. DON (Director of Nursing) and administrative staff came to hall to investigate incident. Skin assessment done – no issues noted. Res cleaned and put in pajamas. Laid down d/t (due to) being tired. (Name of Doctor) and resident ' s (family member) informed of incident. Res placed on q (every) 15 min (minute) checks. Nurse #1, who wrote this note, could not be reached for interview before the survey exit date. The reported maximum temperature for this location on 6/12/17 was 89 degrees. Review of the Care Plan revealed it was updated on 6/12/17 with the following interventions for elopement risk: check placement and function of safety monitoring device as ordered; distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; observe for fatigue and weight loss, and Wanderguard (an electronic device worn as a bracelet that causes a Wanderguard enabled door to alarm and/or lock) as ordered. Interview with the Maintenance Director (M Dir) on 6/15/17 at 4:30 PM revealed that on 6/12/17 after the morning meeting the Housekeeping Supervisor (HS) came to him and told him that he wanted to clean out the rooms that were being used for storage on 300 hall (the locked unit). The M Dir said he and the HS then went to the 300 hall emergency exit door that was at the end of the hall near room [ROOM NUMBER]. The storage rooms were at the end of that hall as well and there was a dumpster just outside that exit door. The M Dir said he then went over the procedure for using the key pad to unlocking the door. If the door was shut securely the look would reengage and this would be indicated by a red light on the key pad. The M Dir said he then turned off the alarm for the door using the alarm key, so that the door would not keep alarming each time it was used to take something out to the dumpster. The M Dir said this occurred at approximately 10:30 AM. He added that he was aware there would be a Housekeeping Aide (HA) coming to help the HS so that they could take turns taking things out to the dumpster. The M Dir also said that the HS was to notify him when the project was complete so he could reengage the alarm. On 6/16/17 at 4:51 PM Medication Aide #1 (MA #1) was interviewed. MA #1 said that she started her shift at 2:00 PM on 300 hall on 6/12/16. At 4:06 PM she gave the resident her scheduled medication. MA #1 indicated the resident did not appear agitated or make any exit seeking verbalizations and had been sitting in the television room earlier in the shift. At approximately 4:25 PM she was on the hall with the emergency exit door the resident had used and heard someone knocking on it. MA #1 went to the door and a neighbor who lived at the apartment complex right behind the facility said there was a facility resident outside. The door had a window that she was able to look out of and she could see Resident #1 to the left and across the apartment complex access road that ran along the left side (when facing the building) of the building. MA #1 said that she informed Nurse #1 that Resident #1 was outside and then she and Nursing Assistant #2 (NA #2) and NA #3 went and brought the resident back to the unit. MA #1 added that she tried to open the emergency exit door but it was locked. She stated that she had never seen this door be used before and although there was a key pad to unlock it she did not know the code for the keypad. MA #1 added that she had not noticed housekeeping doing anything at the end of the hall near the door on her shift but heard later that someone from housekeeping had left the door ajar. On 6/16/17 at 5:52 PM the location where Resident #1 was located outside was observed with NA #1 and the M Dir. The M Dir measured the distance from the emergency exit door as to where the resident was located and it was 64 feet. Interview with NA #2 on 6/17/17 at 1:11 PM revealed that she usually worked on 300 hall but on 6/12/17 she was assigned to do odd jobs in the facility. She stated that when a neighbor from the apartments reported that Resident #1 was outside the facility she (NA #2) was on 300 hall as she had gone back there to check on the residents she typically worked with. NA #2 said that when NA #1 tried to open the emergency exit door it was locked so they went out the keypad locked exit that opened into facility and then out a keypad locked side door to get to get to Resident #1. NA #1 said that Resident #1 did have wandering behaviors and stated that she considered all residents on the unit a potential elopement risk because it was a locked unit and people could start feeling like they want to get out. She said that when residents were observed near the exit doors they were redirected away from them. On 6/17/17 at 1:30 PM a telephone interview was conducted with the Housekeeping Assistant (HA). He stated that on 6/12/17 he helped the Housekeeping Supervisor (HS) remove items from storage from two rooms at the end of 300 hall. He stated the HS had already started when he got there at approximately 11:00 AM. The HA said that the HS shared with him the keypad code for the emergency exit door and told him he needed to check to make sure the door was locked when it was shut by checking to see if the light on the key pad was red. He said they used the keypad to get out the door each time and did not leave the door propped open. He said that when they were almost finished the HS left the HA to clear out the last few things on his own then at 3:00 PM when he was done he made sure the door was locked before he left. The HA said he saw that the red light indicating the door was locked was on before leaving. He stated that no one told him he needed to tell the M Dir they were done so the alarm could be turned on again. On 6/17/17 at 2:08 PM the HS was interviewed. The HS stated that on 6/12/17 he and the HA were cleaning out the rooms used for storage at the end of 300 hall. He stated that before he got started the M Dir instructed him how to make sure the door lock was engaged door and how to make the area secure during the task by having a barricade to deter residents from going that far down the hall. He stated that he started at approximately 10:15 AM and the HA joined him at approximately 11:00 AM. and he instructed the HA on ensuring the door was locked after each time they used it to go in and out of the building to the nearby dumpster. He stated that they took a lunch break at approximately 12:00 PM. The HS said that at 2:45 PM there were only a few things still to be cleaned out and put into the dumpster so he left the HA to finish the task on his own. The HS stated that before leaving he went to the front and told the Administrator he was going, as he always did before he left. The HS said that no one told him that he needed to tell the M Dir that they were done with the task so that the alarm could be turned back on again. He indicated that he figured the M Dir would just turn it on again before he left the building for the day. Since the M Dir checked the doors regularly he said he just thought the M Dir would turn the alarm back on when he checked the door. On 6/17/17 at 2:26 PM interview with the Director of Nursing (DON) revealed that on 6/12/17 she was walking into 300 hall for another reason when the staff brought Resident #1 in from outside. The DON said that she asked Nurse #1 how the resident could have gotten off the unit and Nurse #1 said housekeeping had been back there using the emergency exit door earlier. The DON stated that the door looked like it was shut closed but from afar but it was ajar and she was able to push on it and open the door. The DON indicated she had not been made aware that housekeeping staff would be using the emergency exit door on the locked unit on 6/12/17. She also stated that it was her expectation to be involved in the planning of facility work projects that could impact the care and safety of residents and said the facility now had plans in place to ensure Nursing Leadership was involved. The DON indicated that she thought that neglect referred to purposefully not providing needed care and services. She indicated she was not familiar with the concept that non purposeful omissions like neglecting to ensure the emergency exit door was adequately monitored or securely locked with the alarm engaged could constitute neglect. The DON added that they had already started to retrain staff on the topic of neglect. On 6/17/17 at 3:17 PM the Administrator was interviewed. He indicated that he was informed of the elopement on 300 hall on 6/12/17 almost immediately after the incident and he went to 300 hall with the Maintenance Director (M Dir). He stated he was present when the DON was able to open the emergency exit door. He stated he did not know why NA #1 was not able to open the door and the DON was but said that he and the M Dir tested the door several times and did not find a functional problem. He indicated that the door had been left unlocked and ajar due to human error. The Administrator acknowledged Nursing had not been involved in the planning of how the cleaning out of the storage areas on 300 hall would be conducted but that in future Nursing Leadership would be involved. In addition there would need to be a written plan and the Administrator would need to inspect and sign off at the end of the project. The Administrator indicated that it was his expectation that staff follow the procedures necessary to ensure the facility remained safe and secure for all residents. On 6/16/17 the Administrator, Director of Nursing, District Director of Clinical Services #1 and District Director of Clinical Services #2 were notified of Immediate Jeopardy at 4:42 PM. The Administrator provided the following credible allegation of compliance on 6/17/17 at 3:00 PM. 06/12/17 10:30 pm the Housekeeping Supervisor (HSG) and Assistant discussed, with the Maintenance Director, a plan to remove unused furniture etc from the storage rooms at the end of the hallway closest to room [ROOM NUMBER]. The Maintenance Director instructed the HSG Supervisor on the importance of 2 staff persons being present to barricade the hallway with linen carts and furniture to prevent resident movement down the hallway, to monitor the exit doors at all time and to secure the door prior to completing the task and leaving the 300 Unit and to immediately report to the Maintenance Supervisor after the task is completed. 06/12/17 at approximately 11 am HSG staff proceeded to the 300 Unit and began their task. The door is an emergency exit door and has an alarm that can be turned off with a key that is kept by the Maintenance Director. The alarm was disengaged – the lock was still functioning but the Housekeeping staff used the keypad to unlock the door and go in and out – when the door was firmly shut it would lock automatically. 06/12/17 approximately 4:10 pm based on the investigation- Resident #1 exited through the exterior door closest to room [ROOM NUMBER]. Resident #1 last interacted with staff at 4:06 PM when she received Tylenol from the certified medication aide. At approximately 4:25 pm a resident from the apartments behind the facility came to the door and notified the staff that there was a resident sitting outside the facility. 2 Certified Nursing Assistants immediately went outside, assisted the resident back into the Facility at 4:30pm, the Charge Nurse completed an assessment which revealed no injuries, the resident ' s physician and family were notified. The resident was re-assessed at risk for elopement by the Nurse Manager, a Wanderguard was placed, and the care plan was updated. The director of nursing (DON) was first to assess the door after the resident was returned to the facility and found it not completely closed. The door appeared to be closed from hallway view until the DON actually pushed onto the door and realized the lock was not fully engaged. The Maintenance Director and Maintenance Assistant stayed at the door, investigated the door for proper function, engaged the alarm and stayed to monitor the door until the facility elopement process was implemented. The Second Shift Supervisor remained monitoring both exterior doors by viewing them throughout 2nd shift from the Nurses station until she was relieved by an assigned door monitor. A second door monitor was assigned to sit outside the 300 Unit Hall Unit to monitor this door. On 6/12/17 by 4:45 pm following the event, door monitors were placed at all 3 exit doors. The Administrator was notified of the incident immediately and went with the Maintenance Director to the 300 Hall Unit. The Maintenance Director said that when he got there the door was already securely closed and therefore locked and he used his key to re-engage the alarm. 06/12/17 5:00 pm, the interdisciplinary team (IDT) including the NHA and DON reviewed the unsupervised exit of Resident #1 from the 300 Unit exterior door. The Housekeeping employees involved were no longer in the facility, both were contacted and suspended pending investigation. The Administrator completed a 24 hour report to the Healthcare Personnel Investigation regarding this event. The 5 day investigation is due to be completed on 6/20/17. 06/12/17 5:15 pm the Nurse Managers completed a head count for all residents at risk for elopement throughout the entire facility. Residents with Wanderguards were assessed to validate placement and function of the Wanderguards by the Nurse Managers. Elopement assessments and careplans were reviewed and validated for all residents assessed at risk by the Nurse Managers. Elopement notebooks were reviewed and updated as needed by the Nurse Managers. These notebooks are maintained at each Nurses station. 06/12/17 5:15 pm All exterior facility doors and interior Wanderguarded doors were checked by maintenance to validate proper function and engagement of alarms. 06/12/17 5:20 pm the Staff Development Coordinator (SDC) and Area Staff Development Coordinator (ASDC) initiated education with all facility staff, to include the 100 and 200 Halls and the 300 Hall Unit, present on 2nd shift, all staff received training on ensuring the doors are secure, fire exit doors are to only be used in case of a fire or permission of the Administrator, a complete review of the elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors and redirecting residents, reporting any observations of unsecure doors or windows or concerns related to all aspects of resident safety immediately and directly to the NHA and DON. The 2nd shift supervisor provided training to the 3rd shift and the NHA and DON were in the facility by 6:00am on 6/13/17 to assist the SDC with training 1st shift, no staff has been allowed to work since 2nd shift on 6/12/17 without receiving this training. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted education with all staff on Abuse and Neglect Prevention on June 16, 2017 including resident security and supervision. Beginning June 16th No staff will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide security and supervision can constitute resident neglect. The NHA and DON will have a no tolerance approach to any deviation from the policy. 06/12/17 5:30pm An investigation was initiated, the Administrator and Director of Nursing conducted interviews with 1st and 2nd shift staff on the 300 Hall Unit including Housekeeping staff. It was determined that Resident #1 exited the exterior door by room [ROOM NUMBER] after it was left unlocked due to human error following trash disposal. On 6/13/17 the Administrator and the Maintenance Director re-evaluated the Wanderguard System and security for all interior and exterior doors for the 300 Unit and throughout the facility. Based on the results of this review Wanderguard alarms will be added to the exterior doors of the 300 Unit. These system upgrades will be completed by 6/18/17. This system has been initiated to provide a back-up alert in the event human error occurs. Going forward all residents on the 300 Unit will be considered at risk for elopement and have a Wanderguard in place and all exit doors will have Wanderguard alarms. These Wanderguards will be in place by 6/18/17. Going forward, residents with Wanderguard bracelets in place will activate a second alarm when they are beside the emergency exit and a louder alarm then sounds in the event the door is opened and will not stop alarming until it is reset by a staff member. The annunciator for the Wanderguard System is stationed on the wall across from the nurses ' station that is easily visible from the nurses ' station and heard throughout the unit. On 6/12/17 immediately following this incident door monitors were placed at the 2 fire exits and the exit/entry into the facility from the 300 Hall unit until upgrades completed. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The Administrator will determine when the Door Monitor will be discontinued after discussion with the QAPI committee. On 6/13/17 the IDT also implemented a new process for conducting special projects within the facility, including the 300 Unit. Going forward the IDT, to include the Administrator, Director of Nursing, Nurse Managers, Maintenance Director and Housekeeping Director, will discuss any project prior to initiating and ensure there is a plan for when the project will begin and end, who will be responsible for assigning staff for door or window monitoring required as a result of safety measures expected to be compromised while the project is being completed. The NHA, DON and Maintenance Director will be notified immediately upon completion of the project and monitoring will not be removed until approved by the NHA or DON. Only the Administrator may determine when the Door Monitor will be discontinued after discussion with the QAPI committee. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The 2 exterior doors for the 300 Unit and the Fire Exit doors on the 100 and 200 Hallways will always remain locked and will not be used for entry or exit at any time unless there is a fire or unless there is an emergency that the NHA (Nursing Home Administrator) determines use of these doors as necessary. The Maintenance Director or Maintenance Assistant will check these door daily to validate they remain locked. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17, the IDT was instructed on 6/14/17 of the leadership additions to the 300 Hall Unit and expectations of the Assistant Administrator role going forward. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17. The IDT was instructed on 6/14/17 of the upcoming leadership changes and expectations. On 6/15/17 the Assistant Administrator met with the staff on the 300 Unit to explain her new leadership role and her active participation with supervision on the Unit. 0n 6/15/17 the Director of Quality of Life Programs met with the IDT including leadership from the 300 Hall Unit. A validation of the credible allegation was completed on 6/17/17 at 5:00 PM by the following: Review of the completed head count, review of the every 15 minute observation for Resident #1, review of door audits completed by the facility on 300 hall and throughout the facility, review of the in-service sign in sheets for 6/12/17 through 6/17/17 and the materials regarding the topics covered, interviews with multiple licensed and non-licensed nursing staff to verify their understanding of the information covered in the in-services, interview with the Maintenance Director to verify completion of the Wanderguard modification to the emergency exit doors, observation of the functioning of the emergency exit door near room [ROOM NUMBER], observation of the door monitors and review of the staff monitoring exit doors to 300 hall, and observation of residents on 300 hall and the placement and function of their Wanderguard bracelets including Resident #1.

Based on observation, record review, and staff interview the facility failed to prevent 1 of 3 cognitively impaired residents from exiting a locked unit through an emergency exit door unnoticed, failed to keep an emergency exit door securely locked and failed to ensure the alarm for an emergency exit door was turned on. Resident #1 exited the emergency exit door near Room 318 on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. Immediate Jeopardy began 6/12/17 when Resident #1 exited the facility through an unlocked emergency exit door that also had the alarm disabled. The resident was not with facility staff and was found outside after a concerned neighbor reported seeing someone outside the building. The Immediate Jeopardy was lifted on 6/17/17 when the facility ' s acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement new procedures. The findings included: Resident #1 was admitted [DATE] and readmitted [DATE] to 300 hall (a locked unit) due to dementia with behavioral disturbance. Other [DIAGNOSES REDACTED]. Review of the 1/4/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 9.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired, did not have behaviors such as wandering, walked with supervision and did not use any mobility devices. Review of the Quarterly MDS dated [DATE] revealed Resident #1 was cognitively impaired had wandering behaviors on 4-6 days during the look back period, had physical and verbal behaviors towards others, walked with supervision and did not use any mobility devices. Review of the Care Plan updated 3/31/17 revealed a Plan of Care for impaired cognitive function and for psychosocial well-being problem with interventions including psychiatric consult and when conflict arises, remove residents to a calm and safe environment and allow to vent/share feelings. Review of the 4/7/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 2.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. Review of the 5/8/17 Elopement Risk Assessment revealed the resident was a low risk for elopement with a score of 9.0. According to the Risk Assessment Tool low risk = 0-11 and at risk = 12. The Medication Administration Record for 6/12/17 revealed Resident #1 received a scheduled dose of Tylenol at 4:06 PM. An SBAR (Situation, Background, Assessment and Recommendation) Note dated 6/12/17 revealed the exit door was left open by the housekeeping staff and resident walked outside. Was notified that resident was outside. Sent (Nursing Assistants) out to get res (resident) and this nurse went out to the side door. Res brought onto 300 hall. DON (Director of Nursing) and administrative staff came to hall to investigate incident. Skin assessment done – no issues noted. Res cleaned and put in pajamas. Laid down d/t (due to) being tired. (Name of Doctor) and resident ' s (family member) informed of incident. Res placed on q (every) 15 min (minute) checks. Nurse #1, who wrote this note, could not be reached for interview before the survey exit date. The reported maximum temperature for this location on 6/12/17 was 89 degrees. Review of the Care Plan revealed it was updated on 6/12/17 with the following interventions for elopement risk: check placement and function of safety monitoring device as ordered; distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; observe for fatigue and weight loss, and Wanderguard (an electronic device worn as a bracelet that causes a Wanderguard enabled door to alarm and/or lock) as ordered. Interview with the Maintenance Director (M Dir) on 6/15/17 at 4:30 PM revealed that on 6/12/17 after the morning meeting the Housekeeping Supervisor (HS) came to him and told him that he wanted to clean out the rooms that were being used for storage on 300 hall (the locked unit). The M Dir said he and the HS then went to the 300 hall emergency exit door that was at the end of the hall near room 318. The storage rooms were at the end of that hall as well and there was a dumpster just outside that exit door. The M Dir said he then went over the procedure for using the key pad to unlocking the door. If the door was shut securely the look would reengage and this would be indicated by a red light on the key pad. The M Dir said he then turned off the alarm for the door using the alarm key, so that the door would not keep alarming each time it was used to take something out to the dumpster. The M Dir said this occurred at approximately 10:30 AM. He added that he was aware there would be a Housekeeping Aide (HA) coming to help the HS so that they could take turns taking things out to the dumpster. The M Dir also said that the HS was to notify him when the project was complete so he could reengage the alarm. On 6/15/17 at 4:30 PM further interview with the M Dir revealed that he had been working in room 201 when the Administrator told him they needed to go to the 300 hall due to an elopement. He stated that he did not recall the exact time but it would have been shortly after the resident had been returned to the unit. The M Dir said that when he got to the 300 hall he checked the emergency exit door near room 318 and it was securely locked. He used the alarm key to reengage the alarm at that time. He stated that he had been told that the door had been ajar but said when he got to it someone else had already closed it securely and engaged the lock. He did not know who had closed it. On 6/16/17 at 4:51 PM Medication Aide #1 (MA #1) was interviewed. She stated that she started her shift on 6/12/17 at 2:00 PM on 300 hall. She stated that while the resident did wander in the hallway and into resident rooms she had not ever seen Resident #1 trying to exit the unit. MA #1 said that on 6/12/17 she observed Resident #1 in the television room earlier in the shift. Then at 4:06 PM she gave Resident #1 her scheduled Tylenol near the Nursing Station. After that she saw resident #1 walking down one of the two halls on the unit but it was not the hall with the emergency exit that Resident #1 used to exit the unit. MA #1 said that at approximately 4:25 PM she was on the hall with the emergency exit door the resident had used and heard someone knocking on it. MA #1 went to the door and a neighbor who lived at the apartment complex right behind the facility said there was a facility resident outside. MA #1 added that she tried to open the emergency exit door but it was locked. The door had a window that she was able to look out of and she could see Resident #1 to the left and across the apartment complex access road that ran along the left side (when facing the building) of the building. The NA said that she informed Nurse #1 that Resident #1 was outside and then she and Nursing Assistant #2 (NA #2) and NA #3 went to get the resident. She said that they found the resident exactly when she had been when the NA saw her out the emergency exit door window and that the neighbor from the apartments had stayed with her. MA #1 added that she and NA #2 were able to walk Resident #1 back into the building and then the Nurse did a skin check assessment and they did a head count. On 6/16/17 at 5:52 PM the location where Resident #1 was located outside was observed with MA #1 and the M Dir. The M Dir measured the distance from the emergency exit door as to where the resident was located and it was 64 feet. On 6/16/17 at 5:46 PM NA #5 was interviewed. NA #5 worked first (6:00 AM – 2:00 PM) and second shift (2:00 PM – 10:00 PM) on 300 hall on 6/12/17. She stated that she took Resident #1 her breakfast in her room that morning and that the resident didn ' t get up until after lunch that day around 1:00 PM. After that she saw the resident in the day room with some other residents. NA #5 said that she recalled housekeeping doing some work at the end of the hall but she didn ' t know what they were doing that day. She stated that she saw Resident #1 again at about 4:00 PM that day when she was wandering down the hall but the Medication Technician redirected her back. NA #5 said she went on break at 4:03 PM and when she came back from her break the resident was already back on the unit and the DON, Administrator and Unit Manager were already on the unit and a head count was underway. On 6/17 at 1:30 PM a telephone interview was conducted with the Housekeeping Assistant (HA). He stated that on 6/12/17 he helped the Housekeeping Supervisor (HS) remove items from storage from two rooms at the end of 300 hall. He stated the HS had already started when he got there at approximately 11:00 AM. The HA said that the HS shared with him the keypad code for the emergency exit door and told him he needed to check to make sure the door was locked when it was shut by checking to see if the light on the key pad was red. He said they used the keypad to get out the door each time and did not leave the door propped open. He said that when they were almost finished the HS left the HA to clear out the last few things on his own then at 3:00 PM when he was done he made sure the door was locked before he left. The HA said he saw that the red light indicating the door was locked was on before leaving. He stated that no one told him he needed to tell the M Dir they were done so the alarm could be turned on again. On 6/17/17 at 2:08 PM the HS was interviewed. The HS stated that on 6/12/17 he and the HA were cleaning out the rooms used for storage at the end of 300 hall. He stated that before he got started the M Dir instructed him how to make sure the door lock was engaged door and how to make the area secure during the task by having a barricade to deter residents from going that far down the hall. He stated that he started at approximately 10:15 AM and the HA joined him at approximately 11:00 AM. and he instructed the HA on ensuring the door was locked after each time they used it to go in and out of the building to the nearby dumpster. He stated that they took a lunch break at approximately 12:00 PM. The HS said that at 2:45 PM there were only a few things still to be cleaned out and put into the dumpster so he left the HA to finish the task on his own. The HS stated that before leaving he went to the front and told the Administrator he was going, as he always did before he left. The HS said that no one told him that he needed to tell the M Dir that they were done with the task so that the alarm could be turned back on again. He indicated that he figured the M Dir would just turn it on again before he left the building for the day. Since the M Dir checked the doors regularly he said he just thought the M Dir would turn the alarm back on when he checked the door. On 6/17/17 at 2:26 PM interview with the Director of Nursing (DON) revealed that on 6/12/17 she was walking into 300 hall for another reason when the staff brought Resident #1 in from outside. She stated that she briefly checked the resident ' s condition to see if she was heated or sweating because it had been hot outside that day, but the resident seemed fine. She said she also made sure a skin assessment was done and a head count was being done. The DON added that she asked Nurse #1 how the resident could have gotten off the unit and Nurse #1 said housekeeping had been back there using the emergency exit door earlier. The DON stated that the door looked like it was shut closed but from afar but it was ajar and she was able to push on it and open the door. The DON indicated she had not been made aware that housekeeping staff would be using the emergency exit door on the locked unit on 6/12/17. She also stated that it was her expectation to be involved in the planning of facility work projects that could impact the care and safety of residents and said the facility now had plans in place to ensure Nursing Leadership was involved. On 6/17/17 at 3:17 PM the Administrator was interviewed. He indicated that he was informed of the elopement on 300 hall on 6/12/17 almost immediately after the incident and he went to 300 hall with the Maintenance Director (M Dir). He stated he was present when the DON was able to open the emergency exit door. He stated he did not know why MA #1 was not able to open the door and the DON was but said that he and the M Dir tested the door several times and did not find a functional problem. He indicated that the door had been left unlocked and ajar due to human error. The Administrator acknowledged Nursing had not been involved in the planning of how the cleaning out of the storage areas on 300 hall would be conducted but that in future Nursing Leadership would be involved. In addition there would need to be a written plan and the Administrator would need to inspect and sign off at the end of the project. On 6/16/17 the Administrator, Director of Nursing, District Director of Clinical Services #1 and District Director of Clinical Services #2 were notified of Immediate Jeopardy at 4:42 PM. The Administrator provided the following credible allegation of compliance on 6/17/17 at 12:30 PM. The credible allegation indicated: 06/12/17 10:30 pm the Housekeeping Supervisor and Assistant discussed, with the Maintenance Director, a plan to remove unused furniture etc. from the storage rooms at the end of the hallway closest to room 318. The Maintenance Director instructed the Housekeeping Supervisor on the importance of 2 staff persons being present to barricade the hallway with linen carts and furniture to prevent resident movement down the hallway, to monitor the exit doors at all time and to secure the door prior to completing the task and leaving the 300 Unit and to immediately report to the Maintenance Supervisor after the task is completed. 06/12/17 at approximately 11 am Housekeeping staff proceeded to the 300 Unit and began their task. The door is an emergency exit door and has an alarm that can be turned off with a key that is kept by the Maintenance Director. The alarm was disengaged – the lock was still functioning but the Housekeeping staff used the keypad to unlock the door and go in and out – when the door was firmly shut it would lock automatically. 06/12/17 approximately 4:10 pm based on the investigation- Resident #1 exited through the exterior door closest to room 318. Resident #1 last interacted with staff at 4:06 PM when she received Tylenol from the certified medication aide. At approximately 4:25 pm a resident from the apartments behind the facility came to the door and notified the staff that there was a resident sitting outside the facility. 2 Certified Nursing Assistants immediately went outside, assisted the resident back into the Facility at 4:30pm, the Charge Nurse completed an assessment which revealed no injuries, the resident ' s physician and family were notified. The resident was re-assessed at risk for elopement by the Nurse Manager, a Wanderguard was placed, and the care plan was updated. The Director of Nursing (DON) was first to assess the door after the resident was returned to the facility and found it not completely closed. The door appeared to be closed from hallway view until the DON actually pushed onto the door and realized the lock was not fully engaged. The Maintenance Director and Maintenance Assistant stayed at the door, investigated the door for proper function, engaged the alarm and stayed to monitor the door until the facility elopement process was implemented. The Second Shift Supervisor remained monitoring both exterior doors by viewing them throughout 2nd shift from the Nurses station until she was relieved by an assigned door monitor. A second door monitor was assigned to sit outside the 300 Unit Hall Unit to monitor this door. On 6/12/17 by 4:45 pm following the event, door monitors were placed at all 3 exit doors. The Administrator was notified of the incident immediately and went with the Maintenance Director to the 300 Hall Unit. The Maintenance Director said that when he got there the door was already securely closed and therefore locked and he used his key to re-engage the alarm. 06/12/17 5:00 pm the interdisciplinary team (IDT) including the NHA and DON reviewed the unsupervised exit of Resident #1 from the 300 Unit exterior door. The Housekeeping employees involved were no longer in the facility, both were contacted and suspended pending investigation. 06/12/17, 5:15 pm the Nurse Managers completed a head count for all residents at risk for elopement throughout the entire facility. Residents with Wanderguards were assessed to validate placement and function of the Wanderguards by the Nurse Managers. Elopement assessments and care plans were reviewed and validated for all residents assessed at risk by the Nurse Managers. Elopement notebooks were reviewed and updated as needed by the Nurse Managers. These notebooks are maintained at each Nurses station. 06/12/17 5:15 pm All exterior facility doors and interior Wanderguarded doors were checked by maintenance to validate proper function and engagement of alarms. 06/12/17 5:20 pm the Staff Development Coordinator (SDC) and Area Staff Development Coordinator (ASDC) initiated education with all facility staff, to include the 100 and 200 Halls and the 300 Hall Unit, present on 2nd shift, all staff received training on ensuring the doors are secure, fire exit doors are to only be used in case of a fire or permission of the Administrator, a complete review of the elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors and redirecting residents, reporting any observations of unsecure doors or windows or concerns related to all aspects of resident safety immediately and directly to the NHA and DON. The 2nd shift supervisor provided training to the 3rd shift and the NHA and DON were in the facility by 6:00 am on 6/13/17 to assist SDC with training 1st shift, no staff has been allowed to work since 2nd shift on 6/12/17 without receiving this training. 06/12/17 5:30 pm An investigation was initiated, the Administrator and Director of Nursing conducted interviews with 1st and 2nd shift staff on the 300 Hall Unit including Housekeeping staff. It was determined that Resident #1 exited the exterior door by room 318 after it was left unlocked due to human error following trash disposal. On 6/13/17 the Administrator and the Maintenance Director re-evaluated the Wanderguard System and security for all interior and exterior doors for the 300 Unit and throughout the facility. Based on the results of this review Wanderguard alarms will be added to the exterior doors of the 300 Unit. These system upgrades will be completed by 6/18/17. This system has been initiated to provide a back-up alert in the event human error occurs. Going forward all residents on the 300 Unit will be considered at risk for elopement and have a Wanderguard in place and all exit doors will have Wanderguard alarms. These Wanderguards will be in place by 6/18/17. Going forward, residents with Wanderguard bracelets in place will activate a second alarm when they are beside the emergency exit and a louder alarm that sounds in the event the door is opened and will not stop alarming until it is reset by a staff member. The annunciator for the Wanderguard System is stationed on the wall across from the nurses ' station that is easily visible from the nurses ' station and heard throughout the unit. On 6/12/17 immediately following this incident door monitors were placed at the 2 fire exits and the exit/entry into the facility from the 300 Hall unit until upgrades completed. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The Administrator will determine when the Door Monitor will be discontinued after discussion with the QAPI committee. On 6/13/17 the IDT also implemented a new process for conducting special projects within the facility, including the 300 Unit. Going forward the IDT, to include the Administrator, Director of Nursing, Nurse Managers, Maintenance Director and Housekeeping Director, will discuss any project prior to initiating and ensure there is a plan for when the project will begin and end, who will be responsible for assigning staff for door or window monitoring required as a result of safety measures expected to be compromised while the project is being completed. The NHA, DON and Maintenance Director will be notified immediately upon completion of the project and monitoring will not be removed until approved by the NHA or DON. The 2 exterior doors for the 300 Unit and the Fire Exit doors on the 100 and 200 Hallways will always remain locked and will not be used for entry or exit at any time unless there is a fire or unless there is an emergency that the NHA (Nursing Home Administrator) determines use of these doors as necessary. The Maintenance Director or Maintenance Assistant will check these door daily to validate they remain locked. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17, the IDT was instructed on 6/14/17 of the leadership additions to the 300 Hall Unit and expectations of the Assistant Administrator role going forward. On 6/15/17 the Assistant Administrator met with the staff on the 300 Unit to explain her new leadership role and her active participation with supervision on the Unit. A validation of the credible allegation was completed on 6/17/17 at 5:00 PM by the following: Review of the completed head count, review of the every 15 minute observation for Resident #1, review of door audits completed by the facility on 300 hall and throughout the facility, review of the in-service sign in sheets for 6/12/17 through 6/17/17 and the materials regarding the topics covered, interviews with multiple licensed and non-licensed nursing staff to verify their understanding of the information covered in the in-services, interview with the Maintenance Director to verify completion of the Wanderguard modification to the emergency exit doors, observation of the functioning of the emergency exit door near room 318, observation of the door monitors and review of the staff monitoring exit doors to 300 hall, and observation of residents on 300 hall and the placement and function of their Wanderguard bracelets including Resident #1.

