Every finding on record at Medicana Nursing and Rehab Center

Based on observations, interviews, and record review, the facility failed to adequately monitor side effects for psychotropic medication for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #5). The findings included: Review of the facility's policy titled, Psychotropic Medication Assessment & Monitoring, revised date 8/2023, included the following: Purpose: that each resident's entire drug/medication regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. The center implements gradual dose reduction (GDR) and non-pharmaceutical interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medications; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Procedure:c. The internal disciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via the MSDS process. The resident, and when indicated the family or responsible person, will be included in this process. The consultant pharmacist reviews the use of the psychotropic medication order as part of each drug regimen review and monitors for: Timely completion of reassessment; Reassessment for trial reduction in dose as per acceptable standards of practice, if there is a change in behavior or clinical status. e. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when use: a) In excessive dose; or b) for excessive duration; or c) without adequate monitoring; or d) without adequate indications of its use; or e) in the presence of adverse consequences which indicate the dose should be reduced or discontinued.Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] with a readmission date of 06/23/25 with diagnoses that included: End Stage Renal Disease; Type 2 Diabetes Mellitus with Diabetic Nephropathy; Dementia; Anxiety Disorder; and Major Depressive Disorder, Recurrent, Moderate. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) of 15, which indicated he was cognitively intact. Review of Section N revealed Resident #5 is on the following medications: antidepressant, opioid, hypoglycemic, anticonvulsant medications. Review of the Physician's Orders showed Resident #5 had an order dated 01/26/26 for Pregabalin 25 milligram (mg) capsule, 1 capsule by mouth two times a day for Convulsive; on 02/07/26 an order for Fluoxetine HCl 20 mg capsule, 1 capsule by mouth in the morning for Depression.Further review of Resident #5's physician's orders showed an order dated 02/28/26 to monitor for side effects/adverse reactions related to use of psychoactive medications: anticholinergic effects, irregular heartbeat, drowsiness, unsteady gait, tardive dyskinesia, EPS(shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal idealizations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Review of the Care Plan dated 02/06/26 documented that Resident #5 uses psychotropic medication therapy related to diagnoses of depression and anxiety. Goals were to have decreased risk of discomfort or adverse reactions related to psychotropic therapy through the review date. Interventions were to observe for side effects and adverse reactions of psychoactive medications: anticholinergic effects, irregular heartbeat, drowsiness, unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal idealizations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.Review of the psychiatry consultations dated 02/11/26 and 04/15/26 recommended for Resident #5 to be monitored for medication side effects as part of his treatment plans. Review of the May 2026 Medication Administration Record (MAR) showed Resident #5 has not been monitored for side effects as per physician orders. During an interview conducted on 05/13/26 at 5:27 PM with Staff D, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 1 month. She stated residents on psychotropic medications are monitored for behaviors and side effects which she would document in the MAR. Staff D was asked to pull up Resident #5's MAR and show where she would document for side effects. She then stated Resident #5 does not have an order in the MAR for monitoring side effects. During an interview conducted on 05/14/26 at 12:25 PM with the Director of Nursing (DON), who stated she has worked at the facility since February. She stated there's an order for monitoring side effects of psychoactive medications in the system; and the nurses are to check for side effects and document in the MAR. A side-by-side review of Resident #5's MAR was conducted with the DON, and she was unable to find the order for monitoring of the side effects. She stated she would have to investigate it. At 2:56 PM, the DON stated that it looks like the schedule for the order was not filled out.

Based on interview and record reviews, the facility failed to ensure a completed informed consent for psychotropic medication was obtained for 1 of 5 sampled residents reviewed for unnecessary medication (Resident #1). The findings included:Review of the facility policy titled, Psychotropic Medication Assessment and Monitoring: with a revised date of 08/2023 included in part the following: Procedure: a) Obtain physician's order, b)Psychoactive Medication Consent signed by the resident/resident representative.A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic.Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Quadriplegia and personal history of Malignant Neoplasm of Bladder, and Major Depressive Disorder Recurrent Severe with Psychotic Symptoms. The Brief Interview of Mental Status evaluation dated 05/01/26 documented a score of 11, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #1 revealed in part,the following: An order dated 03/30/26 for Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG, give 1 tablet by mouth one time only for psychosis for 1 Day.An order dated 03/31/26 for Quetiapine Fumarate Oral Tablet 25 MG, give 1 tablet by mouth at bedtime for psychosis.An order dated 3/13/26 for Buspirone (Buspar) HCL Tablet 5mg, give 1 tablet by mouth every 12 hours for anxiety.Review of the Psychoactive Medication Consent form for Resident #1 for Quetiapine Fumarate tab 25mg 1 tab by mouth for psychosis dated 03/30/26 included in part the following:I DO desire the use of the medication(s) indicated above and DO consent to their use. I understand that once the target behavior is controlled the dose should be gradually decreased to the lowest possible dosage and frequency or discontinued unless contraindicated by my physician.I DO consent to the use of the medication interventions but only on a temporary basis for treatment of life-threatening medical symptoms only.I DO NOT desire, nor consent to the use of medication interventions on a regular or temporary basis. I understand that I may reevaluate the need for medication intervention at any time, and that this will be reviewed at each quarterly Care Planning Meeting.The consent form did not have any of the above options documented, as indicated.During an interview conducted on 05/13/26 at 4:24 PM with Director of Nursing (DON) who was asked about informed consents for psychotropic medications, she stated we need informed consent for psychotropic medications if there is an increase in dosage or change in the medication. When asked where the documentation is kept she said it would be under miscellaneous tab in the residents electronic medical record. She was responsible for obtaining the informed consent for psychotropic medication, she said it is typically obtained by the nurse who received the order for the medication. When asked about Resident #1, she acknowledged there was no informed consent for the psychotropic medications. The DON said the resident was admitted taking Buspirone and since he was taking Buspirone prior to being admitted to the facility they did not need to obtain informed consent. During an interview conducted on 05/13/26 at 5:15 PM with Staff N Registered Nurse/Unit Manager (RN/UM) who stated she has worked at the facility for 4 years and only in her current role of RN/UM since January 2026. When asked about informed consent for psychotropic medications she said it is done on admission and if the dose is increased or the medication is changed and a new medication is started. When asked to clarify if the resident was taking the medication at the hospital before admission, would they still obtain an informed consent on admission, she said yes. She said once she obtains the consent (on paper) it goes to medical records who will upload the document to the resident's electronic record. The RN/UM stated it is placed in the cubby for medical records.During an interview conducted on 05/13/26 at 5:20 PM with Staff O HIC (Health Information Clerk) who stated she has worked at the facility for 4 years. When asked how often she picks up the documents from the medical records cubby to upload to the resident's electronic medical record, she said daily. When asked how far behind she is in uploading the documents, she said not far and said it would be within a week or two. When asked about a document that was obtained 03/30/26 and was still not uploaded, she just remained silent and did not answer the surveyor. HIC was then asked to see if she could look for the document and provide a copy to the surveyor.During an interview conducted on 05/13/26 at 5:25 PM with Resident #1 who was asked his full name and he responded appropriately. When asked about his medications if he signed consent for anything, he said no. When asked about the Buspirone he said no but he has been taking it for a while. When asked about the Quetiapine Fumarate also known as Seroquel, he said he did not sign anything but remembers getting the medication pretty quick after he had needed it and he said he is still getting it.On 05/13/26 at 5:30 PM Staff O (HIC) provided the following psychoactive medication consents for Resident #1; the first was dated 03/13/26 for Buspirone 5mg with a check mark next to do desire the use of the medication(s) indicated and do consent to their use. The second one was dated 03/30/26 for Quetiapine Fumarate with no check mark indicting a do desire or do consent, nor was a do not desire or consent to the use of medication intervention on a regular or temporary basis.