Based on observations, staff interviews and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures, and to monitor these interventions, that the committee put into place in May of 2017. This was for one recited deficiency related to accidents (F323), which was originally cited in November of 2016 on a recertification survey, again in March of 2017 on a complaint investigation and again in May of 2017 on a complaint and follow-up investigation. F323 was subsequently recited on the current facility report investigation survey. A second recited deficiency related to Administration (F490) was originally cited in March of 2017 on a complaint investigation and again in May 2017 on a complaint and follow up investigation. F490 was subsequently recited on the current facility report investigation survey. A third recited deficiency related to Prohibit Mistreatment/Neglect/ Misappropriation (F224) was originally cited in March on a complaint investigation. F224 was subsequently recited on the current facility report investigation survey. The continued failure of the facility during two federal surveys of record show a pattern of the facility ' s inability to sustain an effective Quality Assurance Program. Immediate Jeopardy began 6/12/17 when Resident #1 exited the facility through an unlocked emergency exit door that also had the alarm disabled. The resident was not with facility staff and was found outside, after a concerned neighbor reported seeing someone outside the building. The Immediate Jeopardy was lifted on 6/17/17 when the facility ' s acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement new procedures. The findings included: The findings included: This citation is cross referenced to: 1). F224: Based on observation, record review and staff interview the facility neglected cognitively impaired residents by leaving an emergency exit door unlocked and the door alarm disengaged, resulting in the elopement of 1 of 3 residents cognitively impaired residents with wandering behaviors (Resident #1). Resident #1 exited the emergency exit door near room [ROOM NUMBER] on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. 2). F323: Based on observation, record review, and staff interview the facility failed to prevent 1 of 3 cognitively impaired residents from exiting a locked unit through an emergency exit door unnoticed, failed to keep an emergency exit door securely locked and failed to ensure the alarm for an emergency exit door was turned on. Resident #1 exited the emergency exit door near room [ROOM NUMBER] on the locked unit (300 Hall) and walked 64 feet to the left of the door and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #1 had eloped by a neighbor who had seen Resident #1 across the access road on the grass. When Resident #1 was located by staff she was sitting on a grassy area on the far side of the access road and the neighbor who reported her elopement was with her. Resident #1 did not sustain any injuries during the incident. 3). F490: Based on observations, staff interview and record reviews, the administration failed to achieve and maintain compliance related to securing exit doors and maintaining the safety of its residents for 1 of 3 cognitively impaired residents (Resident #1.) The administration failed to have systems in place to ensure special projects which required the use of exit doors were systematically planned and implemented with resident safety and security concerns fully assessed and addressed. Previous citations for F224, F323 and F490 are as follows: 1a). During a complaint survey of 3/11/17, the facility was cited for F224, failure to attend to the needs of one of three residents reviewed (Resident #2) when the Resident was left on the bedpan. 2a). During a recertification and complaint survey of 11/18/16, the facility was cited for F323 failure to provide adequate supervision to prevent an unobserved resident to resident altercation with minor injury for 2 of 2 sampled residents (Resident #130 and #205), failed to thoroughly investigate a resident to resident incident and to identify and implement intervention strategies to prevent future similar incidents for 2 of 2 residents (Resident #130 and #205) and on 1 of 1 behavioral health units (300 Hall). 2b). During a complaint investigation survey of 3/11/17, the facility was cited for F323 failure to supervise one of one sampled residents with known sexually inappropriate behaviors to prevent sexual abuse between this resident (Resident #8) and a cognitively impaired resident (Resident #1) and failed to implement effective interventions to prevent further inappropriate sexual behaviors for one of one sampled residents with known sexually inappropriate behaviors (Resident # 8). 2c). During a complaint and follow-up survey of 5/6/17, the facility was cited for F323, failure to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them. Resident #13 exited a resident room window then walked 43 feet and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #13 had eloped by a neighbor who had seen Resident #13 exit the window. When Resident #13 was located by staff he was at the base of a hill on the other side of the access road. Resident #13 sustained a skin tear during the incident. 3a). During a complaint investigation survey of 3/11/17, the facility was cited for F490 for failure to provide effective leadership to protect one of three sampled residents (Resident # 1) from sexual abuse by a resident (Resident # 8) with known sexually inappropriate behaviors. 3b). During a complaint and follow-up survey of 5/6/17, the facility was cited for F490, failure to 1) provide oversight to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to have monitoring systems in place to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them; and, 2) provide oversight and leadership to retain a Social Worker on a full-time basis, implement an effective discharge planning process, and provide for the safe discharge of one sampled resident (Residents #9) discharged to his home. An interview was conducted with the Administrator on 6/17/17 at 3:56 PM. During the interview he stated that the incident with the resident exiting the facility through an emergency exit was human error. He acknowledged that the facility did not previously have a system in place to ensure a planned approach to carrying out special projects to ensure the safety of residents while these projects were carried out but stated that one was now in place. The Administrator acknowledged that there had been several jeopardy citations regarding accidents but that the staff, Interdisciplinary Management Team and Corporate Staff were committed to resident safety. He added that it required a culture change and that was in progress from the top down to all staff. The Administrator also stated that he had received additional education from District Director of Clinical Services #2 in regards to oversight for resident safety and security, neglect and quality assurance. On 6/16/17 the Administrator, Director of Nursing, District Director of Clinical Services #1 and District Director of Clinical Services #2 were notified of Immediate Jeopardy at 4:42 PM. The Administrator provided the following credible allegation of compliance on 6/17/17 at 4:00 PM. The credible allegation indicated: 06/12/17 10:30 pm the Housekeeping Supervisor (HSG) and Assistant discussed, with the Maintenance Director, a plan to remove unused furniture etc. from the storage rooms at the end of the hallway closest to room [ROOM NUMBER]. The Maintenance Director instructed the HSG Supervisor on the importance of 2 staff persons being present to barricade the hallway with linen carts and furniture to prevent resident movement down the hallway, to monitor the exit doors at all time and to secure the door prior to completing the task and leaving the 300 Unit and to immediately report to the Maintenance Supervisor after the task is completed. 06/12/17 at approximately 11 am HSG staff proceeded to the 300 Unit and began their task. The door is an emergency exit door and has an alarm that can be turned off with a key that is kept by the Maintenance Director. The alarm was disengaged – the lock was still functioning but the Housekeeping staff used the keypad to unlock the door and go in and out – when the door was firmly shut it would lock automatically. 06/12/17 approximately 4:10 pm based on the investigation- Resident #1 exited through the exterior door closest to room [ROOM NUMBER]. Resident #1 last interacted with staff at 4:06 PM when she received Tylenol from the certified medication aide. At approximately 4:25 pm a resident from the apartments behind the facility came to the door and notified the staff that there was a resident sitting outside the facility. 2 Certified Nursing Assistants immediately went outside, assisted the resident back into the Facility at 4:30pm, the Charge Nurse completed an assessment which revealed no injuries, the resident ' s physician and family were notified. The resident was re-assessed at risk for elopement by the Nurse Manager, a Wanderguard (an electronic device worn as a bracelet that causes a Wanderguard enabled door to alarm and/or lock) was placed, and the care plan was updated. The Director of Nursing (DON) was first to assess the door after the resident was returned to the facility and found it not completely closed. The door appeared to be closed from hallway view until the DON actually pushed onto the door and realized the lock was not fully engaged. The Maintenance Director and Maintenance Assistant stayed at the door, investigated the door for proper function, engaged the alarm and stayed to monitor the door until the facility elopement process was implemented. The Second Shift Supervisor remained monitoring both exterior doors by viewing them throughout 2nd shift from the Nurses station until she was relieved by an assigned door monitor. A second door monitor was assigned to sit outside the 300 Unit Hall Unit to monitor this door. On 6/12/17 by 4:45 pm following the event, door monitors were placed at all 3 exit doors. The Administrator was notified of the incident immediately and went with the Maintenance Director to the 300 Hall Unit. The Maintenance Director said that when he got there the door was already securely closed and therefore locked and he used his key to re-engage the alarm. 06/12/17 5:00 pm, the interdisciplinary team (IDT) including the NHA and DON reviewed the unsupervised exit of Resident #1 from the 300 Unit exterior door. The Housekeeping employees involved were no longer in the facility, both were contacted and suspended pending investigation. The Administrator completed a 24 hour report to the Healthcare Personnel Investigation regarding this event. The 5 day investigation is due to be completed on 6/20/17. 06/12/17 5:15 pm the Nurse Managers completed a head count for all residents at risk for elopement throughout the entire facility. Residents with Wanderguards were assessed to validate placement and function of the Wanderguards by the Nurse Managers. Elopement assessments and care plans were reviewed and validated for all residents assessed at risk by the Nurse Managers. Elopement notebooks were reviewed and updated as needed by the Nurse Managers. These notebooks are maintained at each Nurses station. 06/12/17 5:15 pm All exterior facility doors and interior Wanderguarded doors were checked by maintenance to validate proper function and engagement of alarms. 06/12/17 5:20 pm the Staff Development Coordinator (SDC) and Area Staff Development Coordinator (ASDC) initiated education with all facility staff, to include the 100 and 200 Halls and the 300 Hall Unit present on 2nd shift, all staff received training on ensuring the doors are secure, fire exit doors are to only be used in case of a fire or permission of the Administrator, a complete review of the elopement policy including ensuring residents who are assessed at risk for elopement are supervised by facility staff when exiting the facility, identifying exit seeking behaviors and redirecting residents, reporting any observations of unsecure doors or windows or concerns related to all aspects of resident safety immediately and directly to the NHA and DON. The 2nd shift supervisor provided training to the 3rd shift and the NHA and DON were in the facility by 6:00am on 6/13/17 to assist the SDC with training 1st shift, no staff has been allowed to work since 2nd shift on 6/12/17 without receiving this training. The Director of Nursing, Staff Development Coordinator and Nurse Managers have conducted education with all staff on Abuse and Neglect Prevention on June 16, 2017 including resident security and supervision. Beginning June 16th No staff will be allowed to work until the training is complete. This education also included ensuring staff awareness that failure to provide security and supervision can constitute resident neglect. The NHA and DON will have a no tolerance approach to any deviation from the policy. 06/12/17 5:30pm An investigation was initiated, the Administrator and Director of Nursing conducted interviews with 1st and 2nd shift staff on the 300 Hall Unit including Housekeeping staff. It was determined that Resident #1 exited the exterior door by room [ROOM NUMBER] after it was left unlocked due to human error following trash disposal. On 6/13/17 the Administrator and the Maintenance Director re-evaluated the Wanderguard System and security for all interior and exterior doors for the 300 Unit and throughout the facility. Based on the results of this review Wanderguard alarms will be added to the exterior doors of the 300 Unit. These system upgrades will be completed by 6/18/17. This system has been initiated to provide a back-up alert in the event human error occurs. Going forward all residents on the 300 Unit will be considered at risk for elopement and have a Wanderguard in place and all residents on the 300 Unit will have a Wanderguard in place and all exit doors will have Wanderguard alarms. These Wanderguards will be in place by 6/18/17. Going forward, residents with Wanderguard bracelets in place will activate a second alarm when they are beside the emergency exit and a louder alarm then sounds in the event the door is opened and will not stop alarming until it is reset by a staff member. The annunciator for the Wanderguard System is stationed on the wall across from the nurses ' station that is easily visible from the nurses ' station and heard throughout the unit. On 6/12/17 immediately following this incident door monitors were placed at the 2 fire exits and the exit/entry into the facility from the 300 Hall unit until upgrades completed. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The Administrator will determine when the Door Monitor will be discontinued after discussion with the QAPI committee. On 6/13/17 the IDT also implemented a new process for conducting special projects within the facility, including the 300 Unit. Going forward the IDT, to include the Administrator, Director of Nursing, Nurse Managers, Maintenance Director and Housekeeping Director, will discuss any project prior to initiating and ensure there is a plan for when the project will begin and end, who will be responsible for assigning staff for door or window monitoring required as a result of safety measures expected to be compromised while the project is being completed. The NHA, DON and Maintenance Director will be notified immediately upon completion of the project and monitoring will not be removed until approved by the NHA or DON. Only the Administrator may determine when the Door Monitor will be discontinued after discussion with the QAPI committee. The Administrator and DON will randomly observe the door monitor is in place at least 3 times per day and will ensure this position is staffed accordingly with an assigned back up for meal breaks and emergencies. The 2 exterior doors for the 300 Unit and the Fire Exit doors on the 100 and 200 Hallways will always remain locked and will not be used for entry or exit at any time unless there is a fire or unless there is an emergency that the NHA (Nursing Home Administrator) determines use of these doors as necessary. The Maintenance Director or Maintenance Assistant will check these door daily to validate they remain locked. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17, the IDT was instructed on 6/14/17 of the leadership additions to the 300 Hall Unit and expectations of the Assistant Administrator role going forward. On 6/14/17 the Assistant Administrator was re-assigned to provide focused supervision to the 300 Unit, her office will be moved to the Unit by 6/16/17. The IDT was instructed on 6/14/17 of the upcoming leadership changes and expectations. On 6/15/17 the Assistant Administrator met with the staff on the 300 Unit to explain her new leadership role and her active participation with supervision on the Unit. 0n 6/15/17 the Director of Quality of Life Programs met with the IDT including leadership from the 300 Hall Unit. The Director of Clinical Services completed re-education of Administrator and Director of Nursing on 6/17/17. This education included facility policy for Abuse Prohibition and the facility policy for Elopement and the state and federal regulations governing long term care facilities with regards F323 Supervision to Prevent Accidents and F224 Abuse and Neglect Prohibition. On 6/17/17, the Administrator and DON were retrained on the Quality Assurance & Performance Improvement Program by the Division Vice President of Clinical Services. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director · Infection Preventionist The Administrator will lead the committee to complete weekly QAPI meetings with review of action plans and new areas of concern for Performance Improvement, with evidence of root cause analysis and action plans to address potential and actual concerns. District Director of Clinical Services will review weekly QAPI Minutes for 12 weeks and attend meetings as able. On 6/17/17, the Division Vice President of Clinical Services conducted re-education for the Administrator on the facility ' s policy and procedures for assembling a QAPI committee, collecting data and analyzing trends, and development and implementation of a plan to improve with ongoing monitoring to sustain compliance. The facility utilizes the Plan, Do, Study, Act method for Quality Assurance and Performance Improvement Program including scheduling, identification of Quality issues, trends or patterns, submission of data, and initiation of quality improvement plans related to identified areas of opportunity. The committee has met weekly in the past to monitor ongoing compliance with F323 Supervision to prevent Accidents and Elopement but will begin meeting 3 times per week on 6/17/17 to increase monitoring with F323 Supervision to prevent Accidents with a focus on the review of Window Checks and Door checks being conducted to correct and maintain the elopement management process and to evaluate systems for effectiveness of the facility ' s overall compliance with F323 Supervision to prevent Accidents and Elopements. F224 Abuse and Neglect Prohibition will be reviewed daily to validate monitoring and maintain the system for preventing and reporting abuse and neglect. The District Director of Clinical Services reeducated the IDT on 6/17/17 on Federal Regulation F 520 and the Facility QAPI Committee Policy regarding the expectations regarding maintaining an ongoing Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee consists of the Executive Director, Director of Clinical Services, Medical Director and at least 3 other members and meets at least monthly (Medical Director at least quarterly). Education also included the processes and procedures of implementing, reviewing and revising ongoing action plans for areas of deficiency that have been identified to attain and maintain substantial regulatory compliance and provide the highest level of care to residents. Newly hired IDT employees will be educated upon hire. The District Director of Clinical Services or the District Director of Operations will attend QAPI meetings at a minimum of quarterly to assure compliance with Federal Regulation F 520 to sustain and maintain compliance with Federal Regulation F 323-Resident Safety to include ongoing monitoring and revisions to the plan as necessary, and to maintain compliance with F224 the Prohibition of Abuse. A validation of the credible allegation was completed on 6/17/17 at 5:00 PM by the following: Review of the completed head count, review of the every 15 minute observation for Resident #1, review of door audits completed by the facility on 300 hall and throughout the facility, review of the in-service sign in sheets for 6/12/17 through 6/17/17 and the materials regarding the topics covered, interviews with multiple licensed and non-licensed nursing staff to verify their understanding of the information covered in the in-services, interview with the Maintenance Director to verify completion of the Wanderguard modification to the emergency exit doors, observation of the functioning of the emergency exit door near room [ROOM NUMBER], observation of the door monitors and review of the staff monitoring exit doors to 300 hall, and observation of residents on 300 hall and the placement and function of their Wanderguard bracelets including Resident #1. The Administrator and Director of Nursing were also interviewed regarding the education they received from the District Director of Clinical Services #2 in regards to oversight of special projects to ensure resident safety and security.