Based on interviews, and record review, the facility failed to provide nutritional interventions in a timely manner to prevent weight changes including significant weight loss and/or gain for 5 of 6 sampled residents reviewed for nutrition (Resident #30, Resident #27, Resident #36, Resident #49, and Resident #20).The findings included: Review of the facility's policy titled, Weight Measurements, dated 08/2023, included the following: Body weight is a value used to monitor the nutritional status of the resident.Frequency of measurements & Calculations:Residents are weighed weekly, monthly, or according to physician orders. Residents should be weighed at the same time of day, in similar clothing, and using the same scale. Any significant or progressive weight loss or gain is noted and reported to the resident's attending physician, family, or responsible party, and document in the medical record.Note all new admits are weighed weekly for 30 days. 1. Record review for Resident #30 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Sequelae of Cerebral Infarction, Dementia, Type 2 Diabetes Mellitus with Hyperglycemia and Adjustment Disorder with Anxiety. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #30 had a Brief Interview of Mental Status (BIMs) score of 10 which indicated he is moderate cognitively impaired. Review of Section GG revealed Resident #30 was independent for eating. Review of Resident #30's Weight and Vitals Summary report revealed his admission [DATE]) weight was 160.9 pounds and on 02/04/26 he was 151.3 pounds. This showed a significant percent weight loss of 5.96 % in three weeks. Further review revealed Resident #30 was not weighed weekly for 30 days as a newly admitted resident, as per the facility's policy. Record review revealed a Mini Nutritional Assessment (MNA) was conducted on 02/03/26 for Resident #30, who was found to be At Risk for Malnutrition; however, no interventions were implemented at this time. Further review of Resident #30's Weight and Vitals Summary report revealed he was weighed monthly and on 04/02/26 his weight was 144.6 pounds. This showed a severe percent weight loss of 10.13% in three months. Review of the Nutrition Comprehensive Evaluation/Risk Screen with description of significant change conducted by the Licensed Dietitian (LD) dated 04/23/26 revealed the following: Weight history reviewed: -3.7% x 30 days, -4.3% x 90 days, -10% x 180 days. Resident #30's intake of meals is between 51% to 75% average. Resident #30 was reviewed with the team during weekly focus. Current oral intake may not be sufficient to meet needs. Recommendation: weekly weights to monitor trends and add ready care 2.0 120 ml two times daily (nutrition support drink). Review of the Physician's Orders showed Resident #30 had an order dated 04/23/26 for Med Pass 2.0/Ready Care 2.0 for nutrition support give 120 ml by mouth two times a day; and on 04/29/26 a physician order was added for weekly weights, one time a day every Wednesday. Review of the April 2026 and May 2026 Medication Administration Record documented Resident #30 consumed 90-100% of the Med Pass 2.0 (nutrition shake) since it was ordered on 04/23/26. Review of Resident #30's Weight and Vitals Summary report revealed on 04/30/26 his weight was 142.2 pounds and on 05/06/26 he was 143.0 pounds, indicating he has gained weight. On 05/11/26 at 1:30 PM an interview was conducted with Resident #30. He was pleasantly confused and stated he was doing okay but continued to have his own conversation. During an interview conducted on 05/13/26 at 9:25 AM with Staff A, CNA, (Certified Nursing Assistant) who stated she has worked at the facility for 10 years. She stated she is provided with a list of residents that need to be weighed on her shift, then she gives the list with the weights back to the nurse. She confirmed residents are weighed monthly. During an interview conducted on 05/14/26 at 2:54 PM with the LD, who stated she is a contracted employee, has worked at the facility for 8 years and works about 12 hours a week, usually Tuesdays and Thursdays. She stated she assesses new admissions, which means she conducts the MNA, then risk screens and if the resident screens low in the risk screen she will conduct a full evaluation to estimate nutritional needs. She stated new admitted residents will be weighed upon admission, then weekly for 4 weeks, then monthly if no concerns. She stated the interdisciplinary team (IDT) meetings are held every Thursday in which weights are discussed or if any resident had a change of weight. She stated she prints the weight loss reports weekly and weights are done by nursing. Then weights are reviewed monthly by her and the IDT team to identify weight loss or gain to address the changes as soon as possible. She stated significant weight loss is 5% in a month, 7.5 % in 3 months and 10% in 6 months; if she feels the weight is incorrect, she will try to get the resident re-weighted. The LD was asked to review Resident #30's records and interpret the weights. She stated Resident #30 was not weighed weekly as per policy and between 01/17/26 and 02/04/26 Resident #30 weight loss was 5.9% and she acknowledged to be a significant weight loss. She stated she or the team would enter the orders for weekly weights and Resident #30 did not trigger any concerns with nutrition during the admission period or the MNA. She stated she missed the MNA conducted on 02/03/26 which documented Resident #30 was at risk for malnutrition. She was then asked when she conducted the Nutrition Comprehensive Evaluation/Risk Screen with description of significant change dated 04/23/26 which weights was she using to calculate the percentages; she provided a confusing answer and when the weights were reviewed, she simply stated she missed it and is doing the best for the residents. 2. Record review for Resident #49 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux, Depression, Anxiety, and Osteoarthritis of Right Ankle and Foot with Absence of Right Toe. Review of the Significant Change Minimum Data Set (MDS) assessment for Resident #49 dated 04/26/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Record review revealed Resident #49's weights in her Electronic Health Record (EHR) were as follows: 10/17/25 128 pounds (lbs.) 11/13/25 129.5 lbs. 12/03/25 119.0 lbs. 01/02/26 118.6 lbs. The resident was not weighed weekly upon admission for 30 days as per policy. Record review revealed from 11/13/25 to 12/03/25 the resident was noted with a 10.5 lb. weight loss in 20 days which was a severe weight loss at 8.1%. A reweight was not taken to confirm the weight loss. Further record review revealed on 12/04/25 Staff Z, Dietetic Technician Registered (DTR), who is no longer employed by the facility, wrote a progress note titled weight review, where the weight loss was addressed. Staff Z wrote the resident ate small portions, declined supplements, and was at risk for unavoidable weight loss due to post-op toe amputation. Staff Z did not recommend weekly weights to monitor the resident. 3. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Mild Protein-Calorie Malnutrition, and Chronic Kidney Disease. Review of the Significant Change Minimum Data Set (MDS) for Resident #36 dated 04/16/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. Resident #36's weights in her EHR were as follows: 01/08/26 115.6 lbs. 01/09/26 116.2 lbs. 01/15/26 117.2 lbs. 02/05/26 116.0 lbs. 03/05/26 110.5 lbs. 04/05/26 107.1 lbs. 05/05/26 105.6 lbs. 05/11/26 108.4 lbs. The resident was not weighed weekly for 30 days upon admission as per policy. From 02/05/26 to 03/05/26 the resident lost 5.5 lbs. which was a 4.7% weight loss in one month. From 02/05/26 to 04/05/26 the resident lost 8.9 lbs. which was a 7.7% weight loss in 2 months. This was a severe weight loss. Further record review revealed weight loss was not addressed when it began to occur in March 2025. Reweights were never attained to confirm the weight losses. The severe weight loss was addressed 23 days after it was identified when a comprehensive assessment dated [DATE] was completed by the Licensed Dietitian (LD). The comprehensive assessment was completed because of the Significant Change MDS. Weekly weights were initiated in May 2026, a month after severe weight loss occurred and 2 months after the initial weight loss had begun. 4. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Diabetes, Cachexia, Protein-Calorie Malnutrition, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #27 dated 03/19/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #27's weights in his EHR were as follows: 04/03/26 147.9 lbs. 05/03/26 157.8 lbs. The resident experienced a significant 9.9 lb. weight gain which was 6.7% in one month. As of 05/14/26, 11 days, a reweight had not been taken to confirm the significant weight change and it had not been addressed. On 05/14/26 at 02:50 PM an interview was conducted with the LD, whose employment of 8 years was contracted by the facility through the company she worked for. She stated residents who were admitted to facility were weighed weekly for a month. There was otherwise no policy for weights and addressing significant weight changes provided by the facility or the contracted company she was employed by. Weights were taken by Certified Nursing Assistants (CNAs) and entered in the EHRs by the nurses. All the