Based on observations, facility staff, Home Health Care staff, physician, family and resident interviews, and facility and hospital medical record reviews, the administration: 1) failed to provide oversight to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to have monitoring systems in place to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them; and, 2) failed to provide oversight and leadership to retain a Social Worker on a full-time basis, implement an effective discharge planning process, and provide for the safe discharge of one sampled resident (Residents #9) discharged to his home. Immediate jeopardy began on 2/25/17 for Resident #13 and for Resident #9 on 4/1/17. Resident #13 was able to exit a locked unit through a resident room window that he was able to open. The facility did not have monitoring systems in place to ensure the windows in the facility did not open. Resident #9 was discharged to his home without his needs being identified and addressed to ensure a safe discharge from the facility. The resident had a [MEDICAL CONDITION] and multiple co-morbidities (chronic conditions). The resident had not been accepted by a Home Health care agency to receive assistance with his [MEDICAL CONDITION] care upon discharge, as he had expected. The resident did not have the training nor supplies to do the [MEDICAL CONDITION] care on his own at home. He returned to the facility on [DATE] and was immediately sent to the hospital Emergency Department (ED) for an evaluation and treatment of [REDACTED]. He was released from the hospital ED and re-admitted to the facility on [DATE]. Immediate Jeopardy for both Resident #13 and Resident #9 were lifted at 6:00 PM on 5/6/17 when the facility ' s acceptable credible allegation of compliance for F323 and F490 were verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The findings included: This citation is cross-referenced to: F323 - Based on observation, record review and staff interview the facility failed to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them. Resident #13 exited a resident room window then walked 43 feet and across the access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #13 had eloped by a neighbor who had seen Resident #13 exit the window. When Resident #13 was located by staff he was at the base of a treed hill on the other side of the access road. Resident #13 sustained a skin tear during the incident. F204 - Based on observations, facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to arrange Home Health assistance for the care of a resident ' s [MEDICAL CONDITION], resident and/or care provider training on [MEDICAL CONDITION] care, and access to [MEDICAL CONDITION] supplies for 1 of 1 sampled resident (Resident #9) who was discharged home from the facility with a [MEDICAL CONDITION]. This resulted in a lack of [MEDICAL CONDITION] care after discharge; and, the resident was subsequently diagnosed with [REDACTED]. F251-- Based on facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to retain the services of a qualified Social Worker on a full-time basis to assume responsibility for the coordination of discharge planning, including arranging Home Health assistance for the care of a resident ' s [MEDICAL CONDITION], resident and/or care provider training on [MEDICAL CONDITION] care, and access to [MEDICAL CONDITION] supplies. This occurred for 1 of 1 sampled resident (Resident #9) who was discharged home from the facility with a [MEDICAL CONDITION] and resulted in a lack of [MEDICAL CONDITION] care after discharge. The resident was subsequently diagnosed with [REDACTED]. F284-- Based on facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to implement an effective discharge planning process to identify and address the discharge needs for 1 of 1 sampled resident (Resident #9) who was discharged home with a [MEDICAL CONDITION]. Resident #9 was discharged without Home Health care assistance, resident and/or care provider training on [MEDICAL CONDITION] care, or access to [MEDICAL CONDITION] supplies, which resulted in a lack of [MEDICAL CONDITION] care after discharge. Five days after his discharge from the facility, the resident was diagnosed with [REDACTED]. Interview with the Administrator on 5/6/17 at 6:04 PM revealed that the facility did not have a system in place for monitoring the windows because it wasn ' t a known issue. He stated that as far as he knew there had never been a previous elopement incident via the windows and he had not been aware that any of the windows could be opened far enough to allow for elopement. He also said it was his expectation that the windows would not open enough to allow for elopement. During the interview conducted with the facility ' s Administrator on 5/6/17 at 6:04 PM, the Administrator indicated he should have requested interim social services be provided until the facility could hire a qualified Social Worker on a full-time basis. He reported when the position was vacant, A lot of things fell through the cracks, including components of discharge planning. On 5/6/17 at 10:10 AM, District Director of Clinical Services #1 and District Director of Clinical Services #2 were informed of the immediate jeopardy for Resident #13 and Resident #9. The facility provided an acceptable credible allegation of compliance on 5/6/17 at 5:10 PM. The credible allegation indicated: Resident #9 was discharged to his home from (Name of Facility) on 4/1/17. Resident #9 required Home Health Services for Nursing, Oxygen, suction machine, and supplies to manage [MEDICAL CONDITION] care at home. The Facility Administrator completed a referral to the Home Health Agency on 3/28/2017, prior to discharge from the facility. Home Health Agency informed staff nurse prior to discharge that they were unable to provide service for this resident. This information was not communicated with facility management for follow up. This nurse has received education from the Areas Staff Development Coordinator, regarding Discharge Policy and Procedure on 5/5/17 The Oxygen Provider delivered Oxygen. No arrangements for DME (Durable Medical Equipment) was confirmed prior to discharge. Resident #9 was returned to facility by his family on 4/6, was assessed and determined need for care for his [MEDICAL CONDITION], due to drainage and odor, was sent to ER for eval and returned to facility where he was readmitted to (Name of Facility) on 4/6/2017, and treated for [REDACTED].#9 remains a current resident. At time of discharge there was no validation of Home Health admitting resident, no confirmation of DME, and no documented education related to signs and symptoms of problems, what care was necessary to maintain stable health, and consequences of not providing this care, for the resident and his family/ caregiver. Throughout the Discharge Planning Process for Resident #9, the Facility was without a Qualified Social Worker. Facilities Full Time Social Service Director resigned without notice on 1/26/17. Facility went without a qualified Social Worker from 1/26/2017 until a Qualified Social Worker was retained on 3/30/17. Qualified Social Worker remains employed. The administrator had an active role in the discharge process/planning for Resident #9. The Nurse Managers conducted an audit of residents who have discharged from the facility since 4/1/17 to validate each resident received sufficient preparation and orientation to ensure a safe and orderly discharge. This was validated by reviewing the resident record for documentation of coordination of home care services and by conducting phone interviews with the resident or their responsible party to validate successful discharge. This audit was completed by 5/5/17. The results of this meeting and QA Plan were shared with the Facility Medical Director on 5/5/17 and he was in agreement. The Area Staff Development Director completed re-education of all Licensed Nurses and members of the Interdisciplinary Team involved in discharge planning, on 5/5/17, Education included the Administrator, Director of Nursing, Nurse Managers, Social Services Director, Therapy Program Manager, Dietary Services Manager, Resident Care Management Director (MDS Nurse), Business Office Director and Physician. This education includes the facility policy regarding Transfer and Discharge Procedures as follows: Post Discharge Plan of Care: 1. Upon admission the IDT members, in consultation with the resident and/or the Resident ' s legal representative (if practicable), develops the resident ' s discharge plan and anticipated date of discharge. 2. The Social Service Director or designee, the IDT members, and the resident and/or the Resident ' s legal representative determine the individual needs, resources, and services required upon discharge through the IDT care plan meeting and process. 3. Social Service Department arranges for post-discharge services 4. Contact those service agencies who can support resident ' s needs, resources, and services upon discharge (e.g., home health, durable medical equipment, therapy services, meals, transportation, etc.). 5. Initiate the discharge paperwork with all IDT members to ensure that the resident, the Resident ' s legal representative or receiving provider obtains correct and detailed, confidential and protected health information upon discharge. The Social Services Director will contact all residents who discharge home within 1 week of discharge, 2 weeks of discharge and at 30 days post discharge to ensure that they have all care necessary services to safely remain in their home environment. The Administrator, Director of Nursing or Nurse Manager will review residents planned for discharge 3 times per week for 12 weeks to ensure a safe and orderly discharge has been planned by meeting with the resident and/or family and completing the Post Discharge Plan of Care, providing a home visits when possible and validating the completion of appropriate referrals. The Director of Clinical Services completed re-education of Administrator and Director of Nursing on 5/5/2017. This education included facility policy of provision of social work services and state and federal regulations governing long term care facilities with regards to provision of social services. In the absence of the Social Service Director, the Administrator will ensure that appropriate and adequate Social Service support is retained to meet the requirements of regulation. Support will be provided from sister facilities and /or through contract agency support. On 5/4/17, the Administrator, DON and ADON were retrained on the Quality Assurance & Performance Improvement Program by the Area Staff Development Coordinator. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director · Infection Preventionist Resident #13 was admitted to (Name of Facility) on 1/27/17, to room [ROOM NUMBER] in the Secure Unit. Resident #13 was assessed as being at risk for elopement on 1/27/17. At approximately 1:00 pm on 2/25/17, Resident #13 was found outside of the facility after a facility staff was alerted by a facility neighbor. Resident was found 43 feet from window, across the driveway outside facility between facility and neighboring apartment buildings. Was returned to the facility by the Manager on Duty and housekeeping staff. Resident #13 was assisted back into the facility and secure unit. Nurse #7 immediately 2/25/17 completed a Head to Toe Assessment of Resident #13 with minor injury of a skin tear noted, unknown where/how injury occurred, due to not witnessed. An updated Elopement Assessment was completed for Resident #13 on 2/25/17. The care plan was reviewed and updated by the DON on 3/6 to include Window [MEDICATION NAME] and room change. Nurse #7 initiated increased supervision for Resident #1 on 2/25/17 to include every 15 minute checks to monitor location. These checks were completed by the Nursing Assistants and documented on the flow record by the Charge Nurse for 72 hours following the incident. No evidence that resident continued to exit seek during this time. Resident #13 was moved to room [ROOM NUMBER] on 2/25/17 where the window exited to a courtyard enclosed on 3 sides by the building and on the 4th by a 6 foot fence with key pad gate. The window for room [ROOM NUMBER] was checked by the nurse on 2/25/17 and it did not open more than 6 inches. Nurse #7 notified Resident #13 ' s Responsible Party on 2/25/17 at 1:20 pm and Physician on 2/25/17 at 1:30 pm, regarding Resident #13 exiting the facility, physical assessment following the event and plan for increased monitoring. No new physician's order [REDACTED].#7 on 2/25/17. Nurse #7 notified the DON and Administrator of the event on 2/25/17 at approximately 1:00 pm. Maintenance was called on 2/25/17 at approximately 1:00 pm to facility and arrived within a half hour and immediately secured resident ' s window, and conducted an audit of all windows in secure unit to ensure that they were secure, several other windows were found not secured when checked by the nurse, the maintenance assistant put in new window [MEDICATION NAME] screws and then verified that they opened no more than 6 inches. Staff were re-educated 5/4/2017 on Elopement Process by the Area Staff Development Coordinator, no staff shall work until re-educated on process. On 2/27/17 there was education done with nursing staff who worked that day, conducted by the ADON. Nursing staff working 5/4/17 were educated by the Area Staff Development Coordinator that were currently in the facility and completed phone education for those not presently in facility. No staff members who have not received the education will work on the unit until they complete the education. Education includes Policy Procedure when there is an Elopement or suspected elopement, signs/symptoms of elopement risk, and supervision of residents with exit seeking behavior and intervention strategies. All new hires will also receive this education. District Director of Clinical Services and /or the District Director of Operations will provide oversight of the administration to ensure implementation of the credible allegation, by providing on site visits to the facility every week x 4 weeks, and then a minimum of bimonthly visits X 6 months to ensure implementation of all credible allegations. The credible allegation was validated on 5/6/17 at 6:26 PM by the following: Review of the window audits completed by the facility on 300 hall post 2/25/17, interview with the Maintenance Assistant and Maintenance Director to verify their understanding of the education they received regarding monitoring the windows and fixing any identified issues immediately, 100 percent audit of all windows on 300 hall/the locked unit to ensure the windows were secured (all 35 resident rooms on 300 hall) and an audit of selected rooms on 100 and 200 hall to verify the windows did not open more than 6 inches. On 5/6/17 at 6:04 PM, the facility ' s Administrator was interviewed. The Administrator was able to describe the education and in-servicing he had received in regards to the requirement to retain a qualified Social Worker on a full-time basis, implementation of an effective discharge planning process, and provision for the safe discharge of a resident. He was also educated on his role to review residents planned for discharge and ensure the appropriate plans were in place and resources were available for the safe discharge of each resident. During this interview the Administrator revealed that they had not been monitoring the windows because he was not aware of a previous incident of elopement through the windows and because the Management Team believed the windows were secure and could not open. He added that he thought a future citation in the area of Administration areas would be prevented because, due to recent staff changes, the facility now had an effective management team and nursing leadership in place. The Administrator noted that the facility had developed a stabilization plan that included plans to increase staffing over time. He said they had already hired some new positions such as Unit Managers. In addition he said that new systems were being put in place for the Management Team to work more effectively in their day to day clinical meetings and quality assurance activities such as root cause analysis. He stated that there was significant corporate support for the facility now, which had not been as evident in the past. In regards to Corporate Oversight the Administrator said that it would continue for a minimum of six months but that there would also be ongoing corporate support and oversight beyond that time frame as needed.

Based on observation record review and staff interview the facility failed to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them. Resident #13 exited a resident room window then walked 43 feet and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #13 had eloped by a neighbor who had seen Resident #13 exit the window. When Resident #13 was located by staff he was at the base of a hill on the other side of the access road. Resident #13 sustained a skin tear during the incident. Immediate Jeopardy began 2/25/17 when Resident #13 exited the facility unattended by facility staff and was found outside, after a concerned neighbor reported seeing someone exit the building through a window. The Immediate Jeopardy was lifted at 6:00 PM on 5/6/17 when the facility ' s acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement new procedures monitoring windows for potential exit hazards, and for ensuring residents with elopement risk and exit seeking behaviors have appropriate and timely interventions care planned and implemented. The findings included: Resident #13 was admitted [DATE] to the facility ' s locked unit. He had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired, had physical and verbal behavior toward others (1 - 3 days during the 7 day look back period), and had wandering behavior (4-6 days during the 7 day look back period). Resident #13 required limited assistance for transfers, extensive assistance for walking and used a wheelchair and walker according to the MDS. Review of the Elopement Risk assessment dated [DATE] revealed Resident #13 was at high risk for elopement. Review of the physician's order [REDACTED].) On 1/28/17 the 6:01 PM Nursing Note revealed alert male, oriented to self, very determined to ambulate without assistance, agitated that he is here and unable to go home, has tried to call his number numerous times with no answer noted. On 1/31/17 the SBAR (Situation, Background, Assessment, Recommendation) Note revealed resident had been coming up to nurses station multiple times since beginning of shift wanting to go home. Started to become more agitated at 11:45 PM with prn (as needed) Ativan (an anti-anxiety medication 0.5 mg (milligrams). Resident continued to come to nurses (sic) station and agitation continued. No effect noted from Ativan one hour later. Began to wander in and out of other rooms and verbally abusive to staff. The Care Plan initiated 2/17/17 revealed a plan of care for Resident #13 in regards to his elopement risk related to dementia. Interventions at that time included: assess for fall risk, observe for fatigue and weight loss, offer emotional and psychological support, orient resident to environment and reorient/validate and redirect resident as needed. On 2/25/17 at 12:42 PM the SBAR Note revealed resident is frequently confused, at times combative with care. Resident was at nursing desk, then went up hallway toward his room, when housekeeping came and notified staff that resident was crossing the road at side of facility, staff out to assist resident back in facility, staff (sic) became combative, picking up sticks etc. and hitting them, sitting on buttocks, when staff assisted him to standing resident pulled hand away causing a skin tear to left hand. On 2/25/17 a 3:30 PM Nursing Note revealed due to recent happenings, resident will be moved to room 319 where if resident is able to get out it will be within perimeter of facility. Family notified. Review of the Quarter Hour Monitoring Tool revealed every 15 minute observations for Resident #13 were initiated at 12:30 PM on 2/25/17 when he was observed sitting on the ground. At 12:45 PM the documentation indicated he was inside the facility at the desk. Review of an Incident/Accident Report for the elopement incident involving Resident #13 indicated the incident occurred on 2/25/17 at 12:45 PM. The Description of the Incident revealed: crawled out of window of 306 crossed side road attempting to leave (without) assistance became combative when staff attempted to assist him back inside facility jerked hand away and obtained skin tear. A diagram indicated the skin tear was on the top of Resident #13 ' s left hand. The treatments listed were body check, range of motion and skin treatment. The report also indicated the Responsible Party was notified at 1:20 PM and that the physician was notified at 1:30 PM. According to www.wunderground.com the temperature on 2/25/17, in the area the facility was located in, was a high of 77 degrees Fahrenheit (F) and a low of 45 degrees F with a mean of 61 degrees F. An Elopement Risk Assessment was completed for Resident #13 on 2/25/17, after the incident, and he was again assessed as having a high elopement risk. An Incident/Accident Investigation Follow up form dated 2/25/17 revealed was at desk, rolled toward room then was observed crossing side road at building side, staff out to assist resident back inside building, resident after attempting to climb tree, sat down, while being assisted back to standing position resident jerked hand away causing skin tear to left hand. Under Recommendations and New Interventions the following was written head count census, maintenance fixed windows - window stopper, room change, frequent checks. Review of the facility ' s Performance Improvement Project Plan for Elopement, initiated 2/25/17, revealed the following, specific to 300 hall: Root Cause identification - resident was able to open his window and then was able to slide window and exit through opening. Investigation was completed by the IDT (Interdisciplinary Team), it was believed that the resident was able to push the window past the screws securing the window for safety. Under Projected Outcome was the following: all windows will be secured to ensure no residents can open past 6 inches. Action items for the plan included the following actions that were listed as being completed 2/25/17: resident placed on checks every 15 minutes, resident moved to room with a window that faced a courtyard (courtyard was enclosed on 4 sides), windows secured to not open past 6 inches. Review of the Quarter Hour Monitoring Tool for 2/26/17 resident ' s whereabouts were documented every 15 minutes. In addition Resident #13 was noted to be exit seeking at 8:15 PM and again at 8:30 PM. No interventions were documented in the medical record however the resident ' s location was in bed from 9:00 PM and through the night. On 2/26/17 a care plan update revealed the following new interventions window stopper, room change. Review of the Quarter Hour Monitoring Tool for 2/27/17 revealed there was no documentation of the resident ' s whereabouts from 6:00 AM on 2/2717 until 2:00 PM on 2/27/17. Further review of the Facility ' s Performance Improvement Plan for Elopement, on 300 hall, revealed the following actions were listed as being completed 2/27/17: Maintenance Director and Administrator rechecked all windows on 300 hall and a Quality Assurance Performance Improvement (QAPI) meeting was held 2/27/17 to review the plan with the team. Re-education on the elopement process was indicated as having started 2/25/17 but the only sign-in sheet available was for 2/27/17. The Plan also revealed Maintenance would be completing monthly window checks and that the Administrator would check windows on weekly rounds. Review of an in service Attendance Form dated 2/27/17 revealed that 22 staff members received an in service on Elopement. None of the staff listed were those that had worked on 300 hall when Resident #13 eloped. The previous Assistant Director of Nursing (ADON #1) was listed as the instructor. The previous staff member who was the ADON at the time of the incident (ADON #1) was interviewed 5/5/17 at 12:40 PM via telephone and stated she may have done an in-service on elopement on 2/27/17 but she could not really remember doing it so could not elaborate on whether the in service content included exit seeking behaviors and interventions. She added she was off work 2/25/17 and 2/26/17 and said did not find out about the elopement until she returned to work on 2/27/17. She further indicated that if she did an in-service it wouldn't have been until 2/27/17. Review of the Quarter Hour Monitoring Tool for 2/28/17 revealed there was no documentation of the resident ' s whereabouts from 6:00 AM on 2/28/17 until 7:30 AM on 2/28 and again from 1:00 PM on 2/28/15 through 2:00 PM on 2/28/17. Review of the Quarter Hour Monitoring Tool for 3/1/17 revealed there was no documentation of the resident ' s whereabouts from 6:00 AM on 3/1/17 until 2:00 PM on 3/1/17. Review of the Quarter hour monitoring tool for 3/2/17 revealed Resident #13 ' s location was documented every 15 minutes. The documentation concluded at 2:15 PM on 3/2/17 and there were no further Quarter Hour Monitoring Tools for this resident. On 3/3/17 the physician's order [REDACTED]. Review of the Care Plan revealed that on 3/3/17 the plan of care for elopement risk was updated with the following intervention: Wanderguard to upper extremity for elopement risk, check placement and function q (every) shift. Further review of the Care Plan revealed another update to the elopement risk plan of care on 3/21/17 with the intervention Wanderguard replaced. An Elopement Risk Assessment was completed for Resident #13 on 3/22/17 and he was again assessed as having a high elopement risk. On 3/22/17 the physician's order [REDACTED]. Review of the Progress notes and Incident Log from 3/3/17 through 5/4/17 revealed no information regarding concerns or incidents related to the resident ' s Wanderguard. On 5/3/16 at 5:30 PM Resident #13 was observed in his room. He was sitting in his wheelchair beside the window and adjusting the heating control knobs on the heating unit under the window. When asked how he was he said not good I want to go home. When asked how long he had stayed at the facility he indicated he had just arrived and only been there one day. The window beside the resident was noted to have two screws through the sliding window track, to prevent the window from opening more than a few inches. The window looked out onto an enclosed courtyard. Telephone interview with Housekeeping Aide #1 (HA #1) on 5/4/17 at 11:40 AM revealed that she did not work at the facility anymore but recalled the elopement incident that occurred on 2/25/17. She stated that she had gone outside through the back door of the laundry room to place dirty linens in the outside bin for pick up. The door she went out was on the left side of the building (when facing the front entrance). She added that someone who lived in the apartments, which were located on the back side of the building, came by and told her that one of the residents came out a window. HA #1 indicated she did not get contact information for the informant and would not be able to identify her. HA #1 said when she looked she could see Resident #13 trying to go up the hill on the other side of the access road, which ran next to the left side of the facility and back to the apartments. She added that there were trees on the hill and a fence at the top. HA #1 said she then went over to where the resident was and asked him to go back into the building with her but Resident #13 told her he did not want to go back. The Housekeeping Aide said she had a walkie talkie with her at the time of the incident and was able to use it to reach other housekeepers for help. She stated that only the housekeeping staff had these walkie talkies so she could only reach other housekeepers with the device. HA #1 said that 3 housekeepers came to help but they were unable to convince Resident #13 to go back inside so one of them left to get help. The Manager on Duty and a Nursing Assistant came out to assist the resident back in the facility. She said Resident #13 would not walk back into the facility but they eventually got him into a wheelchair and took him inside. When asked who it was that brought the wheelchair out she could not recall. HA #1 said she thought that it took about 20 - 30 minutes before they were able to get the resident back inside the facility. Telephone Interview with Nurse #7 on 5/4/17, at 3:45 PM, revealed that she recalled the elopement incident that occurred on 2/25/17. She said that day was the first time she had worked on the locked unit (300 hall) and added I knew it was a locked unit, no one told me the windows opened. She further said she thought it was a lot of windows to monitor on a locked unit with residents who needed supervision for behaviors like exit seeking. Nurse #7 said that she found out a resident was missing from the unit when a housekeeping person came and said you let someone get off the unit. Nurse #7 indicated her response was no I didn ' t and that ' s when she was told someone was outside. She said that the Manager on Duty and the Nursing Assistant (Medication Aide #2) went out to get the resident. Nurse #7 said that she proceeded to try to determine how a resident got off the unit. She stated that while she was looking another resident said I ' ll show you how he got out and he showed her the window that was wide open in room 306. Nurse #7 stated that she then tried all the other resident room windows on the unit and found about 20 that opened. The Nurse said that she called the Director of Nursing (DON #2) and the Assistant Director of Nursing (ADON #1) and was told to call the Maintenance Director (DON #2 and ADON #1 were no longer employed at the facility at the time of the investigation). She said the Maintenance Assistant (MA) showed up about 30 minutes after she called the Maintenance Director and that she gave him a list of the rooms where the windows could open. Nurse #7 added that the MA said he would fix them and she said she went behind him when he was done and checked herself as well. When Resident #13 was brought back to the unit she did a physical assessment and also moved him to a room that had a window that did not open (Room 319). In addition this room's window faced a courtyard that enclosed on 3 sides by the building and on the 4th side by a 6 foot fence and keypad locked gate. On 5/4/17 at 2:00 PM the Maintenance Assistant (MA) was interviewed. The MA said that the Maintenance Director called him and told him to go the facility and make adjustments to the windows on 300 hall as needed to prevent elopements. He said Nurse #7 showed him the window in Room # 306 and when he tried to open it, the window opened all the way without difficulty. He stated that he fixed the window in Room #306 by inserting a screw in the sliding window track to stop the window from opening. He also said that he put window stopper screws in the other windows on the unit well. Observation of the windows on 300 hall with the MA and the Maintenance Director (M Dir) at 2:10 PM on 5/4/17 revealed the resident room windows had one stationary window panel on the right side of the window and there was a sliding window panel on the left side of the window. To open the window the sliding window panel, when functioning, would slide towards the right, in front of the fixed window panel. Observations of the following windows revealed: Room #306 (on 300 hall/the locked unit and the room with the window that Resident #13 eloped through) - There was one old looking screw drilled strait down vertically into the window track at approximately 6 inches away from the right of the sliding window panel; it was lower than the track edges and appeared as if the sliding window could slide over top. There were 3 shiny, new looking screws drilled down into the window track right up beside the sliding window. These screws prevented the window from opening at all. The window faced a side access road. Room #319 (on 300 hall/the locked unit and the room Resident #13 was transferred to immediately following the elopement) - There was one old looking screw drilled strait down into the window track at approximately 6 inches away from the sliding window, it was higher than the track edges and appeared as if the sliding window could not slide over top. In addition, there was a shiny new looking screw that was screwed horizontally through the sliding window track 4-6 inches away from the right of the sliding window panel. This window faced a courtyard which was enclosed on 3 sides by the building and on the 4th side by a 6 foot fence with a key pad locked gate. Room #329 (on 300 hall/the locked unit and Resident #13 ' s room at the time of the survey) - There was one old looking screw drilled strait down vertically into the window track approximately 6 inches away from the sliding window. This screw was lower than the track edges and appeared as if the sliding window could slide over top. There were two shiny, new looking screws that were screwed horizontally through the sliding window track, one at approximately 2 inches away from the right of the sliding window panel and one at approximately 4 inches away from the right of the sliding window panel. The M Dir attempted to open the window and was able to open it approximately 2 inches. The windows for Room # 319, 329 and #306 and their neighboring room windows were observed from the outside of the facility as well. Mechanisms for securing the windows from the outside were not evident at this time. On 5/4/17 at 2:15 PM during interview with the M Dir, he stated he had checked the 300 hall windows in the past periodically but had checked them on 2/27/17 after the elopement incident and monthly since then. He noted that the exit doors had always been checked daily, and he had an electronic log for the door checks, but said checks on the windows were not in that electronic system. He indicated that he would provide logs for window checks he had done, before the 2/25/17 elopement, if he could locate any. He also indicated that, even before the elopement incident on 2/25/17, the expectation was for the windows to either not open at all or to open no more than 6 inches for ventilation. No logs for window checks prior to the 2/25/27 elopement were provided during the survey. During interview on 5/4/17 at 4:45 PM with the Medical Records Director (MRD), who had been the Duty Manager on 2/25/17, she said that she was on 100 hall on 2/25/17 when a Housekeeping Aide told her that a resident got out to the side of the building. She said she did not recall which Housekeeping Aide it was. The MRD said she asked the HA if someone was the resident and she said yes so the MRD then went to 300 hall and told the Nursing Assistant (Medication Aide #2) that she needed help getting a resident that was outside. The MRD stated that when she got outside she saw Resident #13 at the start of treed hill across the access road. She said he grabbed a tree limb and told them he was not going back in and he started swinging sticks. The MRD stated she did not remember who brought a wheelchair outside and added that it took quite a while but eventually they talked him to getting in the wheelchair and took him inside. Once Resident #13 was back in the building she contacted the Maintenance Director, the Administrator and the Director of Nursing (DON #2) but said they were already aware when she reached them. She added that she also conducted a head count to ensure all the residents were accounted for. On 5/4/17 at 5:00 PM the Maintenance Assistant (MA) was re-interviewed. He stated that he did not recall Nurse #7 giving him a list of windows that could be opened. He also said that the window in Room #306 was the only one he tried to open before inserting a window stopper screw. The MA added that he was asked to make sure the windows did not open so he inserted screws through the sliding window tracks, so the windows would not open more than 6 inches for ventilation. He then checked each window after the stopper screws were inserted to ensure they did not open beyond the window stopper. The MA indicated he put a screw window stopper in all the resident room windows on 300 hall. Review of a facility map revealed there were 35 resident rooms on 300 hall. On 5/5/17 at 10:10 AM the window to Room #306 was observed with the Maintenance Assistant and the Regional Nurse Consultant. The Maintenance Assistant removed all the screws that had been added after the 2/25/17 elopement incident. There was a small ¼ inch hex head screw driven vertically into the sliding window track that had a dull appearance compared to the shiny screws that were removed. The Maintenance Assistant acknowledged the one dull sheen screw was the only one that had been present prior to 2/25/17. This screw was not removed and remained in place. The sliding window panel had a latch that prevented intrusion through the window from outside the facility when engaged. The Maintenance Assistance demonstrated how the latch was manually disengaged, by hand, and then was able to move the sliding window panel all the way to the right, completely in front of the fixed window panel, with minimal effort. With the window fully open there was approximately a 3 foot wide by 4 foot high opening for someone to exit through. The window sill was approximately 3 feet from the ground. The removed screws were replaced after the demonstration and then the window was checked to ensure it did not open. A similar demonstration was conducted with the window in Room #310 after the window in Room #306 was secured. This window opened with more difficulty when the new screws were removed, two hands were required and it had to be rocked back and forth some, but it did open all the way. Similar to Room #306 this window had a previously existing hex head screw that was driven vertically in the sliding window track. This screw was not removed during the demonstration and did not prevent the window from sliding over it. The removed screws were replaced following the demonstration and the window was checked to ensure it did not open. On 5/5/17 at 12:40 PM ADON #1 (who no longer worked at the facility) was interviewed by telephone. She stated that she had been a staff member at the facility on 2/25/17 but did not find out about the elopement until she came into work on the Monday, 2/27/17. She stated that she may have done some in-service education with the nursing staff on 2/17/17 in regards to elopement but she could not recall if the content was just on Elopement incident policy and procedure or if it included elopement risk factors, exit seeking behaviors and interventions. She said that she did investigate the incident and asked staff to show her where Resident #13 was located. ADON #1 also said that she was unable to determine how long Resident #13 was gone from the unit before he was located outside. On 5/5/17 at 4:13 PM a Nurse #7 was re-interviewed by telephone. She stated she could not recall how many NA ' s were working on the unit that day. She said that when the Housekeeping Aide (HA) told her one of their residents was outside the other staff went out to help and she stayed behind by herself with the residents. She stated that Resident #13 had been calm that day and that she saw him approximately 10 minutes before the HA said a resident was outside. Nurse #7 said Resident #13 had been up at the nurse ' s station talking about his friend and then he wheeled down the hall towards his room. She did not recall receiving any reeducation regarding elopement or exit seeking since the incident occurred. Review of the Staff Assignment sheet for 2/25/17 revealed Nursing Assistant #2 and #3 (NA #2, NA #3) were the assigned NA ' s for the hall on 2/25/17 when Resident #13 eloped. NA #2 and NA #3 were not available for interview during the survey and could not be contacted when an attempt to reach them by telephone was made. On 5/5/17 at 5:30 PM Nursing Assistant #1 was interviewed (NA #1). She stated she was not one of the staff members working during the shift that Resident #13 eloped but she was familiar with him. She stated that it was unusual for Resident #13 to try to get out the window and that she was not aware of him trying to do so prior to the elopement incident. She stated that his exit behaviors had focused on exit doors and verbalizations of going home. She said that once he made up his mind he was going he was pretty determined; sometimes he gathered his clothes up in his wheelchair and said someone was coming to pick him up. NA#1 stated that distraction seemed to work for Resident #13 as an intervention for exit seeking. NA #1 said she normally worked 2nd shift (2:00 PM - 10:00 PM) and when he wanted to go home she would say to him ' let ' s go watch TV and wait for your ride. ' She said after watching television for a while Resident #13 would eventually get tired and say he wanted to go to bed. NA#1 also said prior to 2/25/17, she had no idea any of the windows on the unit could open. She added that she had never tried them and just assumed they were locked. On 5/6/17 at 1:20 PM the Regional Nurse Consultant and Corporate Vice President were asked if the facility had ensured the windows on the 100 and 200 hall did not open more than 6 inches, given that there were residents with known high elopement risk on those units as well. They indicated they would need to verify to be sure. On 5/6/17 at 1:30 PM the location where Resident #13 was found was observed with the Medical Records Director (MRD) who had helped bring the resident back inside on 2/25/17. The distance from the window of Room #306 to the spot across the access road, where the MRD said Resident #13 was found when he eloped, was measured with a rolling distance calculator by the Maintenance Director. The measured distance was 43 feet. On 5/6/17 at 1:45 PM the window in Room #109 was observed. The windows on this hall were sliders that opened by sliding the bottom window up in front of the top stationary window, rather than opening by sliding the window to the side like the windows on 300 hall. There was a small screw noted on the sliding window track, on the left hand side, approximately 6 inches above the bottom window. The window did open and was not impeded by the presence of the screw. It was somewhat difficult to open in that it required two hands and rocking back and forth, but it was able to be opened approximately to a 2 foot height. The windows were approximately 3 feet wide and the window sill was approximately 3 feet from the ground. On 5/6/17 at 1:50 PM the District Director of Clinical Services #2 indicated she had tried to open one of the windows on 100/200 halls and she was able to open it with some difficulty that she attributed to the age of the windows. She also said that they were already working to secure all the 100 and 200 hall windows with window stoppers. On 5/6/17 at 1:57 PM Medication Aide #2 (Med Aide #2) was interviewed and said she recalled the elopement incident on 2/25/17. Med Aide #2 said that she saw the resident at and after breakfast that day. He had been roaming around as was normal for him and seemed like his normal self. She said that he talked about his plane but he would do that on a normal basis. The Med Aide revealed Resident #13 would come up and ask when the next flight was and that he had a pass and needed to get on the next flight. She said that was his baseline but that he was not talking about actually leaving that morning, just about his own plane. She stated that when he did talk about needing to take a flight she would redirect him by saying there were no flights until the morning and they would get him on that one. She indicated that she found this effective with him. Med Aide #2 stated that the last time she saw Resident #13, prior to him eloping, was around noon when she gave him some medication. Med Aide #2 stated he was either in the hall or in his room, she could not remember. Resident #13 was observed at this time with the Med Aide #2 in his room. He did not have a Wanderguard on his wrist/upper extremity but the Med Aide located it on his left ankle. During this interview on 5/6/17 at 1:57 PM with Med Aide #2 she stated that she was at the nurse ' s station when a Housekeeping Aide said one of the residents went out a window. She said that she then went outside with the Manager on Duty (Medical Records Director). She thought the unit Nursing Assistants on the hall may have been in the Dining Room at the time. When they got outside she said she saw Resident #13 across the side street in the bushes trying to climb a tree; he had sticks and was trying to swing them at us. He said he was going to get his plane that was across the fence. There was a fence at the top of the bushy, treed hill, and he was near the bottom. She stated that it took a while, possibly 20 minutes, to get Resident #13 inside but they finally got the resident back in the facility around 12:45 PM. On 5/6/17 at 4:00 PM the Director of Clinical Services # 1 reported that the securing of the 100 and 200 hall windows had been completed. The 5/4/17 the Administrator was notified of Immediate Jeopardy at 5:35 PM. The Administrator provided the following credible allegation of compliance on 5/6/17 at 2:00 PM. Resident #13 was admitted to Brian Center Salisbury on 1/27/17, to room 306 in the Secure Unit. Resident #13 was assessed as being at risk for elopement on 1/27/17. At approximately 1:00 pm on 2/25/17, Resident #13 was found outside of the facility after a facility staff was alerted by a facility neighbor. Resident was found 43 feet from window, across the driveway outside facility between facility and neighboring apartment buildings. Was returned to the facility by the Manager on Duty and housekeeping staff. Resident #13 was assisted back into the facility and secure unit. Nurse #7 immediately 2/25/17 completed a Head to Toe Assessment of Resident #13 with minor injury of a skin tear noted, unknown where/how injury occurred, due to not witnessed. An updated Elopement Assessment was completed for Resident #13 on 2/25/17. The care plan was reviewed and updated by the DON #2 on 3/6 to include Window stopper and room change. Nurse #7 initiated increased supervision for Resident #13 on 2/25/17 to include every 15 minute checks to monitor location. These checks were completed by the Nursing Assistants and documented on the flow record by the Charge Nurse for 72 hours following the incident. No evidence that resident continued to exit seek during this time. Resident #13 was moved to room 319 on 2/25/17 where the window exited to a courtyard enclosed on 3 sides by the building and on the 4th by a 6 foot fence with key pad gate. The window for room 319 was checked by the nurse on 2/25/17 and it did not open more than 6 inches. Nurse #7 notified Resident #13 ' s Responsible Party on 2/25/17 at 1:20 pm and Physician on 2/25/17 at 1:30 pm, regarding Resident #13 exiting the facility, physical assessment following the event and plan for increased monitoring. No new physician's order [REDACTED].

Based on observations, facility staff, Home Health Care staff and physician interviews, and facility and hospital medical record reviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in March of 2017. This was for one recited deficiency related to accidents (F323), which was originally cited in November of 2016 on a recertification survey and again in March of 2017 on a complaint investigation. F323 was subsequently recited on the current complaint investigation conducted in conjunction with a follow-up survey. A second recited deficiency related to Administration (F490) was originally cited in March of 2017 on a complaint investigation. F490 was subsequently recited on the current complaint investigation conducted in conjunction with a follow-up survey. The continued failure of the facility during two federal surveys of record show a pattern of the facility ' s inability to sustain an effective Quality Assurance Program. Immediate Jeopardy began on 2/25/17 for Resident #13 and for Resident #9 on 4/1/17. Resident # 13 was able to exit a locked unit through a resident room window that he was able to open. The facility did not have monitoring systems in place to ensure the windows in the facility did not open. Resident #9 was discharged to his home without his needs being identified and addressed to ensure a safe discharge from the facility. The resident had a [MEDICAL CONDITION] and multiple co-morbidities (chronic conditions). The resident had not been accepted by a Home Health care agency to receive assistance with his [MEDICAL CONDITION] care upon discharge, as he had expected. The resident did not have the training nor supplies to do the [MEDICAL CONDITION] care on his own at home. He returned to the facility on [DATE] and was immediately sent to the hospital Emergency Department (ED) for an evaluation and treatment of [REDACTED]. He was released from the hospital ED and re-admitted to the facility on [DATE]. The Immediate Jeopardy for both Resident #13 and Resident #9 were lifted at 6:26 PM on 5/6/17 when the facility ' s acceptable credible allegation of compliance for F323 and F490 were verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The findings included: This citation is cross referenced to: F323: Supervision to Prevent Accidents - Based on observation record review and staff interview the facility failed to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them. Resident #13 exited a resident room window then walked 43 feet and across an access road for the neighboring apartment complex; this access road ran next to the facility. Facility staff were notified that Resident #13 had eloped by a neighbor who had seen Resident #13 exit the window. When Resident #13 was located by staff he was at the base of a hill on the other side of the access road. Resident #13 sustained a skin tear during the incident. F490: Administration - Based on observations, facility staff, Home Health Care staff, physician, family and resident interviews, and facility and hospital medical record reviews, the administration: 1) failed to provide oversight to prevent 1 of 4 cognitively impaired residents, who were assessed as a high elopement risk, (Resident #13) from exiting a locked unit and failed to have monitoring systems in place to identify that there were windows in the building that could be opened sufficiently to allow a resident to elope through them; and, 2) failed to provide oversight and leadership to retain a Social Worker on a full-time basis, implement an effective discharge planning process, and provide for the safe discharge of one sampled resident (Residents #9) discharged to his home. During a recertification and complaint survey of 11/18/16, the facility was cited for F323 failure to provide adequate supervision to prevent an unobserved resident to resident altercation with minor injury for 2 of 2 sampled residents (Resident #130 and #205), failed to thoroughly investigate a resident to resident incident and to identify and implement intervention strategies to prevent future similar incidents for 2 of 2 residents (Resident #130 and #205) and on 1 of 1 behavioral health units (300 Hall). During a complaint investigation survey of 3/11/17, the facility was cited for F323 failure to supervise one of one sampled residents with known sexually inappropriate behaviors to prevent sexual abuse between this resident (Resident #8) and a cognitively impaired resident (Resident #1) and failed to implement effective interventions to prevent further inappropriate sexual behaviors for one of one sampled residents with known sexually inappropriate behaviors (Resident # 8). During a complaint investigation survey of 3/11/17, the facility was cited for F490 for failure to provide effective leadership to protect one of three sampled residents (Resident # 1) from sexual abuse by a resident (Resident # 8) with known sexually inappropriate behaviors. An interview was conducted with the Administrator on 5/6/17 at 6:04 PM. During the interview he stated that the quality assurance process began with identifying any facility issues via daily clinical meetings, falls meetings, and the interdisciplinary team meetings. Any identified issues needed to be brought to the Quality Assurance and Performance Improvement (QAPI) committee to ensure they are resolved. The Administrator acknowledged there had not been a system to monitor the windows because the Management Team believed the windows were secure. He also indicated that not having a Social Worker in place and that this was a requirement and facilitated effective discharge planning. He said that the facility had developed a Stabilization Plan with the support of their Corporate Team and that through Corporate Oversight and Quality Assurance monitoring the facility would be able improve in the areas of Supervision to Prevent Accidents and Administration to prevent further repeat citations in these areas. On 5/6/17 at 10:10 AM, District Director of Clinical Services #1 and District Director of Clinical Services #2 were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 5/6/17 at 3:22 PM. The credible allegation indicated: Resident #9 was discharged to his home from (Name of Facility) on 4/1/17. Resident #9 required Home Health Services for Nursing, Oxygen, suction machine, and supplies to manage [MEDICAL CONDITION] care at home. The Facility Administrator completed a referral to the Home Health Agency on 3/28/2017, prior to discharge from the facility. Home Health Agency informed staff nurse prior to discharge that they were unable to provide service for this resident. This information was not communicated with facility management for follow up. This nurse has received education from the Areas Staff Development Coordinator, regarding Discharge Policy and Procedure on 5/5/17 The Oxygen Provider delivered Oxygen. No arrangements for DME (Durable Medical Equipment) was confirmed prior to discharge. Resident # 9 was returned to facility by his family on 4/6, was assessed and determined need for care for his [MEDICAL CONDITION], due to drainage and odor, was sent to ER for eval and returned to facility where he was readmitted to (Name of Facility) on 4/6/2017, and treated for [REDACTED].# 9 remains a current resident. At time of discharge there was no validation of Home Health admitting resident, no confirmation of DME, and no documented education related to signs and symptoms of problems, what care was necessary to maintain stable health, and consequences of not providing this care, for the resident and his family/ caregiver. Throughout the Discharge Planning Process for Resident #9, the Facility was without a Qualified Social Worker. Facilities Full Time Social Service Director resigned without notice on 1/26/17. Facility went without a qualified Social Worker from 1/26/2017 until a Qualified Social Worker was retained on 3/30/17. Qualified Social Worker remains employed. The administrator had an active role in the discharge process/planning for Resident # 9. The Nurse Managers conducted an audit of residents who have discharged from the facility since 4/1/17 to validate each resident received sufficient preparation and orientation to ensure a safe and orderly discharge. This was validated by reviewing the resident record for documentation of coordination of home care services and by conducting phone interviews with the resident or their responsible party to validate successful discharge. This audit was completed by 5/5/17. The results of this meeting and QA Plan were shared with the Facility Medical Director on 5/5/17 and he was in agreement. The Area Staff Development Director completed re-education of all Licensed Nurses and members of the Interdisciplinary Team involved in discharge planning, on 5/5/17, Education included the Administrator, Director of Nursing, Nurse Managers, Social Services Director, Therapy Program Manager, Dietary Services Manager, Resident Care Management Director (MDS Nurse), Business Office Director and Physician. This education includes the facility policy regarding Transfer and Discharge Procedures as follows: Post Discharge Plan of Care: 1.Up on admission the IDT members, in consultation with the resident and/or the Resident ' s legal representative (if practicable), develops the resident ' s discharge plan and anticipated date of discharge. 2 The Social Service Director or designee, the IDT members, and the resident and/or the Resident ' s legal representative determine the individual needs, resources, and services required upon discharge through the IDT care plan meeting and process. 3. Social Service Department arranges for post-discharge services 4. Contact those service agencies who can support resident ' s needs, resources, and services upon discharge (e.g., home health, durable medical equipment, therapy services, meals, transportation, etc.). 5. Initiate the discharge paperwork with all IDT members to ensure that the resident, the Resident ' s legal representative or receiving provider obtains correct and detailed, confidential and protected health information upon discharge. The Social Services Director will contact all residents who discharge home within 1 week of discharge, 2 weeks of discharge and at 30 days post discharge to ensure that they have all care necessary services to safely remain in their home environment. The Administrator, Director of Nursing or Nurse Manager will review residents planned for discharge 3 times per week for 12 weeks to ensure a safe and orderly discharge has been planned by meeting with the resident and/or family and completing the Post Discharge Plan of Care, providing a home visits when possible and validating the completion of appropriate referrals. The Director of Clinical Services completed re-education of Administrator and Director of Nursing on 5/5/2017. This education included facility policy of provision of social work services and state and federal regulations governing long term care facilities with regards to provision of social services. In the absence of the Social Service Director, the Administrator will ensure that appropriate and adequate Social Service support is retained to meet the requirements of regulation. Support will be provided from sister facilities and /or through contract agency support. On 5/4/17, the Administrator, DON and ADON were retrained on the Quality Assurance & Performance Improvement Program by the Area Staff Development Coordinator. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director · Infection Preventionist Resident # 13 was admitted to (Name of Facility) on 1/27/17, to room [ROOM NUMBER] in the Secure Unit. Resident #13 was assessed as being at risk for elopement on 1/27/17. At approximately 1:00 pm on 2/25/17, Resident # 13 was found outside of the facility after a facility staff was alerted by a facility neighbor. Resident was found 43 feet from window, across the driveway outside facility between facility and neighboring apartment buildings. Was returned to the facility by the Manager on Duty and housekeeping staff. Resident #13 was assisted back into the facility and secure unit. Nurse #7 immediately 2/25/17 completed a Head to Toe Assessment of Resident #13 with minor injury of a skin tear noted, unknown where/how injury occurred, due to not witnessed. An updated Elopement Assessment was completed for Resident #13 on 2/25/17. The care plan was reviewed and updated by the DON on 3/6 to include Window [MEDICATION NAME] and room change. Nurse #7 initiated increased supervision for Resident #13 on 2/25/17 to include every 15 minute checks to monitor location. These checks were completed by the Nursing Assistants and documented on the flow record by the Charge Nurse for 72 hours following the incident. No evidence that resident continued to exit seek during this time. Resident # 13 was moved to room [ROOM NUMBER] on 2/25/17 where the window exited to a courtyard enclosed on 3 sides by the building and on the 4th by a 6 foot fence with key pad gate. The window for room [ROOM NUMBER] was checked by the nurse on 2/25/17 and it did not open more than 6 inches. Nurse #7 notified Resident #13 ' s Responsible Party on 2/25/17 at 1:20 pm and Physician on 2/25/17 at 1:30 pm, regarding Resident #13 exiting the facility, physical assessment following the event and plan for increased monitoring. No new physician's order [REDACTED].#7 on 2/25/17. Nurse #7 notified the DON and Administrator of the event on 2/25/17 at approximately 1:00 pm. Maintenance was called on 2/25/17 at approximately 1:00 pm to facility and arrived within a half hour and immediately secured resident ' s window, and conducted an audit of all windows in secure unit to ensure that they were secure, several other windows were found not secured when checked by the nurse, the maintenance assistant put in new window [MEDICATION NAME] screws and then verified that they opened no more than 6 inches. Staff were re-educated 5/4/2017 on Elopement Process by the Area Staff Development Coordinator, no staff shall work until re-educated on process. On 2/27/17 there was education done with nursing staff who worked that day, conducted by the ADON. Nursing staff working 5/4/17 were educated by the Area Staff Development Coordinator that were currently in the facility and completed phone education for those not presently in facility. No staff members who have not received the education will work on the unit until they complete the education. Education includes Policy Procedure when there is an Elopement or suspected elopement, signs/symptoms of elopement risk, and supervision of residents with exit seeking behavior and intervention strategies. All new hires will also receive this education. On 5/4/17 the Administrator, Director of Nursing and Facility Interdisciplinary Team including the Administrator, DON, ADON, District Director of Clinical Services, Area Staff Development Coordinator and Maintenance Director conducted a root cause analysis regarding facility processes for elopement prevention with regards to Window Safety/Security. Based on the results of this root cause analysis a QA plan was developed to include re-education of all current facility staff regarding the Elopement policy, and systematic approach of more frequent Window Checks on the Secure Unit. This will include Weekly Audits by the Maintenance Director or Assistant, additionally the Administrator will conduct random weekly audits on his facility rounds. The Director of Nursing will implement increased supervision for any resident with an elopement or attempt to elope immediately to establish safety and continue until the investigation has been completed and required interventions have been implemented .Incident Reports will be reviewed by the Interdisciplinary Team daily during the morning Stand Up meeting led by the Administrator. The Interdisciplinary team will determine acceptable interventions and ensure the care plan is revised. Administrator, DON and ADON were educated on the QAPI Process by the District Director of Clinical Services on 5/4/2017. Administrator and IDT to complete monthly QAPI meetings with review of action plans and new areas of concern for Performance Improvement, with evidence of root cause analysis and action plans to address potential and actual concerns. District Director of Clinical Services will review monthly QAPI Minutes X 4 months, and attend meetings as able. On 5/4/17, the Area Staff Development Coordinator conducted re-education for the Administrator on the facility ' s policy and procedures for assembling a QAPI committee, collecting data and analyzing trends, and development and implementation of a plan to improve with ongoing monitoring to sustain compliance. The facility utilizes the Plan, Do, Study, Act method for Quality Assurance and Performance Improvement Program including scheduling, identification of Quality issues, trends or patterns, submission of data, and initiation of quality improvement plans related to identified areas of opportunity. The committee has met monthly in the past to monitor ongoing compliance with F323 Supervision to prevent Accidents and Elopement but will begin meeting weekly on 5/4/17 to increase monitoring with F323 Supervision to prevent Accidents with a focus on the review of Window Checks being conducted to correct and maintain the elopement management process and to evaluate systems for effectiveness of the facility ' s overall compliance with F323 Supervision to prevent Accidents and Elopements. The Regional Director of Clinical Services reeducated the IDT on 5/6/17 on Federal Regulation F 520 and Consulates QAPI Committee Policy regarding the expectations regarding maintaining an ongoing Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee consists of the Executive Director, Director of Clinical Services, Medical Director and at least 3 other members and meets at least monthly (Medical Director at least quarterly). Education also included the processes and procedures of implementing, reviewing and revising ongoing action plans for areas of deficiency that have been identified to attain and maintain substantial regulatory compliance and provide the highest level of care to residents. Newly hired IDT employees will be educated upon hire. The Regional Director of Clinical Services or the District Director of Operations will attend QAPI meetings at a minimum of quarterly to assure compliance with Federal Regulation F 520 to sustain and maintain compliance with Federal Regulation F 323-Resident Safety to include ongoing monitoring and revisions to the plan as necessary, and to maintain compliance with F204, 251, and F284 as they relate to Social Service provisions and adequate Discharge planning and coordination of a safe and orderly discharge for all residents leaving facility. The credible allegation was validated on 5/6/17 at 6:26 PM by the following: Staff members from the Management Team including the Administrator, Director of Nursing, Rehabilitation Manager, Social Services Director, Resident Care Management Director and Maintenance Director were interviewed. During these interviews they indicated that they received in-service training regarding Quality Assurance. The Administrator was interviewed and confirmed the facility ' s Quality Assurance monitoring plans for both F323 and the corporate oversight for F490. The Administrator verbalized his understanding of the need to identify issues or concerns within the facility, and the role of QAPI process in resolving and monitoring these concerns.

Based on observations, facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to arrange Home Health assistance for the care of a resident ' s [MEDICAL CONDITION] (a surgical opening in the neck that allows a curved tube to be inserted into the windpipe to open a restricted airway and enable breathing), resident and/or care provider training on [MEDICAL CONDITION] care, and access to [MEDICAL CONDITION] supplies for 1 of 1 sampled resident (Resident #9) who was discharged home from the facility with a [MEDICAL CONDITION]. This resulted in a lack of [MEDICAL CONDITION] care after discharge; and, the resident was subsequently diagnosed with [REDACTED]. Immediate jeopardy began on 4/1/17 when Resident #9 was discharged from the facility to his home. The resident had a [MEDICAL CONDITION] and multiple co-morbidities (chronic conditions). The resident had not been accepted by a Home Health care agency to receive assistance with his [MEDICAL CONDITION] care upon discharge, as he had expected. The resident did not have the training nor supplies to do the [MEDICAL CONDITION] care on his own at home. He returned to the facility on [DATE] and was immediately sent to the hospital Emergency Department (ED) for an evaluation and treatment of [REDACTED]. He was released from the hospital ED and re-admitted to the facility on [DATE]. The immediate jeopardy was removed on 5/6/17 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The findings included: A review of the Resident #9 ' s medical records revealed he was hosptalized on [DATE] for acute on chronic [MEDICAL CONDITION] and pneumonia. While in the hospital, the resident required intubation and a [MEDICAL CONDITION] (also known as a trach). Resident #9 was discharged from the hospital to the facility on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had intact cognitive skills for daily decision making. He required extensive assistance for bed mobility, dressing, and toileting; limited assistance for transfers and personal hygiene; and, supervision from staff for locomotion on the unit. The resident was independent with eating. Section O of the MDS assessment indicated Resident #9 received Occupational Therapy (OT) and Physical Therapy (PT) services. It also reported he had a [MEDICAL CONDITION] and received oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident and his family participated in the assessment process. The MDS reported his overall goal about returning to the community was unknown or uncertain; and, active discharge planning was not occurring for the resident to return to the community. Section Q of the MDS reported the resident did not want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. However, Section Q of the MDS also indicated the resident wanted to be asked about returning to the community on all subsequent assessments. A review of the resident ' s care plan included the following areas of focus: --(Name of Resident) has a [MEDICAL CONDITION] related to impaired breathing mechanics (Initiated 2/7/17; Revised on 2/7/17). The stated goal for this area of focus was for the resident to have no signs/symptoms of infection through the review date (Initiated on 2/7/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Ensure that the [MEDICAL CONDITION] ties (the bands that go around the neck and hold [MEDICAL CONDITION] in place, also known [MEDICAL CONDITION]) are secured at all times. (Initiated 2/7/17); --Observe/document respiratory rate, depth and quality. Check and document every shift or as ordered (Initiated 2/7/17); and, --Suction as necessary (Initiated 2/7/17). ---(Name of Resident) wishes to be discharged to home when able (Initiated on 3/8/17; Revised on 3/8/17). The stated goal for this area of focus was for the resident to be able to verbalize/communicate the assistance he would need post-discharge and the services required to meet his needs before discharge (Initiated on 3/8/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Establish a pre-discharge plan with the resident/family/caregivers, evaluate progress, and revise the plan as needed with the resident ' s need for assistance with his [MEDICAL CONDITION] care and Activities of Daily Living (ADL) assistance (Initiated on 3/8/17; Revised on 3/8/17); and, --Evaluate the resident ' s motivation to return to the community (Initiated on 3/8/17). A review of the resident ' s medical record included Respiratory Therapist (RT) notes dated 2/7/17, 2/8/17, 2/14/17, 2/23/17, 3/14/17, and 3/21/17. One additional RT note was not dated. No notations were made on the RT notes to indicate the RT provided education/training for the resident on the care of his [MEDICAL CONDITION]. A review of Resident #9 ' s therapy notes revealed a home visit was conducted on 3/27/17 by OT and PT in anticipation of his discharge from the facility. Recommendations made from the home visit included the need for a shower chair, hand held shower head, grab bar in the shower, and oxygen on an as needed (PRN) basis. The notes recommended follow up OT, PT, and Speech Therapy (ST) upon discharge. A review of the resident ' s current physician orders [REDACTED]. --[MEDICAL CONDITION]: Change tubing and equipment every night shift every Wednesday (Initiated 2/7/17); --Oxygen saturation (also known as an O2 Sat) to be checked every shift and notify the Medical Doctor (MD) if the O2 Sat is less than 88% (Initiated 2/7/17). (An O2 Sat is a relative measure of the amount of oxygen carried in the blood. Normal blood oxygen levels are typically considered to be 95-100%); --Trach #6 Shiley long (referring to the inner diameter and length of the [MEDICAL CONDITION]): [MEDICAL CONDITION] care to be completed every shift and as needed (Initiated 2/7/17); and, --Oxygen (O2) at 5 liters (referring to the oxygen flow rate per minute) every shift (Initiated 3/2/17). A review of the resident ' s medical record included a Respiratory Therapist (RT) note dated 3/31/17. The respiratory assessment note revealed Resident #9 was sitting up in the chair with a pleasant demeanor. [MEDICAL CONDITION] care was done and the RT noted there was no change in the stoma (surgical opening) site at that time. Resident #9 was noted to be scheduled for discharge to home on 4/1/17. There was no notation on the RT note to indicate the resident was trained on care of the [MEDICAL CONDITION]. A review of the resident ' s medical record included a physician ' s note dated 3/31/17 at 12:51 PM. The physician noted Resident #9 was seen for a discharge summary. The notation read as follows, in part: (Name of Resident) is seen today in anticipation of his discharge from the facility this weekend. He was admitted to the (Name of Facility) on 2/8/17 after being hospitalized for [REDACTED]. Since his admission he has done well with rehabilitation and [MEDICAL CONDITION]. For the past several weeks he has been seen ambulating around the facility without any SOB or imbalance and has not been requiring oxygen when walking . Plan: [MEDICAL CONDITION]: Diminished breath sounds and is high risk for re-hospitalization but is felt stable to go home. HH (Home Health) nursing, PT/OT. A review of Resident #9 ' s medical record revealed a Nursing Note dated 4/1/17 at 7:35 PM reported, in part: .Patient went home. A review of the Home Health agency notes dated 4/1/17 (not timed) included the following text: Call from (name of resident ' s Family Member #2) regarding waiting for (name of Home Health agency) to come out. Informed non-admitted due to trach. Spoke with (name of Home Health representative) who informed (name of Nurse #1) at (name of facility). Also spoke with (name of Home Health staff member), could not accept referral as it would take 2-3 weeks to set up PDN (private duty nurse). She informed marketing manager (name of manager). Tried to call (name of facility), but they would not provide any information and CM (Case Management) Department is closed until Monday. An email dated 4/3/17 at 4:16 PM was provided by the Home Health agency for review. The email was sent from the Home Health agency ' s Marketing Manager to both the Office Manager for Resident #9 ' s primary care physician and the facility ' s Administrator. The text of the email read: I have copied (name of facility ' s Administrator) on this email as well to keep everyone in the loop. I spoke with the other Home Health Agencies and even though (name of Resident #9 ' s insurance company) approved Home Health hours for this client he is not appropriate for Home Care. He is high risk for a hospitalization and his best place is back in (name of facility) where he can get the proper care he needs. The client wanted to go home and when (name of resident ' s physician at the facility) saw him last week he even stated he would end up back in the hospital. I talked with (name of representative for the oxygen supply company) and they only delivered Oxygen to the home and [MEDICAL CONDITION]-When you guys see this client tomorrow I would recommend sending him back to (name of the facility). I hate it for (resident ' s name) but his best place for the care he needs is at SNF (skilled nursing facility) level. (Name of facility ' s Administrator) will have his team prepare a bed to make a smooth transition just in case. A review of Resident #9 ' s paper medical record included documentation from a follow-up diabetic visit on 4/4/17 with an outside Internal Medicine service. Progress notes written by the Physician Assistant (PA) on 4/4/17 included the following notations, in part: .Recently hospitalized for [REDACTED]. discharged to SNF (name of facility). Patient was told he could be discharged over the weekend. He was released however has had difficulty getting home health to come out [MEDICAL CONDITION]. (Name of Family Member #2) accompanies the patient today-she states he will not go back to (name of facility) because he doesn ' t want to. Patient has a history of noncompliance and refusing home health. He lives at home with his (name of Family Member #1). No fever or difficulty breathing since discharge. The PA ' s Impression/Plan from the 4/4/17 visit read: Do not think patient is appropriate for outpatient care. Discussed at length my concerns of not returning to a SNF for care given multiple comorbidities. Both he and his (name of Family Member #2) are adamant that patient will not be returning to (name of facility). (Name of another Home Health agency) will bring supplies out to patient. Patient is in agreement for close follow up-will return in 2 weeks for BP (blood pressure) check. Labs pending. A review of the hospital Emergency Department (ED) records from 4/6/17 revealed Resident #9 arrived to the ED at 2:48 PM via Emergency Medical Services (EMS). The ED history included the following comments: Patient presents today complaining of need for [MEDICAL CONDITION] care. He was released from the (name of facility) on Saturday and has been home for the last 5 days. He is referred back to the (name of facility) today because of inability to care for himself in the home but upon return to the Center, they sent him here because he had foul discharge from his [MEDICAL CONDITION] site. Patient is denying any other problems. He states that he does get confused to time so he is unclear as to exact dates when his [MEDICAL CONDITIONS] changed. The hospital ED records revealed upon examination, Resident #9 had [DIAGNOSES REDACTED]tous (redness) and superficial skin breakdown all around [MEDICAL CONDITION] site. The resident was diagnosed with [REDACTED]. The ED Respiratory Notes dated 4/6/17 at 3:57 PM read, trach was in place [MEDICAL CONDITION]-foul smell coming [MEDICAL CONDITION] states last changed Saturday-collar wet with drainage-Respiratory at bedside will change [MEDICAL CONDITIONS] . The resident was discharged from the ED to the facility on [DATE]. His discharge medication orders included 2% [MEDICATION NAME] (a topical antibiotic ointment) and 875-125 milligrams (mg) [MEDICATION NAME]-clavulanate (an oral antibiotic) to be given as one tablet by mouth every 12 hours for 10 days. A review of the Resident #9 ' s electronic medical record dated 4/6/17 at 9:49 PM indicated the resident was readmitted to the facility. No distress was noted and he was assessed as being alert and oriented. A review of the resident ' s physician orders [REDACTED]. --[MEDICAL CONDITION]: Change tubing and equipment every night shift every Wednesday (Initiated 4/7/17); --Trach #6 Shiley long: [MEDICAL CONDITION] care to be completed every shift and as needed (Initiated 4/7/17); --Check O2 Sat every shift and notify MD if O2 Sat is less than 88% (Initiated 4/7/17); --Trach collar with 5 liters O2 per minute as needed during the day for O2 Sats less than 91% (Initiated 4/8/17); and, --Trach collar with 5 liters O2 per minute every evening and night shift (Initiated 4/8/17). A review of the resident ' s medical record included a Respiratory Therapist (RT) note dated 4/7/17. The respiratory assessment revealed Resident #9 ' [MEDICAL CONDITION] changed on 4/6/17 at the hospital. The respiratory assessment noted the resident was readmitted on [DATE] after going to the ED for [MEDICAL CONDITION] around his trach. It read, in part: [MEDICAL CONDITION] was done while he was at home. He is on ABT (antibiotic) and [MEDICATION NAME]. The resident ' [MEDICAL CONDITION] was noted as red, sore, and bleeding easily. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. He was independent for all of his ADLs, with the exception of requiring supervision from staff for eating. Section O of the MDS assessment reported he received [MEDICAL CONDITION] care and oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident participated in the assessment process and was expecting to remain in the facility. However, the MDS also revealed the resident did want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. An interview was conducted on 5/4/17 at 2:15 PM with the facility ' s Unit Manager and the Area Staff Development Coordinator (SDC). Upon inquiry, the Unit Manager and the SDC recalled Resident #9 came back into the facility on [DATE] sometime between 2:00-4:00 PM. The nurses reported Resident #9 was not expected and the facility did not have any admission orders [REDACTED]. The resident returned from the hospital later on that same date (4/6/17). When asked what time he returned, the nurses reviewed the medical record. The first note which indicated he had returned to the facility was made on 4/6/17 at 9:49 PM. An interview was conducted on 5/4/17 at 2:20 PM with a Corporate Director of Nursing (Corporate DON #1). During the interview, the Corporate DON stated she recalled the facility ' s Administrator had worked with Resident #9 quite a bit and suggested he might be able provide additional insight into the events of 4/6/17. An interview was conducted on 5/4/17 at 2:30 PM with the facility ' s Administrator. During the interview, the administrator reported Resident #9 ' s family knew ahead of time they wanted the resident to go home. The Administrator stated he himself arranged Home Health care well in advance of the resident ' s discharge on 4/1/17. Upon request, the Administrator provided contact information for the Home Health representative. The Administrator stated, Everybody knew what was happening. He reported on Friday night (3/31/17) around 6:00 PM, both he and Resident #9 met with an oxygen supply company when they brought his oxygen to take home and educated him on its use. The Administrator confirmed Resident #9 was discharged on Saturday, 4/1/17. As the interview continued on 5/4/17 at 2:30 PM, the Administrator reported Resident #9 ' s insurance company contacted him on Monday (4/3/17) and reported the resident ' s family was concerned he wasn ' t doing well at home with the [MEDICAL CONDITION]. The Administrator spoke with the resident ' s family member (Family Member #2) by telephone on 4/3/17, 4/4/17, and 4/5/17. He told this family member that the facility would be happy to take the resident back. However, the resident had a physician appointment scheduled that week and the family planned to take him to it. On Thursday, 4/6/17, the Administrator reported he called the family member (Family Member #2) around 12:00 PM and was basically told they were on their way to bring the resident back to the facility. When the resident arrived, the Administrator stated he could smell [MEDICAL CONDITION] and wanted to get it evaluated. The facility called 911 and the hospital ED to tell them the resident was being sent over. The Administrator reported the resident was seen in the ED and returned to the facility around 8:00 -9:00 PM the evening of 4/6/17. A telephone interview was conducted on 5/4/17 at 4:35 PM with the Marketing Manager for the Home Health agency who had received a referral from the Administrator for Resident #9 ' s home care. During the interview, the resident ' s discharge arrangements for 4/1/17 were discussed. As the Marketing Manager reviewed the resident ' s Home Health record, she reported the agency was given the Home Care referral on 3/28/17. The Manager explained their Home Health agency was divided into two sections: the Hourly care side (which did work with tracheostomies) and the Home Health care side (which did not work with trachs). On 3/31/17, the agency learned the resident did not have insurance coverage for the Hourly care; and the Home Health care side did not [MEDICAL CONDITION]. The Home Health office contacted the Marketing Manager on 3/31/17. On 3/31/17, the Marketing Manager telephoned the facility and informed Nurse #1 their Home Health agency couldn ' t take this resident. She also reported her agency contacted two other Home Health agencies, but Resident #9 was not accepted by either of them. With the discharge still planned for 4/1/17, the Marketing Manager stated she coordinated a delivery of oxygen to the facility on Friday night (3/31/17) so the resident would have it when he went home. On Monday (4/3/17), she went to the facility for follow-up because she was concerned about an unsafe discharge if the resident actually went home over the weekend. The Marketing Manager stated she also wanted to make sure the facility had a bed for the resident if he decided to come back. The Marketing Manager reported she talked with the Office Manager for Resident #9 ' s primary care physician on 4/3/17, then followed up with an email to both the Office Manager and the facility ' s Administrator to be sure everyone had the information. An interview was conducted on 5/5/17 at 8:00 AM with Resident #9. During the interview, the resident recalled he and the Administrator met with someone on Friday night (3/31/17) to get his oxygen arranged for discharge. When the resident was asked what was arranged for him prior to discharge, he reported that in addition to the oxygen he had a shower chair, a shower bar, and a railing for the commode at home that his family had purchased. He stated the shower bar and railing for the commode had not yet been installed by his landlord when he arrived home on 4/1/17. Upon further inquiry, the resident stated someone on the phone had told him he would get 24-hour nursing care when he got home. He reported he did not know how to do his [MEDICAL CONDITION] and did not receive [MEDICAL CONDITION] to use at home when he was discharged from the facility. He reported he expected a Home Health nurse to come out to his home to take care of his [MEDICAL CONDITION], but no one did. A telephone interview was conducted on 5/5/17 at 10:48 AM with the Respiratory Therapist (RT) who worked with Resident #9. The RT reported she worked for a contracted company and came to the facility on ce a week to provide [MEDICAL CONDITION] care for the resident. Prior to his 4/1/17 discharge, the RT noted Resident #9 had issues with his skin under the [MEDICAL CONDITION] due to a small amount of drainage and having some trouble keeping the skin dry. She reported the skin looked a little irritated and was a little sore when cleaned. The RT stated she was hoping the Home Health nurse would continue to follow this issue under his [MEDICAL CONDITION] collar. When asked what kind [MEDICAL CONDITION] the resident required, the RT stated he received [MEDICAL CONDITION] once every shift (3 times a day) while in the facility, but may have been able to do [MEDICAL CONDITION] twice daily upon discharge. She reported routine [MEDICAL CONDITION] care involved cleaning the area behind the flange (the area where the ties or sutures are connected to secure the tube in place) and making sure there were no secretions; changing [MEDICAL CONDITION] and cannula (the body of the tube that is inserted into the trachea), and replacing the drain sponge underneath. The RT stated she was under the impression the resident and a family member would do some of [MEDICAL CONDITION], with the Home Health nurse going out a few times a week to make sure it was done appropriately. Without reviewing her notes, the RT did not recall if she had done [MEDICAL CONDITION] care training with the resident, but was certain she did not train a family member on [MEDICAL CONDITION]. The RT stated if she had [MEDICAL CONDITION] teaching with the resident, she would have included a notation documenting this in her Respiratory Notes. The RT stated if the resident was trained, he may be able to do the procedure for [MEDICAL CONDITION]. However, she was unsure if he would reliably do the care twice daily every day. When asked if she had understood this resident would be going home with Home Health, she stated, Absolutely. Upon further inquiry, the RT reported having a suction machine would usually be a standard for anyone going home with a [MEDICAL CONDITION]. When asked what her thoughts were regarding the resident going home without a suction machine, the RT reported that although she didn ' t think he ' d have a big problem, she stated, You never know. The RT stated she saw the resident the day after he was readmitted to the facility on [DATE]. She recalled he had been put on an antibiotic for neck [MEDICAL CONDITION] and reported the condition of the skin had improved significantly over the last few weeks. An interview was conducted on 5/5/17 at 12:24 PM with Nurse #2. Nurse #2 worked as a 3rd shift nurse assigned to care for Resident #9. When asked if she had done any [MEDICAL CONDITION] care teaching with the resident, Nurse #2 reported since she worked on the 3rd shift, she would typically talk him through it. The nurse stated the resident never did a return demonstration for her. Nurse #2 stated, I do know when he left the facility he was not doing his [MEDICAL CONDITION]. A follow-up interview was conducted on 5/5/17 at 12:52 PM with Resident #9. A family member (Family Member #1) was visiting the resident at that time. During the interview, the resident stated he lived with Family Member #1 after he was discharged from the facility. When the resident and his family member were asked [MEDICAL CONDITION] was done during the time he was home, the resident stated, nothing. The resident acknowledged he was shown how to use his oxygen equipment, but reiterated he was not shown how to do [MEDICAL CONDITION] for himself. When Family Member #1 was asked if she was trained to [MEDICAL CONDITION] for the resident, both the resident and family member responded by saying, No. The resident consented to have a second family member interviewed by telephone (Family Member #2). He reported the second family member provided his transportation and had been in contact with his health care providers. A follow-up interview was conducted on 5/5/17 at 1:21 PM with the facility ' s Unit Manager. Upon inquiry, the Unit Manager reported that to her knowledge, the resident did not do any of his [MEDICAL CONDITION] during his stay at the facility. The Unit Manager reported she was at the facility when the resident presented on 4/6/17 with foul smelling drainage from his [MEDICAL CONDITION]. The Unit Manager stated she did not assess the [MEDICAL CONDITION] and could not tell what color the drainage was. She reported two nurses who may have assessed the drainage prior to sending the resident out to the hospital no longer worked at the facility. A telephone interview was conducted on 5/5/17 at 1:24 PM with Nurse #1. Nurse #1 was identified as the nurse who received a phone call from the Home Health agency on 3/31/17, informing the facility Resident #9 was not admitted to Home Health due to having a [MEDICAL CONDITION]. When asked about this phone call, the nurse stated, I believe they did speak with me .the Administrator was involved. Someone called .the supply company maybe .and the Administrator was going to call and confirm with (name of the Marketing Manager) everything was in place. When asked what preparations were made prior to the resident ' s discharge, the nurse stated she knew someone brought out portable oxygen for the resident ' s trip home and they were also going to deliver his home oxygen. When asked if the resident had received any training or education [MEDICAL CONDITION], the nurse reported, Anytime I worked with [MEDICAL CONDITION] tried to teach him. When asked if the resident ever did the [MEDICAL CONDITION] care himself, the nurse stated, Not really. A follow-up interview was conducted on 5/5/17 at 3:20 PM with the facility ' s Administrator. During the interview, an inquiry was made as to who was involved in the discharge process for Resident #9. The Administrator stated the facility had been between Social Workers, so he, the MDS nurse and the Activities Manager, shared the duties of the Social Worker while the position was vacant. He reported the discharge for Resident #9 was handled between himself, nursing, and possibly the Activities Manager. Upon inquiry, the Administrator stated he was not aware the facility was notified on 3/31/17 by the Home Health agency that Resident #9 was not accepted for home care. He reported he did not find this information out until Monday, 4/3/17. A telephone interview was conducted on 5/5/17 at 3:45 PM with the resident ' s physician at the facility. This physician also served as the facility ' s Medical Director. The physician recalled that when he saw the resident on 3/31/17, he expected the resident to receive Home Health services upon discharge. The physician stated that if he was not going to receive these services, he would have wanted to be informed. The MD stated, I certainly would not want this to happen again. A telephone interview was conducted on 5/6/17 at 9:25 AM with the resident ' s 2nd family member (Family Member #2) who provided transportation for the resident and had been in contact with his health care providers after he was discharged from the facility. Family Member #2 reported she began talking with the facility about the resident ' s discharge sometime in March. When asked who chose 4/1/17 as his discharge date , she stated, I guess they did. They told us they could get things in place for April 1st. The family member reported oxygen was delivered to the home where Resident #9 would be staying on 3/31/17 in preparation for his discharge. When she picked the resident up from the facility on 4/1/17 (between 10:00 AM - 12:00 PM), he had portable oxygen for the trip home. Family Member #2 stated the staff seemed a little surprised he was being discharged . The family member stated she signed a paper saying she was picking up the resident, and was given prescriptions for his medications. When asked if either she or the resident were given any instructions for home, she said, No. She recalled asking the nurse (Nurse #3) if the Home Health was set up, and was told they thought so and the Home Health nurse would be out to the house later that day. Family Member #2 stated she was not sure how often the Home Health nurse was going to be coming out, but expected to find out more when the nurse came to the house on 4/1/17. She stated her main concern was making sure the resident ' [MEDICAL CONDITION] cleaned, changed, and generally taken care of. Family Member #2 stated when she got the resident home to stay with Family Member #1, they couldn ' t get a nurse to come out. The resident told her he didn ' t know how [MEDICAL CONDITION] to be cleaned. Family Member #2 reported she called the facility two to three times on 4/1/17 to ask why the Home Health care people weren ' t coming to the home and she was told they would be coming. After waiting with the resident at his home for hours, Family Member #2 stated she went to her own home and called the Home Health agency herself. The Home Health agency told her nobody was coming. The family member stated she questioned that because he was already at home and stated, Had I known nobody was coming, I would not have taken him home. They said they didn ' t do patients with trachs and said they had told somebody at the facility they didn ' t do them. The family member stated she made an appointment with the resident ' s physician to see if they could help get someone out to take care of the trach, but they didn ' t check it either. She recalled sometime during the week a nurse from another Home Health agency came to the house, but she didn ' t touch [MEDICAL CONDITION] he didn ' t have anybody at home who was able to provide help with [MEDICAL CONDITION]. Family Member #2 reported she had talked with the facility ' s Administrator each day during the week Resident #9 was home. She was told the facility would take him back, but the resident did not want to go back. The family member stated, I was scared with nobody checking [MEDICAL CONDITION] it was already kinda messy. She reported bringing the resident back to the facility on that Thursday (4/6/17) and stated, It (the [MEDICAL CONDITION]) was smelling and everybody was standing back. It was a mess. The family member stated the facility sent him to the hospital ED after he arrived there. Resident #9 returned to the facility later that evening. A telephone interview was conducted 5/6/17 at 10:32 AM with Nurse #3. The nurse reported she worked at the facility on an as needed basis, ranging in frequency from twice a month to twice a week. Nurse #3 was identified as the nurse who worked the 1st shift on 4/1/17 when Resident #9 was discharged . The nurse recalled when Resident #9 ' s family member came to pick up the resident on the morning of 4/1/17. Nurse #3 reported she had not been told ahead of time that the resident was going to be discharged that morning. Nurse #3 recalled telling the resident and family member a Home Care agency would come out to the home. When asked what was sent home with the resident, the nurse reported she gave him prescriptions for his medications and 3 [MEDICAL CONDITION] kits from the facility. However, the family member said they would wait for the Home

Based on facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to retain the services of a qualified Social Worker on a full-time basis to assume responsibility for the coordination of discharge planning, including arranging Home Health assistance for the care of a resident ' s tracheostomy (a surgical opening in the neck that allows a curved tube to be inserted into the windpipe to open a restricted airway and enable breathing), resident and/or care provider training on tracheostomy care, and access to tracheostomy supplies. This occurred for 1 of 1 sampled resident (Resident #9) who was discharged home from the facility with a tracheostomy and resulted in a lack of tracheostomy care after discharge. The resident was subsequently diagnosed with [REDACTED]. Immediate jeopardy began on 4/1/17 when Resident #9 was discharged from the facility to his home. The resident had a tracheostomy and multiple co-morbidities (chronic conditions). The resident had not been accepted by a Home Health care agency to receive assistance with his tracheostomy care upon discharge, as he had expected. The resident did not have the training nor supplies to do the tracheostomy care on his own at home. He returned to the facility on [DATE] and was immediately sent to the hospital Emergency Department (ED) for an evaluation and treatment of [REDACTED]. He was released from the hospital ED and re-admitted to the facility on [DATE]. The immediate jeopardy was removed on 5/6/17 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The findings included: A review of the Resident #9 ' s medical records revealed he was hosptalized on [DATE] for acute on chronic respiratory failure and pneumonia. While in the hospital, the resident required intubation and a tracheostomy (also known as a trach). Resident #9 was discharged from the hospital to the facility on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had intact cognitive skills for daily decision making. He required extensive assistance for bed mobility, dressing, and toileting; limited assistance for transfers and personal hygiene; and, supervision from staff for locomotion on the unit. The resident was independent with eating. Section O of the MDS assessment indicated Resident #9 received Occupational Therapy (OT) and Physical Therapy (PT) services. It also reported he had a tracheostomy and received oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident and his family participated in the assessment process. The MDS reported his overall goal about returning to the community was unknown or uncertain; and, active discharge planning was not occurring for the resident to return to the community. Section Q of the MDS reported the resident did not want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. However, Section Q of the MDS also indicated the resident wanted to be asked about returning to the community on all subsequent assessments. A review of the resident ' s care plan included the following areas of focus: ---(Name of Resident) has a tracheostomy related to impaired breathing mechanics (Initiated 2/7/17; Revised on 2/7/17). The stated goal for this area of focus was for the resident to have no signs/symptoms of infection through the review date (Initiated on 2/7/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Ensure that the tracheostomy ties (the bands that go around the neck and hold the trach tube in place, also known as trach collars) are secured at all times (Initiated 2/7/17); --Observe/document respiratory rate, depth and quality. Check and document every shift or as ordered (Initiated 2/7/17); and, --Suction as necessary (Initiated 2/7/17). ---(Name of Resident) wishes to be discharged to home when able (Initiated on 3/8/17; Revised on 3/8/17). The stated goal for this area of focus was for the resident to be able to verbalize/communicate the assistance he would need post-discharge and the services required to meet his needs before discharge (Initiated on 3/8/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Establish a pre-discharge plan with the resident/family/caregivers, evaluate progress, and revise the plan as needed with the resident ' s need for assistance with his tracheostomy care and Activities of Daily Living (ADL) assistance (Initiated on 3/8/17; Revised on 3/8/17); and, --Evaluate the resident ' s motivation to return to the community (Initiated on 3/8/17). A review of the resident ' s medical record included Respiratory Therapist (RT) notes dated 2/7/17, 2/8/17, 2/14/17, 2/23/17, 3/14/17, and 3/21/17. One additional RT note was not dated. No notations were made on the RT notes to indicate the RT provided education/training for the resident on the care of his tracheostomy. A review of Resident #9 ' s therapy notes revealed a home visit was conducted on 3/27/17 by OT and PT in anticipation of his discharge from the facility. Recommendations made from the home visit included the need for a shower chair, hand held shower head, grab bar in the shower, and oxygen on an as needed (PRN) basis. The notes recommended follow up OT, PT, and Speech Therapy (ST) upon discharge. A review of the resident ' s current physician orders [REDACTED]. --Tracheostomy: Change tubing and equipment every night shift every Wednesday (Initiated 2/7/17); --Oxygen saturation (also known as an O2 Sat) to be checked every shift and notify the Medical Doctor (MD) if the O2 Sat is less than 88% (Initiated 2/7/17). An O2 Sat is a relative measure of the amount of oxygen carried in the blood. Normal blood oxygen levels are typically considered to be 95-100%; --Trach #6 Shiley long (referring to the inner diameter and length of the tracheostomy tube): Tracheostomy care to be completed every shift and as needed (Initiated 2/7/17); and, --Oxygen (O2) at 5 liters (referring to the oxygen flow rate per minute) every shift (Initiated 3/2/17). A review of the resident ' s medical record included a Respiratory Therapist (RT) note dated 3/31/17. The respiratory assessment note revealed Resident #9 was sitting up in the chair with a pleasant demeanor. Tracheostomy care was done and the RT noted there was no change in the stoma (surgical opening) site at that time. Resident #9 was noted to be scheduled for discharge to home on 4/1/17. There was no notation on the RT note to indicate the resident was trained on care of the tracheostomy. A review of the resident ' s medical record included a physician ' s note dated 3/31/17 at 12:51 PM. The physician noted Resident #9 was seen for a discharge summary. The notation read as follows, in part: (Name of Resident) is seen today in anticipation of his discharge from the facility this weekend. He was admitted to the (Name of Facility) on 2/8/17 after being hospitalized for [REDACTED]. Since his admission he has done well with rehabilitation and with trach care. For the past several weeks he has been seen ambulating around the facility without any SOB or imbalance and has not been requiring oxygen when walking . Plan: COPD: Diminished breath sounds and is high risk for re-hospitalization but is felt stable to go home. HH (Home Health) nursing, PT/OT. A review of Resident #9 ' s medical record revealed a Nursing Note dated 4/1/17 at 7:35 PM reported, in part: .Patient went home. A review of the Home Health agency notes dated 4/1/17 (not timed) included the following text: Call from (name of resident ' s Family Member #2) regarding waiting for (name of Home Health agency) to come out. Informed non-admitted due to trach. Spoke with (name of Home Health representative) who informed (name of Nurse #1) at (name of facility). Also spoke with (name of Home Health staff member), could not accept referral as it would take 2-3 weeks to set up PDN (private duty nurse). She informed marketing manager (name of manager). Tried to call (name of facility), but they would not provide any information and CM (Case Management) Department is closed until Monday. An email dated 4/3/17 at 4:16 PM was provided by the Home Health agency for review. The email was sent from the Home Health agency ' s Marketing Manager to both the Office Manager for Resident #9 ' s primary care physician and the facility ' s Administrator. The text of the email read: I have copied (name of facility ' s Administrator) on this email as well to keep everyone in the loop. I spoke with the other Home Health Agencies and even though (name of Resident #9 ' s insurance company) approved Home Health hours for this client he is not appropriate for Home Care. He is high risk for a hospitalization and his best place is back in (name of facility) where he can get the proper care he needs. The client wanted to go home and when (name of resident ' s physician at the facility) saw him last week he even stated he would end up back in the hospital. I talked with (name of representative for the oxygen supply company) and they only delivered Oxygen to the home and no Trach supplies-When you guys see this client tomorrow I would recommend sending him back to (name of the facility). I hate it for (resident ' s name) but his best place for the care he needs is at SNF (skilled nursing facility) level. (Name of facility ' s Administrator) will have his team prepare a bed to make a smooth transition just in case. A review of Resident #9 ' s paper medical record included documentation from a follow-up diabetic visit on 4/4/17 with an outside Internal Medicine service. Progress notes written by the Physician Assistant (PA) on 4/4/17 included the following notations, in part: .Recently hospitalized for [REDACTED]. discharged to SNF (name of facility). Patient was told he could be discharged over the weekend. He was released however has had difficulty getting home health to come out with trach supplies. (Name of Family Member #2) accompanies the patient today-she states he will not go back to (name of facility) because he doesn ' t want to. Patient has a history of noncompliance and refusing home health. He lives at home with his (name of Family Member #1). No fever or difficulty breathing since discharge. The PA ' s Impression/Plan from the 4/4/17 visit read: Do not think patient is appropriate for outpatient care. Discussed at length my concerns of not returning to a SNF for care given multiple comorbidities. Both he and his (name of Family Member #2) are adamant that patient will not be returning to (name of facility). (Name of another Home Health agency) will bring supplies out to patient. Patient is in agreement for close follow up-will return in 2 weeks for BP (blood pressure) check. Labs pending. A review of the hospital Emergency Department (ED) records from 4/6/17 revealed Resident #9 arrived to the ED at 2:48 PM via Emergency Medical Services (EMS). The ED history included the following comments: Patient presents today complaining of need for tracheostomy care. He was released from the (name of facility) on Saturday and has been home for the last 5 days. He is referred back to the (name of facility) today because of inability to care for himself in the home but upon return to the Center, they sent him here because he had foul discharge from his tracheostomy site. Patient is denying any other problems. He states that he does get confused to time so he is unclear as to exact dates when his last trach collar and trach was changed. The hospital ED records revealed upon examination, Resident #9 had [DIAGNOSES REDACTED]tous (redness) and superficial skin breakdown all around the trach collar site. The resident was diagnosed with [REDACTED]. The ED Respiratory Notes dated 4/6/17 at 3:57 PM read, trach was in place with trach collar-foul smell coming from trach area states last changed Saturday-collar wet with drainage-Respiratory at bedside will change out trach and replace trach collar . The resident was discharged from the ED to the facility on [DATE]. His discharge medication orders included 2% Bactroban (a topical antibiotic ointment) and 875-125 milligrams (mg) amoxicillin-clavulanate (an oral antibiotic) to be given as one tablet by mouth every 12 hours for 10 days. A review of the resident ' s electronic medical record dated 4/6/17 at 9:49 PM indicated the resident was readmitted to the facility. No distress was noted and he was assessed as being alert and oriented. A review of the resident ' s physician orders [REDACTED]. --Tracheostomy: Change tubing and equipment every night shift every Wednesday (Initiated 4/7/17); --Trach #6 Shiley long: Tracheostomy care to be completed every shift and as needed (Initiated 4/7/17); --Check O2 Sat every shift and notify MD if O2 Sat is less than 88% (Initiated 4/7/17); --Trach collar with 5 liters O2 per minute as needed during the day for O2 Sats less than 91% (Initiated 4/8/17); and, --Trach collar with 5 liters O2 per minute every evening and night shift (Initiated 4/8/17). A review of the resident ' s medical record included a Respiratory Therapist (RT) note dated 4/7/17. The respiratory assessment revealed Resident #9 ' s trach was changed on 4/6/17 at the hospital. The respiratory assessment noted the resident was readmitted on [DATE] after going to the ED for cellulitis around his trach. It read, in part: No trach care was done while he was at home. He is on ABT (antibiotic) and Bactroban to trach site. The resident ' s trach site was noted as red, sore, and bleeding easily. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. He was independent for all of his ADLs, with the exception of requiring supervision from staff for eating. Section O of the MDS assessment reported he received tracheostomy care and oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident participated in the assessment process and was expecting to remain in the facility. However, the MDS also revealed the resident did want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. An interview was conducted on 5/4/17 at 2:15 PM with the facility ' s Unit Manager and the Area Staff Development Coordinator (SDC). Upon inquiry, the Unit Manager and the SDC recalled Resident #9 came back into the facility on [DATE] sometime between 2:00-4:00 PM. The nurses reported Resident #9 was not expected and the facility did not have any admission orders [REDACTED]. The resident returned from the hospital later on that same date (4/6/17). When asked what time he returned, the nurses reviewed the medical record. The first note which indicated he had returned to the facility was made on 4/6/17 at 9:49 PM. An interview was conducted on 5/4/17 at 2:30 PM with the facility ' s Administrator. During the interview, the administrator reported Resident #9 ' s family knew ahead of time they wanted the resident to go home. The Administrator stated he himself arranged Home Health care well in advance of the resident ' s discharge on 4/1/17. Upon request, the Administrator provided contact information for the Home Health representative. The Administrator stated, Everybody knew what was happening. He reported on Friday night (3/31/17) around 6:00 PM, both he and Resident #9 met with an oxygen supply company when they brought his oxygen to take home and educated him on its use. The Administrator confirmed Resident #9 was discharged on Saturday, 4/1/17. As the interview continued on 5/4/17 at 2:30 PM, the Administrator reported Resident #9 ' s insurance company contacted him on Monday (4/3/17) and reported the resident ' s family was concerned he wasn ' t doing well at home with the tracheostomy. The Administrator spoke with the resident ' s family member (Family Member #2) by telephone on 4/3/17, 4/4/17, and 4/5/17. He told this family member that the facility would be happy to take the resident back. However, the resident had a physician appointment scheduled that week and the family planned to take him to it. On Thursday, 4/6/17, the Administrator reported he called the family member (Family Member #2) around 12:00 PM and was basically told they were on their way to bring the resident back to the facility. When the resident arrived, the Administrator stated he could smell the trach collar and wanted to get it evaluated. The facility called 911 and the hospital ED to tell them the resident was being sent over. The Administrator reported the resident was seen in the ED and returned to the facility around 8:00 -9:00 PM the evening of 4/6/17. A telephone interview was conducted on 5/4/17 at 4:35 PM with the Marketing Manager for the Home Health agency who had received a referral from the Administrator for Resident #9 ' s home care. During the interview, the resident ' s discharge arrangements for 4/1/17 were discussed. As the Marketing Manager reviewed the resident ' s Home Health record, she reported the agency was given the Home Care referral on 3/28/17. The Manager explained their Home Health agency was divided into two sections: the Hourly care side (which did work with tracheostomies) and the Home Health care side (which did not work with trachs). On 3/31/17, the agency learned the resident did not have insurance coverage for the Hourly care; and the Home Health care side did not do trach care. The Home Health office contacted the Marketing Manager on 3/31/17. On 3/31/17, the Marketing Manager telephoned the facility and informed Nurse #1 their Home Health agency couldn ' t take this resident. She also reported her agency contacted two other Home Health agencies, but Resident #9 was not accepted by either of them. With the discharge still planned for 4/1/17, the Marketing Manager stated she coordinated a delivery of oxygen to the facility on Friday night (3/31/17) so the resident would have it when he went home. On Monday (4/3/17), she went to the facility for follow-up because she was concerned about an unsafe discharge if the resident actually went home over the weekend. The Marketing Manager stated she also wanted to make sure the facility had a bed for the resident if he decided to come back. The Marketing Manager reported she talked with the Office Manager for Resident #9 ' s primary care physician on 4/3/17, then followed up with an email to both the Office Manager and the facility ' s Administrator to be sure everyone had the information. An interview was conducted on 5/5/17 at 8:00 AM with Resident #9. During the interview, the resident recalled he and the Administrator met with someone on Friday night (3/31/17) to get his oxygen arranged for discharge. When the resident was asked what was arranged for him prior to discharge, he reported that in addition to the oxygen he had a shower chair, a shower bar, and a railing for the commode at home that his family had purchased. He stated the shower bar and railing for the commode had not yet been installed by his landlord when he arrived home on 4/1/17. Upon further inquiry, the resident stated someone on the phone had told him he would get 24-hour nursing care when he got home. He reported he did not know how to do his own trach care and did not receive any trach supplies to use at home. He reported he expected a Home Health nurse to come out to his home to take care of his tracheostomy, but no one did. A telephone interview was conducted on 5/5/17 at 10:48 AM with the Respiratory Therapist (RT) who worked with Resident #9. The RT reported she worked for a contracted company and came to the facility on ce a week to provide tracheostomy care for the resident. Prior to his 4/1/17 discharge, the RT noted Resident #9 had issues with his skin under the tracheostomy due to a small amount of drainage and having some trouble keeping the skin dry. She reported the skin looked a little irritated and was a little sore when cleaned. The RT stated she was hoping the Home Health nurse would continue to follow this issue under his tracheostomy collar. When asked what kind of trach care the resident required, the RT stated he received routine trach care once every shift (3 times a day) while in the facility, but may have been able to do the trach care twice daily upon discharge. She reported routine tracheostomy care involved cleaning the area behind the flange (the area where the ties or sutures are connected to secure the tube in place) and making sure there were no secretions; changing the trach ties and cannula (the body of the tube that is inserted into the trachea), and replacing the drain sponge underneath. The RT stated she was under the impression the resident and a family member would do some of his trach care, with the Home Health nurse going out a few times a week to make sure it was done appropriately. Without reviewing her notes, the RT did not recall if she had done tracheostomy care training with the resident, but was certain she did not train a family member on the trach care. The RT stated if she had done trach care teaching with the resident, she would have included a notation documenting this in her Respiratory Notes. The RT stated if the resident was trained, he may be able to do the procedure for the trach care. However, she was unsure if he would reliably do the care twice daily every day. When asked if she had understood this resident would be going home with Home Health, she stated, Absolutely. Upon further inquiry, the RT reported having a suction machine would usually be a standard for anyone going home with a tracheostomy. When asked what her thoughts were regarding the resident going home without a suction machine, the RT reported that although she didn ' t think he ' d have a big problem, she stated, You never know. The RT stated she saw the resident the day after he was readmitted to the facility on [DATE]. She recalled he had been put on an antibiotic for neck cellulitis and reported the condition of the skin had improved significantly over the last few weeks. An interview was conducted on 5/5/17 at 12:24 PM with Nurse #2. Nurse #2 worked as a 3rd shift nurse assigned to care for Resident #9. When asked if she had done any tracheostomy care teaching with the resident, Nurse #2 reported since she worked on the 3rd shift, she would typically talk him through it. The nurse stated the resident never did a return demonstration for her. Nurse #2 stated, I do know when he left the facility he was not doing his own trach care. A follow-up interview was conducted on 5/5/17 at 12:52 PM with Resident #9. A family member (Family Member #1) was visiting the resident at that time. During the interview, the resident stated he lived with Family Member #1 after he was discharged from the facility. When the resident and his family member were asked what trach care was done during the time he was home, the resident stated, nothing. The resident acknowledged he was shown how to use his oxygen equipment, but reiterated he was not shown how to do the trach care for himself. When Family Member #1 was asked if she was trained to provide trach care for the resident, both the resident and family member responded by saying, No. The resident consented to have a second family member interviewed by telephone (Family Member #2). He reported the second family member provided his transportation and had been in contact with his health care providers. A follow-up interview was conducted on 5/5/17 at 1:21 PM with the facility ' s Unit Manager. Upon inquiry, the Unit Manager reported that to her knowledge, the resident did not do any of his own trach care during his stay at the facility. The Unit Manager reported she was at the facility when the resident presented on 4/6/17 with foul smelling drainage from his tracheostomy. The Unit Manager stated she did not assess the tracheostomy and could not tell what color the drainage was. A telephone interview was conducted on 5/5/17 at 1:24 PM with Nurse #1. Nurse #1 was identified as the nurse who received a phone call from the Home Health agency on 3/31/17, informing the facility Resident #9 was not admitted to Home Health due to having a tracheostomy. When asked about this phone call, the nurse stated, I believe they did speak with me .the Administrator was involved. Someone called .the supply company maybe .and the Administrator was going to call and confirm with (name of the Marketing Manager) everything was in place. When asked what preparations were made prior to the resident ' s discharge, the nurse stated she knew someone brought out portable oxygen for the resident ' s trip home and they were also going to deliver his home oxygen. When asked if the resident had received any training or education on trach care, the nurse reported, Anytime I worked with his trach I tried to teach him. When asked if the resident ever did the tracheostomy care himself, the nurse stated, Not really. An interview was conducted on 5/5/17 at 2:54 PM with the facility ' s Social Worker (SW). Upon inquiry, the SW stated she started her position on 3/30/17 and first recalled Resident #9 when he returned to the facility on [DATE]. During the interview, the SW discussed the facility ' s discharge process. She reported her role as the SW was to contact the Home Health agency and provide them with information needed on the resident. From there, a date would be set for the Home Health agency to meet with the resident at their home (usually the day after discharge from the facility). The SW reported the facility typically recommended PT, OT, and ST for residents upon discharge, which allowed the Home Health care agency to do their own assessments on each and determine any services needed. The SW reported the residents ' discharge paperwork was kept separate from his/her medical record. When asked what the discharge paper work included, the SW reported both a Post-Discharge Plan of Care and an Interdisciplinary Discharge Summary needed to be completed prior to a resident ' s discharge from the facility. A follow-up interview was conducted on 5/5/17 at 3:20 PM with the facility ' s Administrator. During the interview, an inquiry was made as to who was involved in the discharge process for Resident #9. The Administrator stated the facility had been between Social Workers, so he, the MDS nurse and the Activities Manager, shared the duties of the Social Worker while the position was vacant. He reported the discharge for Resident #9 was handled between himself, nursing, and possibly the Activities Manager. Upon inquiry, the Administrator stated he was not aware the facility was notified on 3/31/17 by the Home Health agency that Resident #9 was not accepted for home care. He reported he did not find this information out until Monday, 4/3/17. When asked where the discharge planning paper work was kept for Resident #9, the Administrator stated he did not know but would ask the Activities Manager. A request was made to review the discharge paper work for Resident #9. A telephone interview was conducted on 5/5/17 at 3:45 PM with the resident ' s physician at the facility. This physician also served as the facility ' s Medical Director. The physician recalled that when he saw the resident on 3/31/17, he expected the resident to receive Home Health services upon discharge. The physician stated that if he was not going to receive these services, he would have wanted to be informed. The MD stated, I certainly would not want this to happen again. A follow-up interview was conducted on 5/5/17 at 3:55 PM with the Administrator. During the interview, the Administrator reported no discharge papers had been completed for Resident #9 ' s discharge on 4/1/17. When asked, the Administrator stated he had a degree in Health Care Management. He reported between mid-January and 3/30/17, no one who worked at the facility had a degree in Social Work. A telephone interview was conducted on 5/6/17 at 9:25 AM with the resident ' s 2nd family member (Family Member #2) who provided transportation for the resident and had been in contact with his health care providers after he was discharged from the facility. Family Member #2 reported she began talking with the facility about the resident ' s discharge sometime in March. When asked who chose 4/1/17 as his discharge date , she stated, I guess they did. They told us they could get things in place for April 1st. The family member reported oxygen was delivered to the home where Resident #9 would be staying on 3/31/17 in preparation for his discharge. When she picked the resident up from the facility on 4/1/17 (between 10:00 AM - 12:00 PM), he had portable oxygen for the trip home. Family Member #2 stated the staff seemed a little surprised he was being discharged . The family member stated she signed a paper saying she was picking up the resident, and was given prescriptions for his medications. When asked if either she or the resident were given any instructions for home, she said, No. She recalled asking the nurse (Nurse #3) if the Home Health was set up, and was told they thought so and the Home Health nurse would be out to the house later that day. Family Member #2 stated she was not sure how often the Home Health nurse was going to be coming out, but expected to find out more when the nurse came to the house on 4/1/17. She stated her main concern was making sure the resident ' s trach was cleaned, changed, and generally taken care of. Family Member #2 stated when she got the resident home to stay with Family Member #1, they couldn ' t get a nurse to come out. The resident told her he didn ' t know how the trach had to be cleaned. Family Member #2 reported she called the facility two to three times on 4/1/17 to ask why the Home Health care people weren ' t coming to the home and she was told they would be coming. After waiting with the resident at his home for hours, Family Member #2 stated she went to her own home and called the Home Health agency herself. The Home Health agency told her nobody was coming. The family member stated she questioned that because he was already at home and stated, Had I known nobody was coming, I would not have taken him home. They said they didn ' t do patients with trachs and said they had told somebody at the facility they didn ' t do them. The family member stated she made an appointment with the resident ' s physician to see if they could help get someone out to take care of the trach, but they didn ' t check it either. She recalled sometime during the week a nurse from another Home Health agency came to the house, but she didn ' t touch the trach because he didn ' t have anybody at home who was able to provide help with the trach care. Family Member #2 reported she had talked with the facility

Based on facility staff, Home Health Care staff, physician, resident and family interviews, and facility and hospital medical record reviews, the facility failed to implement an effective discharge planning process to identify and address the discharge needs for 1 of 1 sampled resident (Resident #9) who was discharged home with a [MEDICAL CONDITION] (a surgical opening in the neck that allows a curved tube to be inserted into the windpipe to open a restricted airway and enable breathing). Resident #9 was discharged without Home Health care assistance, resident and/or care provider training on [MEDICAL CONDITION] care, or access to [MEDICAL CONDITION] supplies, which resulted in a lack of [MEDICAL CONDITION] care after discharge. Five days after his discharge from the facility, the resident was diagnosed with [REDACTED]. Immediate jeopardy began on 4/1/17 when Resident #9 was discharged from the facility to his home. The resident had a [MEDICAL CONDITION] and multiple co-morbidities (chronic conditions). The resident had not been accepted by a Home Health care agency to receive assistance with his [MEDICAL CONDITION] care upon discharge, as he had expected. The resident did not have the training nor supplies to do the [MEDICAL CONDITION] care on his own at home. He returned to the facility on [DATE] and was immediately sent to the hospital Emergency Department (ED) for an evaluation and treatment of [REDACTED]. The resident was released from the hospital ED and re-admitted to the facility on [DATE]. The immediate jeopardy was removed on 5/6/17 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put into place are effective. The findings included: A review of the Resident #9 ' s medical records revealed he was hosptalized on [DATE] for acute on chronic [MEDICAL CONDITION] and pneumonia. While in the hospital, the resident required intubation and a [MEDICAL CONDITION] (also known as a trach). Resident #9 was discharged from the hospital to the facility on [DATE]. His cumulative [DIAGNOSES REDACTED]. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had intact cognitive skills for daily decision making. He required extensive assistance for bed mobility, dressing, and toileting; limited assistance for transfers and personal hygiene; and, supervision from staff for locomotion on the unit. The resident was independent with eating. Section O of the MDS assessment indicated Resident #9 received Occupational Therapy (OT) and Physical Therapy (PT) services. It also reported he had a [MEDICAL CONDITION] and received oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident and his family participated in the assessment process. The MDS reported his overall goal about returning to the community was unknown or uncertain; and, active discharge planning was not occurring for the resident to return to the community. Section Q of the MDS reported the resident did not want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. However, Section Q of the MDS also indicated the resident wanted to be asked about returning to the community on all subsequent MDS assessments. A review of the resident ' s care plan included the following areas of focus: ---(Name of Resident) has a [MEDICAL CONDITION] related to impaired breathing mechanics (Initiated 2/7/17; Revised on 2/7/17). The stated goal for this area of focus was for the resident to have no signs/symptoms of infection through the review date (Initiated on 2/7/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Ensure that the [MEDICAL CONDITION] ties (the bands that go around the neck and hold [MEDICAL CONDITION] in place, also known [MEDICAL CONDITION]) are secured at all times (Initiated 2/7/17); --Observe/document respiratory rate, depth and quality. Check and document every shift or as ordered (Initiated 2/7/17); and, --Suction as necessary (Initiated 2/7/17). ---(Name of Resident) wishes to be discharged to home when able (Initiated on 3/8/17; Revised on 3/8/17). The stated goal for this area of focus was for the resident to be able to verbalize/communicate the assistance he would need post-discharge and the services required to meet his needs before discharge (Initiated on 3/8/17; Revised on 3/16/17). The interventions outlined to meet this goal included: --Establish a pre-discharge plan with the resident/family/caregivers, evaluate progress, and revise the plan as needed with the resident ' s need for assistance with his [MEDICAL CONDITION] care and Activities of Daily Living (ADL) assistance (Initiated on 3/8/17; Revised on 3/8/17); and, --Evaluate the resident ' s motivation to return to the community (Initiated on 3/8/17). A review of the resident ' s medical record included Respiratory Therapist (RT) notes dated 2/7/17, 2/8/17, 2/14/17, 2/23/17, 3/14/17, and 3/21/17. One additional RT note was not dated. No notations were made to indicate the RT provided education/training for the resident on the care of his [MEDICAL CONDITION]. A review of Resident #9 ' s therapy notes revealed a home visit was conducted on 3/27/17 by OT and PT in anticipation of his discharge from the facility. Recommendations made from the home visit included the need for a shower chair, hand held shower head, grab bar in the shower, and oxygen on an as needed (PRN) basis. The notes recommended follow up OT, PT, and Speech Therapy (ST) upon discharge. A review of the resident ' s current physician orders [REDACTED]. --[MEDICAL CONDITION]: Change tubing and equipment every night shift every Wednesday (Initiated 2/7/17); --Oxygen saturation (also known as an O2 Sat) to be checked every shift and notify the Medical Doctor (MD) if the O2 Sat is less than 88% (Initiated 2/7/17). An O2 Sat is a relative measure of the amount of oxygen carried in the blood. Normal blood oxygen levels are typically considered to be 95-100%; --Trach #6 Shiley long (referring to the inner diameter and length of the [MEDICAL CONDITION]): [MEDICAL CONDITION] care to be completed every shift and as needed (Initiated 2/7/17); and, --Oxygen (O2) at 5 liters (referring to the oxygen flow rate per minute) every shift (Initiated 3/2/17). A review of the resident ' s medical record included an additional Respiratory Therapist (RT) note dated 3/31/17. The respiratory assessment note revealed Resident #9 was sitting up in the chair with a pleasant demeanor. [MEDICAL CONDITION] care was done and the RT noted there was no change in the stoma (surgical opening) site at that time. Resident #9 was noted to be scheduled for discharge to home on 4/1/17. There was no notation on the RT note to indicate the resident was trained on care of his [MEDICAL CONDITION]. A review of the resident ' s medical record included a physician ' s note dated 3/31/17 at 12:51 PM. The physician noted Resident #9 was seen for a discharge summary. The notation read as follows, in part: (Name of Resident) is seen today in anticipation of his discharge from the facility this weekend. He was admitted to the (Name of Facility) on 2/8/17 after being hospitalized for [REDACTED]. Since his admission he has done well with rehabilitation and [MEDICAL CONDITION]. For the past several weeks he has been seen ambulating around the facility without any SOB or imbalance and has not been requiring oxygen when walking . Plan: [MEDICAL CONDITION]: Diminished breath sounds and is high risk for re-hospitalization but is felt stable to go home. HH (Home Health) nursing, PT/OT. A review of Resident #9 ' s medical record revealed a Nursing Note dated 4/1/17 at 7:35 PM reported, in part: .Patient went home. A review of the Home Health agency notes dated 4/1/17 (not timed) included the following text: Call from (name of resident ' s Family Member #2) regarding waiting for (name of Home Health agency) to come out. Informed non-admitted due to trach. Spoke with (name of Home Health representative) who informed (name of Nurse #1) at (name of facility). Also spoke with (name of Home Health staff member), could not accept referral as it would take 2-3 weeks to set up PDN (private duty nurse). She informed marketing manager (name of manager). Tried to call (name of facility), but they would not provide any information and CM (Case Management) Department is closed until Monday. An email dated 4/3/17 at 4:16 PM was provided by the Home Health agency for review. The email was sent from the Home Health agency ' s Marketing Manager to both the Office Manager for Resident #9 ' s primary care physician and the facility ' s Administrator. The text of the email read: I have copied (name of facility ' s Administrator) on this email as well to keep everyone in the loop. I spoke with the other Home Health Agencies and even though (name of Resident #9 ' s insurance company) approved Home Health hours for this client he is not appropriate for Home Care. He is high risk for a hospitalization and his best place is back in (name of facility) where he can get the proper care he needs. The client wanted to go home and when (name of resident ' s physician at the facility) saw him last week he even stated he would end up back in the hospital. I talked with (name of representative for the oxygen supply company) and they only delivered Oxygen to the home and [MEDICAL CONDITION]-When you guys see this client tomorrow I would recommend sending him back to (name of the facility). I hate it for (resident ' s name) but his best place for the care he needs is at SNF (skilled nursing facility) level. (Name of facility ' s Administrator) will have his team prepare a bed to make a smooth transition just in case. A review of Resident #9 ' s paper medical record included documentation from a follow-up diabetic visit on 4/4/17 with an outside Internal Medicine service. Progress notes written by the Physician Assistant (PA) on 4/4/17 included the following notations, in part: .Recently hospitalized for [REDACTED]. discharged to SNF (name of facility). Patient was told he could be discharged over the weekend. He was released however has had difficulty getting home health to come out [MEDICAL CONDITION]. (Name of Family Member #2) accompanies the patient today-she states he will not go back to (name of facility) because he doesn ' t want to. Patient has a history of noncompliance and refusing home health. He lives at home with his (name of Family Member #1). No fever or difficulty breathing since discharge. The PA ' s Impression/Plan from the 4/4/17 visit read: Do not think patient is appropriate for outpatient care. Discussed at length my concerns of not returning to a SNF for care given multiple comorbidities. Both he and his (name of Family Member #2) are adamant that patient will not be returning to (name of facility). (Name of another Home Health agency) will bring supplies out to patient. Patient is in agreement for close follow up-will return in 2 weeks for BP (blood pressure) check. Labs pending. A review of the hospital Emergency Department (ED) records from 4/6/17 revealed Resident #9 arrived to the ED at 2:48 PM via Emergency Medical Services (EMS). The ED history included the following comments: Patient presents today complaining of need for [MEDICAL CONDITION] care. He was released from the (name of facility) on Saturday and has been home for the last 5 days. He is referred back to the (name of facility) today because of inability to care for himself in the home but upon return to the Center, they sent him here because he had foul discharge from his [MEDICAL CONDITION] site. Patient is denying any other problems. He states that he does get confused to time so he is unclear as to exact dates when his [MEDICAL CONDITIONS] changed. The hospital ED records revealed upon examination, Resident #9 had [DIAGNOSES REDACTED]tous (redness) and superficial skin breakdown all around [MEDICAL CONDITION] site. The resident was diagnosed with [REDACTED]. The ED Respiratory Notes dated 4/6/17 at 3:57 PM read, trach was in place [MEDICAL CONDITION]-foul smell coming [MEDICAL CONDITION] states last changed Saturday-collar wet with drainage-Respiratory at bedside will change [MEDICAL CONDITIONS] . The resident was discharged from the ED to the facility on [DATE]. His discharge medication orders included 2% [MEDICATION NAME] (a topical antibiotic ointment) and 875-125 milligrams (mg) [MEDICATION NAME]-clavulanate (an oral antibiotic) to be given as one tablet by mouth every 12 hours for 10 days. A review of the resident ' s electronic medical record dated 4/6/17 at 9:49 PM indicated the resident was readmitted to the facility. No distress was noted and he was assessed as being alert and oriented. A review of the resident ' s physician orders [REDACTED]. --[MEDICAL CONDITION]: Change tubing and equipment every night shift every Wednesday (Initiated 4/7/17); --Trach #6 Shiley long: [MEDICAL CONDITION] care to be completed every shift and as needed (Initiated 4/7/17); --Check O2 Sat every shift and notify MD if O2 Sat is less than 88% (Initiated 4/7/17); --Trach collar with 5 liters O2 per minute as needed during the day for O2 Sats less than 91% (Initiated 4/8/17); and, --Trach collar with 5 liters O2 per minute every evening and night shift (Initiated 4/8/17). A review of the resident ' s medical record included a Respiratory Therapist (RT) note dated 4/7/17. The respiratory assessment revealed Resident #9 ' [MEDICAL CONDITION] changed on 4/6/17 at the hospital. The respiratory assessment noted the resident was readmitted on [DATE] after going to the ED for [MEDICAL CONDITION] around his trach. It read, in part: [MEDICAL CONDITION] was done while he was at home. He is on ABT (antibiotic) and [MEDICATION NAME]. The resident ' [MEDICAL CONDITION] was noted as red, sore, and bleeding easily. A review of Resident #9 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. He was independent for all of his ADLs, with the exception of requiring supervision from staff for eating. Section O of the MDS assessment reported he received [MEDICAL CONDITION] care and oxygen therapy while he was a resident. Section Q of the MDS assessment revealed the resident participated in the assessment process and was expecting to remain in the facility. However, the MDS also revealed the resident did want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community at the time of the assessment. An interview was conducted on 5/4/17 at 2:15 PM with the facility ' s Unit Manager and the Area Staff Development Coordinator (SDC). Upon inquiry, the Unit Manager and the SDC recalled Resident #9 came back into the facility on [DATE] sometime between 2:00-4:00 PM. The nurses reported Resident #9 was not expected and the facility did not have any admission orders [REDACTED]. The resident returned from the hospital later on that same date (4/6/17). When asked what time he returned, the nurses reviewed the medical record. The first note which indicated he had returned to the facility was made on 4/6/17 at 9:49 PM. An interview was conducted on 5/4/17 at 2:30 PM with the facility ' s Administrator. During the interview, the administrator reported Resident #9 ' s family knew ahead of time they wanted the resident to go home. The Administrator stated he himself arranged Home Health care well in advance of the resident ' s discharge on 4/1/17. Upon request, the Administrator provided contact information for the Home Health representative. The Administrator stated, Everybody knew what was happening. He reported on Friday night (3/31/17) around 6:00 PM, both he and Resident #9 met with an oxygen supply company when they brought his oxygen to take home and educated him on its use. The Administrator confirmed Resident #9 was discharged on Saturday, 4/1/17. As the interview continued on 5/4/17 at 2:30 PM, the Administrator reported Resident #9 ' s insurance company contacted him on Monday (4/3/17) and reported the resident ' s family was concerned he wasn ' t doing well at home with the [MEDICAL CONDITION]. The Administrator spoke with the resident ' s family member (Family Member #2) by telephone on 4/3/17, 4/4/17, and 4/5/17. He told this family member that the facility would be happy to take the resident back. However, the resident had a physician appointment scheduled that week and the family planned to take him to it. On Thursday, 4/6/17, the Administrator reported he called the family member (Family Member #2) around 12:00 PM and was basically told they were on their way to bring the resident back to the facility. When the resident arrived, the Administrator stated he could smell [MEDICAL CONDITION] and wanted to get it evaluated. The facility called 911 and the hospital ED to tell them the resident was being sent over. The Administrator reported the resident was seen in the ED and returned to the facility around 8:00 -9:00 PM the evening of 4/6/17. A telephone interview was conducted on 5/4/17 at 4:35 PM with a Marketing Manager for the Home Health agency who had received a referral from the Administrator for Resident #9 ' s home care. During the interview, the resident ' s discharge arrangements for 4/1/17 were discussed. As the Marketing Manager reviewed the resident ' s Home Health record, she reported the agency was given the Home Care referral on 3/28/17. The Manager explained their Home Health agency was divided into two sections: the Hourly care side (which did work with tracheostomies) and the Home Health care side (which did not work with trachs). On 3/31/17, the agency learned the resident did not have insurance coverage for the Hourly care; and the Home Health care side did not [MEDICAL CONDITION]. The Home Health office contacted the Marketing Manager on 3/31/17. On 3/31/17, the Marketing Manager telephoned the facility and informed Nurse #1 their Home Health agency couldn ' t take this resident. She also reported her agency contacted two other Home Health agencies, but Resident #9 was not accepted by either of them. With the discharge still planned for 4/1/17, the Marketing Manager stated she coordinated a delivery of oxygen to the facility on Friday night (3/31/17) so the resident would have it when he went home. On Monday (4/3/17), she went to the facility for follow-up because she was concerned about an unsafe discharge if the resident actually went home over the weekend. The Marketing Manager stated she also wanted to make sure the facility had a bed for the resident if he decided to come back. The Marketing Manager reported she talked with the Office Manager for Resident #9 ' s primary care physician on 4/3/17, then followed up with an email to both the Office Manager and the facility ' s Administrator to be sure everyone had the information. An interview was conducted on 5/5/17 at 8:00 AM with Resident #9. During the interview, the resident recalled he and the Administrator met with someone on Friday night (3/31/17) to get his oxygen arranged for discharge. When the resident was asked what was arranged for him prior to discharge, he reported that in addition to the oxygen he had a shower chair, a shower bar, and a railing for the commode at home that his family had purchased. He stated the shower bar and railing for the commode had not yet been installed by his landlord when he arrived home on 4/1/17. Upon further inquiry, the resident stated someone on the phone had told him he would get 24-hour nursing care when he got home. He reported he did not know how to do his [MEDICAL CONDITION] and did not receive [MEDICAL CONDITION] to use at home. He reported he expected a Home Health nurse to come out to his home to take care of his [MEDICAL CONDITION], but no one did. A telephone interview was conducted on 5/5/17 at 10:48 AM with the Respiratory Therapist (RT) who worked with Resident #9. The RT reported she worked for a contracted company and came to the facility on ce a week to provide [MEDICAL CONDITION] care for the resident. Prior to his 4/1/17 discharge, the RT noted Resident #9 had issues with his skin under the [MEDICAL CONDITION] due to a small amount of drainage and having some trouble keeping the skin dry. She reported the skin looked a little irritated and was a little sore when cleaned. The RT stated she was hoping the Home Health nurse would continue to follow this issue under his [MEDICAL CONDITION] collar. When asked what kind [MEDICAL CONDITION] the resident required, the RT stated he received [MEDICAL CONDITION] once every shift (3 times a day) while in the facility, but may have been able to do [MEDICAL CONDITION] twice daily upon discharge. She reported routine [MEDICAL CONDITION] care involved cleaning the area behind the flange (the area where the ties or sutures are connected to secure the tube in place) and making sure there were no secretions; changing [MEDICAL CONDITION] and cannula (the body of the tube that is inserted into the trachea), and replacing the drain sponge underneath. The RT stated she was under the impression the resident and a family member would do some of [MEDICAL CONDITION], with the Home Health nurse going out a few times a week to make sure it was done appropriately. Without reviewing her notes, the RT did not recall if she had done [MEDICAL CONDITION] care training with the resident, but was certain she did not train a family member on [MEDICAL CONDITION]. The RT stated if she had [MEDICAL CONDITION] teaching with the resident, she would have included a notation documenting this in her Respiratory Notes. The RT stated if the resident was trained, he may be able to do the procedure for [MEDICAL CONDITION]. However, she was unsure if he would reliably do the care twice daily every day. When asked if she had understood this resident would be going home with Home Health, she stated, Absolutely. Upon further inquiry, the RT reported having a suction machine would usually be a standard for anyone going home with a [MEDICAL CONDITION]. When asked what her thoughts were regarding the resident going home without a suction machine, the RT reported that although she didn ' t think he ' d have a big problem, she stated, You never know. The RT stated she saw the resident the day after he was readmitted to the facility on [DATE]. She recalled he had been put on an antibiotic for neck [MEDICAL CONDITION] and reported the condition of the skin had improved significantly over the last few weeks. An interview was conducted on 5/5/17 at 12:24 PM with Nurse #2. Nurse #2 worked as a 3rd shift nurse assigned to care for Resident #9. When asked if she had done any [MEDICAL CONDITION] care teaching with the resident, Nurse #2 reported since she worked on the 3rd shift, she would typically talk him through it. The nurse stated the resident never did a return demonstration for her. Nurse #2 stated, I do know when he left the facility he was not doing his [MEDICAL CONDITION]. A follow-up interview was conducted on 5/5/17 at 12:52 PM with Resident #9. A family member (Family Member #1) was visiting the resident at that time. During the interview, the resident stated he lived with Family Member #1 after he was discharged from the facility. When the resident and his family member were asked [MEDICAL CONDITION] was done during the time he was home, the resident stated, nothing. The resident acknowledged he was shown how to use his oxygen equipment, but reiterated he was not shown how to do [MEDICAL CONDITION] for himself. When Family Member #1 was asked if she was trained to [MEDICAL CONDITION] for the resident, both the resident and family member responded by saying, No. The resident consented to have a second family member interviewed by telephone (Family Member #2). He reported the second family member provided his transportation and had been in contact with his health care providers. A follow-up interview was conducted on 5/5/17 at 1:21 PM with the facility ' s Unit Manager. Upon inquiry, the Unit Manager reported that to her knowledge, the resident did not do any of his [MEDICAL CONDITION] during his stay at the facility. The Unit Manager reported she was at the facility when the resident presented on 4/6/17 with foul smelling drainage from his [MEDICAL CONDITION]. The Unit Manager stated she did not assess the [MEDICAL CONDITION] and could not tell what color the drainage was. She reported two nurses who may have assessed the drainage prior to sending the resident out to the hospital no longer worked at the facility. A telephone interview was conducted on 5/5/17 at 1:24 PM with Nurse #1. Nurse #1 was identified as the nurse who received a phone call from the Home Health agency on 3/31/17, informing the facility Resident #9 was not admitted to Home Health due to having a [MEDICAL CONDITION]. When asked about this phone call, the nurse stated, I believe they did speak with me .the Administrator was involved. Someone called .the supply company maybe .and the Administrator was going to call and confirm with (name of the Marketing Manager) everything was in place. When asked what preparations were made prior to the resident ' s discharge, the nurse stated she knew someone brought out portable oxygen for the resident ' s trip home and they were also going to deliver his home oxygen. When asked if the resident had received any training or education [MEDICAL CONDITION], the nurse reported, Anytime I worked with [MEDICAL CONDITION] tried to teach him. When asked if the resident ever did the [MEDICAL CONDITION] care himself, the nurse stated, Not really. An interview was conducted on 5/5/17 at 2:54 PM with the facility ' s Social Worker (SW). Upon inquiry, the SW stated she started her position on 3/30/17. During the interview, the SW discussed the facility ' s discharge process. She reported her role as the SW was to contact the Home Health agency and provide them with information needed on the resident. From there, a date would be set for the Home Health agency to meet with the resident at their home (usually the day after discharge from the facility). The SW reported the facility typically recommended PT, OT, and ST for residents upon discharge, which allowed the Home Health care agency to do their own assessments on each and determine any services needed. The SW reported the residents ' discharge paperwork was kept separate from his/her medical record. When asked what the discharge paper work included, the SW reported both a Post-Discharge Plan of Care and an Interdisciplinary Discharge Summary needed to be completed prior to a resident ' s discharge from the facility. A follow-up interview was conducted on 5/5/17 at 3:20 PM with the facility ' s Administrator. During the interview, an inquiry was made as to who was involved in the discharge process for Resident #9. He reported the discharge for Resident #9 was handled between himself, nursing, and possibly the Activities Manager. Upon inquiry, the Administrator stated he was not aware the facility was notified on 3/31/17 by the Home Health agency that Resident #9 was not accepted for home care. He reported he did not find this information out until Monday, 4/3/17. When asked where the discharge planning paper work was kept for Resident #9, the Administrator stated he did not know but would ask the Activities Manager. A request was made to review the discharge paper work for Resident #9. A telephone interview was conducted on 5/5/17 at 3:45 PM with the resident ' s physician at the facility. This physician also served as the facility ' s Medical Director. The physician recalled that when he saw the resident on 3/31/17, he expected the resident to receive Home Health services upon discharge. The physician stated that if he was not going to receive these services, he would have wanted to be informed. The MD stated, I certainly would not want this to happen again. A follow-up interview was conducted on 5/5/17 at 3:55 PM with the Administrator. During the interview, the Administrator reported no discharge papers had been completed for Resident #9 ' s discharge on 4/1/17. A telephone interview was conducted on 5/6/17 at 9:25 AM with the resident ' s 2nd family member (Family Member #2) who provided transportation for the resident and had been in contact with his health care providers after he was discharged from the facility. Family Member #2 reported she began talking with the facility about the resident ' s discharge sometime in March. When asked who chose 4/1/17 as his discharge date , she stated, I guess they did. They told us they could get things in place for April 1st. The family member reported oxygen was delivered to the home where Resident #9 would be staying on 3/31/17 in preparation for his discharge. When she picked the resident up from the facility on 4/1/17 (between 10:00 AM - 12:00 PM), he had portable oxygen for the trip home. Family Member #2 stated the staff seemed a little surprised he was being discharged . The family member stated she signed a paper saying she was picking up the resident, and was given prescriptions for his medications. When asked if either she or the resident were given any instructions for home, she said, No. She recalled asking the nurse (Nurse #3) if the Home Health was set up, and was told they thought so and the Home Health nurse would be out to the house later that day. Family Member #2 stated she was not sure how often the Home Health nurse was going to be coming out, but expected to find out more when the nurse came to the house on 4/1/17. She stated her main concern was making sure the resident ' [MEDICAL CONDITION] cleaned, changed, and generally taken care of. Family Member #2 stated when she got the resident home to stay with Family Member #1, they couldn ' t get a nurse to come out. The resident told her he didn ' t know how [MEDICAL CONDITION] to be cleaned. Family Member #2 reported she called the facility two to three times on 4/1/17 to ask why the Home Health care people weren ' t coming to the home and she was told they would be coming. After waiting with the resident at his home for hours, Family Member #2 stated she went to her own home and called the Home Health agency herself. The Home Health agency told her nobody was coming. The family member stated she questioned that because he was already at home and stated, Had I known nobody was coming, I would not have taken him home. They said they didn ' t do patients with trachs and said they had told somebody at the facility they didn ' t do them. The family member stated she made an appointment with the resident ' s physician to see if they could help get someone out to take care of the trach, but they didn ' t check it either. She recalled sometime during the week a nurse from another Home Health agency came to the house, but she didn ' t touch [MEDICAL CONDITION] he didn ' t have anybody at home who was able to provide help with [MEDICAL CONDITION]. Family Member #2 reported she had talked with the facility ' s Administrator each day during the week Resident #9 was home. She was told the facility would take him back, but the resident did not want to go back. The family member stated, I was scared with nobody checking [MEDICAL CONDITION] it was already kinda messy. She reported bringing the resident back to the facility on that Thursday (4/6/17) and stated, It (the tra

Based on record review, observations, and interviews, the facility ' s Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 3/11/2017 complaint investigation survey. This was for a recited deficiency in the area of dignity (F241). This deficiency was cited again on the current complaint investigation survey of 4/11/2017. The continued failure of the facility during two federal surveys of record showed a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This tag is cross referenced to: F241-Dignity During the compliant investigation survey of 3/11/2017, the facility was cited F241 for failing to attend to the needs of one of three residents reviewed for dignity, when the resident was left on a bedpan for two hours and resulted in the resident being embarrassed and upset. The current complaint investigation of 4/11/2017 the facility failed to maintain a resident ' s dignity when a pancake style call light was not placed within a resident ' s reach to allow the resident to request staff assistance if needed. An interview was conducted with the Administrator on 4/11/2017 at 4:45 PM. He reported the QAPI meeting took place monthly with him, the Director of Nurses, Assistant Director of Nurses, the medical director and other department leaders attending. The Administrator reported the QAPI team will outline the deficiency, discuss a plan of correction, plan audits and follow up. The Administrator further reported he did not feel that dignity was a widespread issue in the facility and was an isolated incident.

Based on record review and staff interviews the facility's administration failed to provide effective leadership to protect one of three sampled residents (Resident # 1) from sexual abuse by a resident (Resident # 8) with known sexually inappropriate behaviors. Immediate jeopardy began on 3/6/17 when Resident # 8 was found by staff in a sexual altercation with Resident # 1 and was removed on 3/11/17 at 1:50 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on monitoring residents for inappropriate behaviors, taking immediate action to protect resident's from sexual behaviors, and assessing newly admitted residents for socially inappropriate behaviors. Findings Included: Cross refer to F 323: Based on record review and staff interviews the facility failed to supervise one of one sampled residents with known sexually inappropriate behaviors to prevent sexual abuse between this resident (Resident #8) and a cognitively impaired resident (Resident #1) and failed to implement effective interventions to prevent further inappropriate sexual behaviors for one of one sampled residents with known sexually inappropriate behaviors (Resident # 8). On 3/10/17 at 6:05 PM, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 3/11/17 at 12:35 PM. The allegation of compliance indicated: How corrective action will be accomplished to remove the IJ for each resident that was affected by the IJ situation, (Resident #8 and Resident #1): Resident #8 was admitted to the facility on [DATE]. Resident #8 displayed inappropriate behavior of touching female resident on Friday 3/03, and was sent out to the hospital for evaluation. The resident returned to the facility with no new orders. The Resident was observed closely throughout the remainder of weekend, and had frequent redirection by staff members assigned to this unit. The resident displayed inappropriate touching of female residents and staff and attempted to take residents to his room or empty rooms. Also, the resident made inappropriate remarks to staff and female residents. On Monday 3/6/17, the resident was found in his room by a nurse with his pants down and his penis in Resident #1's mouth. The nurse removed Resident #1 and she stayed with Resident #8 until other staff arrived. Both residents were put on one on one supervision. The police was notified. The Administrator and DON on site were notified of event. Administrator completed involuntary transfer for Resident #8. Resident #8 will not return to facility. Resident #1 was sent to the hospital for evaluation and then returned to the facility with no new orders. MD and family were notified on 3/6/17. Resident #1 care plan was updated based upon psychosocial well-being related to sexual encounter on 3/6/17. She was seen by psych services on 3/7/17. Admitting Nurse received education and Final Written Warning for failure to report information found in red folder (which revealed information from the hospital that resident was a known sex offender) upon her knowledge of the information, and failure to put immediate interventions in place on 3/4 upon residents return from hospital to prevent future behaviors. Address how corrective action will be accomplished for those residents having the potential to be affected by the same IJ: The DON /ADON/MDS Nurse and Unit Managers audited all behaviors of current residents for sexual inappropriateness to ensure interventions are in place at this time on 3/10/17. As a result of the behavior audit, two residents were identified as having inappropriate verbal sexual behaviors. 1) One of the resident's care plan was updated on 3/10/17 and followed by psych services. 2) The other resident's care plan was initiated on 3/10/17 and he was referred to psych services. As a result of the audit, two residents were identified as having inappropriate sexual behaviors. The two residents' care plans were in place and they were followed by psych services. Following this review of the behavior audit, the Administrator, Director of Nursing, or Manager on Duty will ensure interventions are care planned and appropriate notification and follow up actions are taken to prevent sexually inappropriate behaviors. Completed on 3/10/17. Facility staff will be educated on reviewing and taking immediate action to protect residents from sexual behaviors, and implementing interventions to prevent future behaviors, including notification of Administrator and/or DON/ADON. The education included all staff. The Director of Nursing, ADON, Unit Managers, and Dept. Heads will complete education for their staff. Licensed staff were education on 3/10/17. Any remaining staff that have not received education will be educated prior to returning to duty. Education included in the event of behaviors staff are to put residents on 1:1, notify authorities, and notify Administration. This education completed by DON, ADON and Administrator. The Director of Nursing, ADON, Unit Managers, and Dept. Heads will re-educate all staff to observe residents for signs of inappropriate behavior and appropriate interventions for management, to include reporting these observations to the Director of Nursing, Assistant Director of Nursing or Unit Manager and or Administrator immediately. Licensed staffs were education on 3/10/17. Remaining staff will be educated prior to returning to duty. Beginning 3/11/2017 all new hires will receive this education. Nurses will assess new admissions for behaviors (including socially inappropriate behaviors) and document in the medical record, this documentation will completed on the Skilled Nursing Assessment. Nurse Consultant provided education to Administrator, DON, and ADON, UM regarding follow up to behaviors/adverse events, to include instructing staff to place residents on 1:1 as needed, notify authorities as needed, and send out of facility as situation warrants to protect other residents. This education completed on 3/11/2017. To address F490, the District Director of Clinical Services will provide oversight of the administration to ensure implementation of the credible allegation, this will be conducted through weekly conference calls and monthly visits, as well as District Director of Clinical Services review of monthly Quality Assurance and Performance Improvement minutes. The Quality Assessment and Performance Improvement Committee met on 3/10/2017 to review this action plan. DON, ADON or designee will monitor behavior documentation routinely to ensure appropriate follow up and actions/interventions taken. Results of this monitoring to be followed by Quality Assurance and Performance Improvement Committee. The credible allegation was verified on 3/11/17 at 1:50 PM by interviewing the staff to ensure that they had been educated on reviewing and taking immediate action to protect residents from sexual behaviors, implementing interventions to prevent future behaviors including notifying the Administrator and/or DON, and the assessment of/documentation of newly admitted residents with behaviors. The results of the behavior audit were reviewed and record review was conducted to ensure the care plan was updated for the residents identified as having inappropriate verbal sexual behaviors and inappropriate sexual behaviors. In-service forms were reviewed to ensure Administrator, DON, Assistant Director of Nursing, and Unit Managers were educated in regards to following up on behaviors/adverse events, instructing staff on implementing appropriate interventions.

Based on record review and staff interviews the facility failed to supervise one of one sampled residents with known sexually inappropriate behaviors to prevent sexual abuse between this resident (Resident #8) and a cognitively impaired resident (Resident #1) and failed to implement effective interventions to prevent further inappropriate sexual behaviors for one of one sampled residents with known sexually inappropriate behaviors (Resident # 8). Immediate jeopardy began on 3/6/17 when Resident # 8 was found by staff in a sexual altercation with Resident # 1 and was removed on 3/11/17 at 1:50 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on monitoring residents for inappropriate behaviors, taking immediate action to protect resident's from sexual behaviors, and assessing newly admitted residents for socially inappropriate behaviors. Findings included: Resident # 8 was admitted to the facility from a hospital on [DATE]. The resident's admission [DIAGNOSES REDACTED]. Resident #8 resided on the facility's Behavioral Health unit on the 300 hallway. Review of Resident #8's referral paperwork dated 2/28/17 which was provided to the facility by the transferring hospital prior to the resident's admission to the facility revealed nursing progress notes and a psychiatric consult. A progress note dated 2/19/17 indicated that Resident # 8 had some altered mental status. A psychiatric consult dated 2/21/17 revealed that Resident # 8 had a medical history significant for dementia, psychosis, substance abuse disorder and schizophrenia. The consult noted concerns regarding Resident # 8's ability to care for himself and the potential risk of harm to himself and others. The consult indicated that Resident # 8's current/on-going psychiatric symptoms included dementia. The consult indicated that Resident # 8's insight and judgment were limited. The consult recommended one to one observation for elopement risk/cognitive deficits, social work services, and psychiatric services as needed. Resident # 8 was involuntarily discharged from the facility on 3/6/17 to the local hospital, therefore a comprehensive admission Minimum Data Set assessment was not completed and a comprehensive care plan had not been developed. An admission note written by Nurse # 3 on 3/3/17 at 3:25 PM indicated Resident # 8 arrived to the facility with a driver. The medication technician answered the door and Resident # 8 entered unit. The driver handed the medication technician Resident # 8's paperwork. The medication technician asked if the driver would like to see a nurse. The driver replied, no, my responsibility was to just get him here. The Physician's Assistant verified the resident's medications. Resident # 8 was oriented to his room, the bathroom and call bell. Resident # 8 verbalized his understanding. An interview conducted with the Admissions Director on 3/9/17 at 5:05 PM indicated that the initial referral she received for Resident # 8 indicated he had altered mental status, was forgetful and needed long-term care placement. The referral paperwork indicated he was homeless and had been on one on one observation because of elopement risk at the hospital. The Admissions Director indicated she had written that Resident # 8 was at zero risk of harm to self or others on the top page of the referral sheet. The Admissions Director indicated she did not know Resident # 8 was a sex offender and that information had not been included with his referral paperwork. The Admissions Director indicated she did not receive notice from the transferring hospital to let the facility know when Resident # 8 would arrive. The Admissions Director indicated that Resident # 8 arrived to the facility unexpectedly on 3/3/17 and she was not sure who had admitted him or what was done with his admission packet. The Admissions Director indicated after the incident on 3/6/17 she contacted the social worker at the transferring hospital to enquire as to why the facility was not made aware of Resident # 8's sex offender status. The Admissions Director indicated she was told that Resident # 8 had not had any behaviors at the hospital with any female staff members. Review of Resident # 8's progress notes since his admission to the facility on [DATE] revealed the following notes which identified inappropriate behaviors: A behavior note was written on 3/4/17 at 2:45 pm by Nurse # 2 as a late entry for the 3 PM - 11 PM shift on 3/3/17. The note indicated Resident # 8 was found in the hallway fondling a female residents breasts. Both residents were immediately separated. At 7:15 PM, Resident # 8 brought a female resident into an empty room. Nursing assistants intervened and the residents were separated. At 7:25 PM, Resident # 8 brought a different female resident into an empty room. The female resident was heard to yell, NO! Again, the residents were separated and Resident # 8 was taken to his room. Calls were placed to the Medical Director, Administrator, and Director of Nursing (DON). The Medical Director called back and the situation was explained to him. A new order was given, and at 8 PM Resident # 8 was sent out to the emergency room (ER). The Administrator called back and the situation was explained to him. A nursing note made on 3/4/17 at 1:34 AM indicated that Resident # 8 returned from the hospital with no new orders. No signs or symptoms of distress were noted. A behavior note made on 3/4/17 at 5:55 AM indicated Resident #8 was walking around and opening other resident's doors. Resident # 8 was redirected by staff. Resident # 8 asked staff how old they were and told them I like pretty girls. Resident was redirected back to his room. A nursing note written by Nurse # 4 on 3/4/17 at 11:16 AM indicated that Resident #8 required redirection after attempting to lead a female residents into his room. A behavior note written by Nurse # 4 on 3/4/17 at 7:13 PM indicated that Resident #8 was observed trying to make a female resident kiss him in the hallway. Resident # 8 had the back of the female residents head and pulled her face toward him. A nurse intervened and Resident # 8 stated he did not know it was wrong to try and be friendly. Nurse # 4 indicated Resident # 8 was educated on acceptable behaviors. The nurse indicated Resident # 8 was able to verbalize his understanding and was able to repeat what behaviors were against the rules. A nursing note written on 3/5/17 at 4:06 AM indicated that Resident #8 had been to the nurse's station multiple times during the night. Resident # 8 touched a NA inappropriately on the breast and was advised that behavior was not acceptable. Resident # 8 was monitored closely by staff and advised that he could either sit in dayroom or lie down in his bed. Resident # 8 looked in each room as he walked by them. Resident # 8 was advised that inappropriate behavior were not acceptable. Staff continued to monitor Resident # 8. A nursing note written by Nurse # 4 on 3/5/17 at 12:09 PM indicated that Resident #8 attempted to get female residents to go into his room to watch TV with him. Resident # 8 also wandered into female residents' rooms. Resident # 8 was redirected numerous times. The female residents were removed from his room and returned to day room. A nursing note written by Nurse # 4 on 3/5/17 at 8:50 PM indicated Resident #8 continued to require redirection regarding keeping his hands to himself. Resident # 8 was able to repeat regulations regarding other resident. The note indicated that Resident # 8 stated he was just being friendly. A nursing note written on 3/6/17 at 2:47 AM indicated that Resident #8 was out of bed wandering on the halls, looking in rooms and making attempts to enter other resident's rooms. Staff continually redirected Resident # 8 and reminded him not to enter other resident's rooms. Resident # 8 was noted with increased agitation and anxiety at 1:00 am and 1 milligram (mg) of Ativan (antianxiety medication) was given as needed. Resident # 8 was encouraged to go back to bed. Resident # 8 got out of bed and was seen ambulating on the hall when he was observed urinating on the floor in the hallway. Resident was taken back to his room and encouraged to go back to bed. Staff continued to monitor Resident # 8. A general note written by speech therapy on 3/6/17 at 9:00 AM indicated Resident # 8 exhibited sexual behaviors towards staff and was inappropriate for treatment services at that time. A behavior note written by Nurse # 1 on 3/6/17 at 11:32 indicated that Resident #8 was pacing the hall and making sexual advances towards female residents and staff. Resident # 8 asked the nurse to help him find his room so they could go in the room together. Resident # 8 was verbally redirected and educated that his comments were inappropriate. Resident # 8 appeared to disregard the nurse and continued having inappropriate behaviors. The Medical Director was notified of Resident # 8's behaviors. The Psychiatry Nurse Practitioner (NP) was also notified of Resident # 8's behaviors and recommended that Resident # 8 be closely monitored. The Psychiatry NP indicated that she would be at the facility to evaluate Resident # 8 on 3/6/17. Resident # 8 was noted to be in his room lying in bed with his eyes closed. Staff continued to monitor Resident # 8. A nursing note written on 3/6/17 at 1:35 pm indicated that Resident # 1's RP was notified of the event and she was being sent to the hospital for evaluation. A summary note written by Nurse # 1 on 3/6/17 at 2:02 PM indicated that Resident # 8 was involved in a sexual encounter (with Resident #1). The Police were notified. The Medical Director and Resident #8's responsible party were notified of the encounter. A nursing note written by Nurse # 1 on 3/6/17 at 2:12 PM clarified that Resident # 8 was placed immediately on one to one observation with staff. A discharge note written by Nurse # 2 on 3/6/17 at 4:00 PM indicated Resident # 8 was escorted out of facility in handcuffs by police. A call was placed to the ER and Resident # 8's paperwork was faxed to the ER. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 1 had severe cognitive impairment. The assessment also indicated Resident # 1 had no behaviors and did not reject care. Review of a hospital discharge summary dated 3/6/17 revealed Resident # 1 was very alert but extremely demented and unable to follow commands or answer questions appropriately. Resident # 1 had no obvious injuries. Resident # 1 was being seen in the emergency room because staff at the nursing facility witnessed another demented resident (Resident #8) putting his penis in Resident # 1's mouth. Resident # 1 was fine the entire visit in the emergency room according to the discharge summary. The police department confirmed a report was filed by the nursing facility. Review of a nursing note dated 3/6/17 at 5:20 PM revealed that Resident # 1 returned to the facility from the emergency room . Resident # 1 was in no acute distress. The responsible party was informed that Resident # 1 was back at the facility. Resident # 1 had no signs or symptoms of mental anguish or trauma at that time. Review of a written statement made by Nurse # 1 dated 3/6/17 at 12:20 pm revealed she walked into room 312 and found resident # 8 shoving his private parts into a female residents mouth (resident # 1). Nurse #1 immediately told him to stop and attempted to separate him from her. Resident # 8 refused to stop and continued act. Nurse # 1 immediately stepped between them and removed the female resident (resident # 1) from the room and placed her one to one with staff. Nurse # 1 stayed with resident # 8 until staff arrived. Resident # 8 was placed one to one with staff as well. An interview with the Administrator on 3/9/17 at 10:00 AM revealed that he was currently in the process of completing the 5 day report for the incident involving Resident # 1 and Resident # 8. The Administrator revealed that Resident # 8 was admitted to the facility on [DATE]. The Administrator indicated there were some concerns about Resident # 8 touching other residents on the evening of 3/3/17. The Administrator indicated that Resident # 8 was sent out to the hospital for a psychiatric evaluation on 3/3/17. He further indicated the hospital returned Resident # 8 to the facility with no psychiatric concerns found. The Administrator revealed that on 3/6/17 a nurse walked into a room and discovered that Resident # 8 had his pants down and his penis was in Resident # 1's mouth. The Administrator indicated the nurse separated the residents. The police were then called and Resident # 1 was sent out for evaluation and her RP was notified. The Administrator indicated a police officer came to the facility and contacted the medical center police where Resident # 8 had been transferred from. The Administrator indicated the medical center police were familiar with Resident # 8 and at this point in time the Administrator learned that Resident # 8 was a registered sex offender. The Administrator indicated that the police officer contacted his sergeant and the district attorney's office at this time. The Administrator indicated that once the police officer notified him that Resident # 8 would not be arrested the Administrator went to the magistrate's office and filed involuntary commitment paperwork to have the police remove him from the facility. The Administrator indicated that the police removed Resident # 8 from the facility on 3/6/17. The Administrator indicated that the facility was not informed by the transferring hospital that Resident # 8 was a registered sex offender. The Administrator indicated if the facility had known that Resident # 8 was a registered sex offender the facility would not have accepted him. An interview with Nursing Assistant (NA) # 2 on 3/9/17 at 3:35 PM revealed that she worked on the 300 hall on 3/4/17 and 3/5/17 on 2nd shift. NA # 2 indicated that she had to check on Resident # 8 often because he would follow women up and down the hall, would rub their shoulders and asked them did they want to come with him. NA # 2 indicated that staff would remove the women residents away from Resident # 8. NA # 2 indicated that Resident # 8 was not on one to one and she was told if she did not see Resident # 8 within a five minute period she should check on him. An interview with Nurse # 1 on 3/9/17 at 4:28 PM revealed that she worked on the 300 hall on 3/6/17 on 1st shift. Nurse # 1 indicated that she had been monitoring resident # 8 throughout the shift because she had noticed him wandering. Nurse # 1 indicated she stepped off the unit for about 10 minutes. When she returned to the unit she did not see Resident # 8 so she went to his room and found the door closed. Nurse # 1 indicated she knocked on the door and entered the room. Resident # 1 was sitting on the bed facing the doorway and Resident # 8 was standing facing her with his penis in her mouth. Nurse # 1 indicated that Resident # 8 was shoving his penis into Resident # 1's mouth. Nurse # 1 indicated she asked Resident # 8 to stop and he did not stop or respond. Resident # 1 did not say anything. Nurse # 1 indicated that Resident # 1 had a blank face with no emotion. She indicated that Resident # 1 was not fighting Resident # 8 off and was not trying to get away, she was just sitting there. Nurse # 1 indicated that she immediately separated the residents. She indicated Resident # 1 took her hand and she took her out of the room to a NA. Nurse # 1 indicated she radioed for additional help and remained with Resident # 8 until additional male staff could stay with him one on one to ensure nothing else happened. Nurse # 1 indicated that staff called 911 and that Resident # 1 was sent out to the hospital. Nurse # 1 indicated that she had seen both residents right before she left the unit and had only been off the unit for about 10 minutes. Nurse # 1 indicated that Resident # 1 had been walking in the hallway and Resident # 8 was in his room lying in bed. Nurse # 1 indicated she was not aware of any interventions that were in place for Resident # 8's behaviors. Nurse # 1 indicated she heard that he had wandering behaviors but not anything sexual related. Nurse # 1 indicated that she had noticed that Resident # 8 had increased wandering behaviors the day of the incident and had tried to keep a close eye on him for that reason. An interview conducted with Nurse # 2 on 3/9/17 at 5:43 PM revealed that she had been working on the 300 hall the evening of 3/3/17. Nurse # 2 revealed that around 5:00 PM on 3/3/17 she saw Resident # 8 with a red envelope. Nurse # 2 recalled asking Resident # 8 to see the red folder and opened it to find information regarding him being a registered sex offender. Nurse # 2 indicated that she was floored and really angry. She indicated that staff watched Resident # 8 to make sure nothing happened. Nurse # 2 indicated that she put the red folder containing the sex offender paperwork in Resident # 8's chart so other staff would know. Nurse # 2 indicated that later on, she observed Resident # 8 was seen trying to bring a female resident into a room. She recalled thinking to herself that something had to be done. Nurse # 2 indicated that she called the Physician to ask what could be done and the Physician said to send Resident # 8 out to the hospital. Nurse # 2 indicated she called the Administrator and Director of Nursing (DON) and told them that Resident # 8 needed to go out of the facility. Nurse # 2 indicated that she thought she made it clear to the Administrator that Resident # 8 was a convicted sex offender. Nurse # 2 was not certain if the folder containing the sex offender paperwork went with Resident # 8 to the hospital. Nurse # 2 indicated that she called the Administrator and asked did he want Resident # 8 to come back to the facility from the hospital and was told yes. Nurse # 2 indicated that she was shocked and could not believe that the facility accepted Resident # 8 back from the hospital. A second interview with Nurse # 2 conducted on 3/10/17 at 12:18 PM revealed that she thought she had told the Administrator about Resident # 8's sex offender status on Friday, 3/3/17, when she called him but indicated to be completely honest, I would not swear to it. Nurse # 2 indicated it was a busy night and she did not know. Nurse # 2 indicated she was told by the Physician to send Resident # 8 out to the ER for altered mental status so she did. Nurse # 2 indicated she did not tell EMS about the inappropriate behaviors but she thought she had told the ER nurse, but could not be certain. An interview with Nurse # 3 on 3/9/17 at 5:55 PM revealed that on 3/3/17 Nurse # 2 indicated to her that Resident # 8 had a red folder on his person and that she had some trouble getting Resident # 8 to give her the folder. Nurse # 3 indicated that she and Nurse # 2 opened the red folder around 4:30-5 PM on 3/3/17 and discovered it contained information regarding registering as a sex offender. Nurse # 3 indicated around the same time Resident # 8 started to have some behavior issues of touching people. Nurse # 3 indicated that she did not see Resident # 8 touch anyone. Nurse # 3 indicated she was there when Nurse # 2 called the Administrator, DON, and MD. She indicated that Nurse # 2 left a message for the Administrator and the DON to return her call. Nurse # 3 heard the conversation with the MD in which Nurse # 2 indicated that Resident # 8 had tried to fondle some of the women and pull some women in a room. The MD indicated to send Resident # 8 out to the hospital for evaluation. Nurse # 3 indicated that Resident # 8 was sent out via ambulance to the hospital. An interview conducted with the Physician on 3/9/17 at 6:25 PM revealed that on 3/3/17 Resident # 8 was being inappropriate. The Physician indicated that Resident # 8 was on the facility's behavioral health unit which also had dementia residents. The Physician indicated that sexual inappropriateness is not unusual with behavior disturbances. The Physician indicated that Resident # 8's behaviors were more than unusual and it didn't feel safe so he was sent out to the hospital. The Physician did not recall the nurse who telephoned him about Resident # 8 telling him that he was a registered sex offender but was not sure. The Physician indicated he thought the first time he became aware of Resident # 8's sex offender status was on Monday, 3/6/17, after the incident. The Physician indicated that when a resident returned from the hospital with no new orders he was not made aware so he was not aware Resident # 8 returned to the facility. The Physician indicated that he did not see Resident # 8 because he was not in the facility over the weekend (3/4/17 or 3/5/17). On 3/9/17 at 8:30 PM, in a telephone interview, Nurse # 4 stated when she came to work on Saturday, March 4, 2017 at 6 AM, she received report from the nurse leaving the overnight shift. The night nurse stated that Resident # 8 arrived on Friday and went out and the Administrator let him come back. Nurse # 4 stated she kept a close eye on the resident who did try to get other residents to come to his room, but she would quickly re-direct him and so he stayed in the day room. Nurse # 4 stated at one point he held hands with a female resident and Nurse # 4 told him he could not do that, and the resident asked why not. Nurse # 4 stated she told him that touching was not okay. Nurse # 4 indicated the resident followed the medication cart and talked to her for quite a while about his past history. Nurse # 4 noted Sunday was the same, Resident # 8 was kept in the day room or walked around with the nurse who was giving medications. An interview with the Administrator on 3/10/17 at 10:30 AM indicated that the Administrator did not recall being told that Resident # 8 was a sex offender when Nurse # 2 called him on 3/3/17. The Administrator indicated he was told that Resident # 8 had some inappropriate behaviors but was not aware he was a sex offender until Monday, 3/6/17. The Administrator indicated if he had known Resident # 8 was a sex offender he would have gotten him out of the building on Friday, 3/3/17. The Administrator indicated that nothing was said to him on Friday, 3/3/17, to make him think the facility should not take Resident # 8 back after he went to the hospital. The Administrator indicated that the resident had been cleared by psychiatric services at the hospital prior to his admission and did not see psychiatric services when the facility sent him out to the ER. An interview conducted with NA # 1 on 3/10/17 at 11:35 AM indicated that she was working on the 300 hall on the morning of 3/6/17. NA # 1 indicated that she saw Resident # 8 right after lunch (approximately 12 PM) as well walking in the hallway. She indicated that Resident # 8 asked her how old she was and told staff he had gotten out of prison for rape. NA # 1 indicated Resident # 8 was touchy with staff members. On 3/10/17 at 2:12 PM an interview was conducted with the Police Officer (PO) who came to the facility on [DATE] following the incident. The PO indicated he was dispatched to the facility for a sexual assault case that had already occurred. He indicated that an employee caught a male patient putting his penis into a female resident's mouth. The PO spoke with the Administrator when he arrived. The PO spoke with Nurse # 1 and she told him that she had been watching resident # 8 due to his erratic behavior that morning and making inappropriate comments to the nurses. She had been keeping an eye on him to make sure he was being watched. She left resident # 8 in his room, room 312. She said she was gone for 10 minutes. When Nurse # 1 returned to his room she saw Resident # 1 sitting on Resident # 8's bed. Nurse # 1 said he (Resident # 8) was standing over Resident # 1 with his penis in her mouth. Nurse # 1 said she told him to stop and he did not stop. Nurse # 1 said that Resident # 1 looked distressed. After he did not stop she physically separated both parties. The residents were kept separated with one to one staff, then the police were called. The nurse indicated to the officer that resident # 8 was doing it for sexual gratification and that he knew what was going on. The officer learned from staff that Resident # 1 cannot give consent. The PO indicated he asked to speak with Resident # 1 and it was like speaking with a child. The PO indicated that Resident # 1 was smiling and seemed happy to see a new face. She did not seem upset or distressed when he saw her. The PO indicated he spoke with Resident # 8 and he seemed fine. He was alert and conscious. The PO indicated he confronted Resident # 8 about the allegations. He indicated Resident # 8 would go off on a tangent about wanting to go to another facility and that he was a Veteran. The PO indicated he asked Resident # 8 if he knew why the PO was here. The PO indicated to Resident # 8 that he wanted Resident # 8 to tell him what happened. The PO indicated Resident # 8 looked confused and deflected him. The PO indicated he thought Resident # 8 knew what was going on. The PO indicated he clarified for Resident # 8 what he was talking about, and asked what happened between Resident # 8 and the female who was in here earlier. The PO indicated Resident # 8 said Resident # 1 came into his room and hugged him. The PO indicated that Resident # 8 again went off on multiple tangents and had to be reminded to tell the PO what happened with the girl. The PO indicated he was very blunt and asked Resident # 8 what he did to the girl. The PO indicated that Resident # 8 said Resident # 1 came into his room, gave him a hug, sat on his bed and then Resident # 8 went on another tangent. The PO asked Resident # 8 did he have his penis in her mouth. The PO indicated Resident # 8 said yeah, I did. The PO indicated that Resident # 8 finally admitted that he did have his penis in her mouth and said we are both adults. The PO indicated that he explained that what happened was not OK because Resident # 1 cannot consent. The PO indicated that Resident # 8 again said they were both adults and indicated that he didn't finish. The PO indicated that Resident # 8's facial expressions seemed to imply that he knew he was in trouble and he asked the PO was he going to get a warrant to arrest him. The PO told him no, not at this time. The PO indicated he spoke with his Sargent and relayed the events. The PO indicated he was seeking guidance because he had never been in this situation before. The PO indicated his Sargent directed him to call District Attorney's (DA) office to see what they advised. The DA's office was informed of the situation and indicated due to Resident # 8's advanced age and prior offender status the case should be forwarded to the criminal investigations division. The PO indicated that the case was still open and on-going. The PO called Adult Protective Services (APS) and filed a report over the phone. The PO indicated that it was his opinion that Resident # 8 knew what he did was wrong based on their conversations. An interview conducted with Certified Medication Aide (CMA) # 1 on 3/10/17 at 3:37 PM revealed that she worked with Resident # 8 on Sunday, 3/5/17. CMA # 1 indicated Resident # 8 was alert and oriented. CMA # 1 indicated he was very sexual in the things he said. She indicated that Resident # 8 told staff about some of the things for which he had been in prison. She also indicated that Resident # 8 was not confused and seemed to understand what he was saying to staff when he was being inappropriate. An interview conducted with the Director of Nursing (DON) on 3/10/17 at 4:02 PM revealed that the Administrator called her on 3/3/17 about Resident # 8 touching Resident # 1's breast. The DON revealed that the Physician decided to send Resident # 8 out to the hospital. The DON indicated that she and the Administrator were in agreement with sending the resident out to the hospital. The DON indicated that she thought Resident # 8 might have some altered mental status and that was pretty much it. The DON indicated that she did not speak with Nurse # 2 that night. The DON further revealed that she did not speak to anyone else the rest of the weekend regarding Resident # 8 and was not aware the behaviors had continued throughout the weekend. The DON indicated that Resident # 8 returned to the facility early Saturday morning (3/4/17) with no new orders. The DON indicated she did not know he was back in the facility until Monday morning (3/6/17) when she returned to work. The DON indicated that after the incident she asked Resident # 8 what was going on and he said nothing. The DON indicated she asked Resident # 8 if he exposed himself and he said no. The DON indicated that she asked Resident # 8 if he was aware what he did was inappropriate. The DON indicated Resident # 8 replied with something along the lines of his zipper was down and he was having problems with his zipper. At this point the DON indicated male staff were with Resident # 8 so she went to check on Resident # 1. The DON indicated Resident # 1 acted as her normal self. The DON indicated that Resident # 1 did not have any injuries to her face or mouth. The DON indicated that she called the Physician, obtained orders and Resident # 1 was sent to the hospital. The DON indicated that she went to the nursing station to get both charts and at that point discovered the red folder with Resident # 8's sex offender paperwork inside. She indicated that she called the Administrator over to let him know at that time as well. The DON indicated the police came and interviewed Resident # 8. The police did not remove Resident # 8 from the facility at that time so the facility started the involuntary commitment process to have Resident # 8 removed from the facility. The DON indicated that on Friday, 3/3/17, she thought that Resident # 8 just had dementia, he was in a new environment and getting oriented to the facility. The DON indicated that at that time she thought Resident # 8 might have been disoriented to his surroundings or he was testing the facility's boundaries. The DON indicated she had no idea he was a sex offender. The DON indicated that from her interactions with Resident # 8 on Monday morning before the incident took place that she did not think he was alert to the place and situation. The DON indicated that Resident # 8 did not answer her questions totally and she felt that there was some impairment there. An interview conducted with the Administrator on 3/10/17 at 4:34 PM revealed the Administrator was not notified Resident # 8 returned to the facility after being sent out to the hospital. The Administrator indicated he was asked if it was OK to take Resident # 8 back from the hospital. The Administrator indicated that based on the information presented to him by the nurse he did not see any reason not to take Resident # 8 back. The Administrator indicated this call occurred on 3/3/17 around 10 PM, while the resident was still at the hospital. The Administrator indicated that he would not be notified when a resident returned from the hospital so he would not have been aware that no new treatments or interventions were put into place. The Administrator indicated if there were new orders the MD would have been called. Since there were no new orders there was no reason to call the MD. The Administrator indicated the hospital did not make any changes or interventions. He indicated that he can only recommend the hospital do something but the ER doctor makes the decision to send the resident back to the facility. The Administrator indicated that

Based on observations, record review and staff interviews the facility failed to complete a care plan with interventions to prevent a pressure ulcer from reoccuring for one of two sampled residents with pressure ulcers. Resident #79 The findings included: Resident #79 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated memory and cognition were not assessed due to persistant vegetative state. The MDS indicated Resident #79 required extensive assistance of two staff for bed mobility, extensive assistance of one person was required for toileting and personal hygiene and total assistance of one person was required for bathing. The bowel and bladder assessment indicated Resident #79 was always incontinent of both. Pressure ulcers were indicated as being present as a stage 3 on this MDS. Total nutrition and hydration for this resident was provided by a feeding tube. Resident #79 was assessed as having a [MEDICAL CONDITION] in place. Review of the Care Area Assessments (CAAS) dated 7/30/14 indicated " Pressure Ulcer " was triggered due to the resident had a new stage 3 on the coccyx and developed a stage 3 pressure ulcer on her neck due to the [MEDICAL CONDITION] strap. The stated goal included there would be no further signs of break down. The decision was made to proceed to care plan and monitor for and prevent pressure ulcers. Review of the care plan with an update of 7/23/14 included the pressure ulcers on the coccyx and the neck. Approaches included pressure reduction mattress to the bed, pressure reduction cushion to the chair or wheelchair, complete a full body check weekly and document, wound care physician and a wedge to be used at all times. Updates to the care plan indicated the coccyx wound would heal and re open. Review of the medical record for Resident #79 revealed the pressure ulcer on the posterior neck first occurred on 7/20/14 and healed on 9/3/14. A pressure ulcer reoccurred on 9/23/14 on the back of her neck and healed again on 10/8/14. Review of the Treatment Administration Records for December and January revealed the order to place an ABD pad (thick padded dressing) to the posterior neck every day. These records did not include the use of soft Velcro ties for the [MEDICAL CONDITION] ties. Interview with the MDS nurse on 01/29/2015 at 3:03 PM revealed she was not sure why Resident #79 was not care planned for interventions to prevent reoccurrence of the pressure ulcer on the posterior neck. The ABD pad was ordered and must have been overlooked. The type of ties for the [MEDICAL CONDITION] to prevent pressure ulcers from reoccurring was missed and not added to the care plan.

Based on observations, record review and staff interviews the facility failed to prevent a pressure ulcer and failed to implement physician ordered interventions for pressure ulcers for one of two sampled residents with pressure ulcers. Resident #79. The findings included: Resident #79 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated memory and cognition were not assessed due to persistant vegetative state. The MDS indicated Resident #79 required extensive assistance of two staff for bed mobility, extensive assistance of one person was required for toileting and personal hygiene and total assistance of one person was required for bathing. The bowel and bladder assessment indicated Resident #79 was always incontinent of both. Pressure ulcers were indicated as being present as a stage 3 on this MDS. Total nutrition and hydration for this resident was provided by a feeding tube. Review of the Care Area Assessments (CAAS) dated 7/30/14 indicated "Pressure Ulcer" was triggered due to the resident had a new stage 3 on the coccyx and developed a stage 3 pressure ulcer on her neck due to the [MEDICAL CONDITION] strap. The stated goal included there would be no further signs of break down. The decision was made to proceed to care plan and monitor for and prevent pressure ulcers. Review of the care plan with an update of 7/23/14 included the pressure ulcers on the coccyx and the neck. Approaches included pressure reduction mattress to the bed, pressure reduction cushion to the chair or wheelchair, complete a full body check weekly and document, wound care physician and a wedge to be used at all times. a. Review of a nurse's note dated 7/20/14 at 2:10 PM provided documentation of an area to the back of neck that measured 16 centimeters (cm) length (L) by 0.5 cm width (W) and .2 cm depth (D). The nurse ' s note indicated the treatment nurse did an assessment of the wound and initiated a treatment of [REDACTED]. Review of the Treatment Administration Record for 7/20/14 indicated the neck wound would be cleaned with normal saline solution. Santyl would be applied to the wound. An ABD pad would be placed to the area under the [MEDICAL CONDITION] collar at the back of neck. Review of the Respiratory Therapist note dated 7/23/14 indicated she made a visit to provide respiratory/[MEDICAL CONDITION] care. A wound was noted at the back of the neck when the neck collar was changed. " ...appears green elastic strap [MEDICAL CONDITION] ([MEDICAL CONDITION] collar) is what caused open area. ABD pad wrapped around strap & (and) taped together to protect skin. DON (Director of Nursing) aware. " Review of a wound note dated 7/23/14 by the wound physician indicated the neck wound was caused by pressure from the [MEDICAL CONDITION] collar strap. The physician indicated he would look into options to replace collar strap. The wound physician assessed the wound as a stage 3, (a full thickness tissue loss) that measured 17.5 cm L by .2 cm D by .7 cm W. The wound had light serous exudate (drainage). Review of the physician orders [REDACTED]. The new order was to clean the neck wound with normal saline and apply hydrogel with an ABD pad every day. The documentation on the July 2014 TAR indicated the treatments were provided as evidenced by the presence of the nurses' initials. Review of the Respiratory Therapist note dated 8/18/14 revealed "Trach ([MEDICAL CONDITION]) care done & ties changed. Dressing change done on back of the neck, area is still open. Remove elastic strap [MEDICAL CONDITION] & replaced it c (with) a [MEDICAL CONDITION] ... " Review of the wound physician's note dated 9/3/14 revealed the pressure ulcer on the back of the neck was resolved. Review of the Respiratory Therapist note dated 9/23/14 revealed "When [MEDICAL CONDITION] noted they were wet & had an odor. Neck checked there is an open area [MEDICAL CONDITION] strap again. Nsg (nursing) notified & dressing was put on area. Removed elastic [MEDICAL CONDITION] & used [MEDICAL CONDITION] ... " Review of the wound physician's progress note dated 9/24/14 indicated a stage 2 (partial thickness tissue loss) that measured .2 cm L by 3.0 cm W and .1cm D. The drainage was light serous. Additional Information: "wound has reopened. This area will be vulnerable to breakdown due [MEDICAL CONDITION]. Dressing: Dry Protective Dressing - once Daily, Hydrogel - Once Daily." Review of January monthly signed physician orders [REDACTED]. This was to be checked every shift. Documentation by the nurses on the TAR indicated the ABD pad was being used as evidenced by nurses' initials each day for "6-2" shift. Observations on 01/28/2015 at10:56 AM revealed the ABD pad was not in place at the back of Resident #79's neck. Interview with nurse #2 on 1/28/15 at 11:13 AM revealed supplies were available [MEDICAL CONDITION]. Supplies included use of soft ties to secure [MEDICAL CONDITION] humidification. Nurse #2 checked Resident #79 ' s skin behind the neck which revealed the skin was intact with no breakdown. Further interview with nurse #2 revealed the respiratory therapist had changed the type of ties used to secure the humidification collar. The skin breakdown had occurred at the fold in the back of neck. Nurse # 2 was not sure if Resident #79 was to have padded dressing to the back of the neck. At the time of this interview an ABD pad was not located at the back of the resident's neck. Nurse #2 explained she thought the dressing order (padded dressing) was used when the wound had been present. Interview on 01/29/2015 at 10:59 AM with nurse #2 revealed Resident #79 should have an ABD pad as protection at the back of the neck. Observations on 01/29/2015 at 11:06 AM revealed Resident #79 did not have an ABD pad under the [MEDICAL CONDITION] ties at the back of her neck. The soft Velcro ties were observed around her neck. An interview with nurse #7, who worked on the evening shift, was conducted on 01/29/2015 at 2:53 PM. Nurse # 7 was asked what treatments she had provided Resident #79 on her shift. She explained she did not do any dressing changes on her shift. When asked if an ABD pad was supposed to be kept at the back of Resident #79's neck, she stated she could not remember. On 01/29/2015 at 1:18 PM an interview was conducted with the Respiratory Therapist who made monthly visits and provided [MEDICAL CONDITION] care for Resident #79. The Respiratory Therapist explained she could not remember exactly when the ties (to the [MEDICAL CONDITION] and collar) were switched from the green elastic to the soft velcro. She could not remember if it was replaced after the first occurrence or after the last occurrence of the pressure ulcer on the neck. Further interview revealed she did not bring in supplies when respiratory care was provided. She explained she " used what the facility had in the room. " Interview with the supply clerk on 1/29/15 at 11:35 PM revealed she could not say when the Velcro ties were ordered. She thought there had been a large order in the building and the staff had used from that supply. When asked if she could locate a date of the order, she stated she couldn't. The supplies had been in the building for residents with tracheostomies. Interview with the Corporate Regional Nurse on 1/29/15 at 2:30 PM revealed the weekly skin checks for September 2014 were not available for review. The Director of Nursing and Administrator who had been aware of the resident ' s wounds was not available for interview. The Interim Administrator and interim DON had no knowledge about this resident ' s care. b. Review of the wound care physician's progress note dated 1/21/15 included an assessment of a coccyx pressure ulcer for Resident #79. The pressure ulcer was present upon admission to the facility. The physician assessed the wound as a stage 3 (full thickness of tissue) and measured 2.5 cm by .1cm by .1 cm. The wound had light serous exudate. Healing was assessed as 80% of the wound. Interventions included use of a gel cushion in the wheelchair, multivitamins and protein supplement. Monthly orders for January 2015 included a treatment to be done every shift to the coccyx pressure ulcer. The treatment consisted of cleaning the wound with normal saline and applying Therahoney and a cover dressing. Observations on 01/28/2015 at 1:13 PM revealed Resident #79 was sitting in a reclined Geri -chair. A pressure reduction cushion was not observed under the resident's buttocks in chair. Interview on 1/28/15 at 3:35 PM with the aide #4 revealed Resident #79 did not have a cushion in Geri-chair when she transferred her back to bed. Interview with nurse #6 on 01/29/2015 at 8:08 AM revealed she had changed the dressing on the coccyx on her shift (night shift). Observations on 01/29/2015 at 11:06 AM of wound care provided by nurse #2 revealed the dressing on Resident's #79 ' s coccyx was dated 1/28/15 with initials "MW." Interview with nurse #2 revealed the initials were the treatment nurse's that had worked on 1/28/15. Nurse #2 explained the wound was a healing stage III pressure ulcer with a red/pink wound bed. Interview with nurse #7 on 01/29/2015 at 2:53 PM revealed she had worked on 3-11 on 1/28/15 and provided care for Resident #79. Nurse #7 explained she did not do any dressing changes on her shift. Further interview revealed she had thought the treatment nurse had done the treatment to the coccyx. She had seen the treatment nurse in the facility that day. The Director of Nursing and Administrator who had been aware of the resident's wounds were not available for interview. The Interim Administrator and interim DON had no knowledge about this resident's care.