residents' weights were in the EHR including weekly weights and reweights. If a resident refused to get weighed, she would document it in the resident's care plan and in a progress note. The LD stated she ran a weekly report that identified significant weight changes and she tries to address them as soon as possible. She stated an acceptable time frame to address an identified significant weight change would be by the following week since she was at the facility twice a week, usually Tuesdays and Thursdays. A resident who lost 4.5% or more would also be assessed because it reflected a trend. Interventions for a resident who had experienced a significant weight change would include weekly weights until stable. If a significant weight change was identified, a reweight to confirm the change would be preferably attained by the next day if not the next week. The weights and dietary notes for Resident #49 were reviewed with the LD. She confirmed the resident was not weighed weekly upon admission as per facility policy and the doctor did not order weekly weights when a significant weight loss was identified. She did not comment when the doctor's note stating unavoidable weight loss was due to post toe amputation was brought to her attention. The weights and dietary notes for Resident #36 were reviewed with the LD. She confirmed reweight was not taken and the weight losses were not addressed and monitored in a timely manner. The weights for Resident #27 were reviewed with the LD. She agreed that a reweight should have already been taken to confirm if the resident had a significant weight gain. Bottom of Form

Based on observations, interviews and record review the facility failed to ensure tube feeding administered as ordered and ensure the tube feeding bottle was labeled with a time started for 1 of 2 sampled residents reviewed for tube feeding (Resident #6). The findings included:Review of the facility's policy titled, Person-Centered Medication Administration Schedule with a revised date of 08/14/24 included in part the following: Medications shall be administered according to established schedules. Medications may be administered one hour before to one hour after the prescribed times. A physician's order for specific times supersedes any routine schedule.Review of the facility's policy titled, Enteral Feeding: Ready-to-Hang with a revised date of 08/2023 included in part, the following: Fill in information on label (resident's name, room, date, start time and rate. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Vascular Dementia, and Gastrostomy Status. The Brief Interview of Mental Status evaluation dated 05/07/26 documented a score of 99 indicating the interview was not able to be completed. Review of the Physician's Orders for Resident #6 revealed an order dated 02/17/26 in the morning for Feeding turn off at 10:00am, turn tube feed on at 2:00pm (1000 ml/24 hours) Nepro 1.8 carbsteady continuous at 50 ml per hour for 20 hours and in the afternoon for Feeding turn on at 2:00pm (100 ml/24 hours) Nepro 1.8 carbsteady continuous at 50 ml per hour for 20 hours. Turn tube feed off at 10:00am. Review of the actual medication administration times for enteral feed order for Resident #6 from 05/04/26 to 05/13/26 documented the following:On 05/04/26 the tube feeding was documented as being turned on at 3:21 PM (1 hour and 21 minutes late).On 05/05/26 the tube feeding was documented as being turned off at 11:22 AM (1 hour and 22 minutes late).On 05/05/26 the tube feeding was documented as being turned on at 3:19 PM (1 hour and 19 minutes late).On 5/06/26 the tube feeding was documented as being turned on at 11:03 AM (1 hour and 3 minutes late).On 05/07/26 the tube feeding was documented as being turned off at 11:07 AM (1 hour and 7 minutes late).On 05/07/26 the tube feeding was documented as being turned on at 3:32 PM (1 hour and 32 minutes late).On 05/08/26 the tube feeding was documented as being turned off at 11:06 AM (1 hour and 6 minutes late).On 05/08/26 the tube feeding was documented as being turned on at 3:36 PM (1 hour and 36 minutes late).On 05/09/26 the tube feeding was documented as being turned off at 11:50 AM (1 hour and 50 minutes late).On 05/09/26 the tube feeding was documented as being turned on at 3:38 PM (1 hour and 38 minutes late).On 05/10/26 the tube feeding was documented as being turned off at 11:21 AM (1 hour and 21 minutes late).On 05/12/26 the tube feeding was documented as being turned on at 3:48 PM (1 hour and 48 minutes late).On 05/11/2026 10:45 AM, observation was made of Resident #6 out of bed in a Geri chair with no tube feeding. Review of the nursing progress notes for Resident #6 from 05/04/26 to 05/14/26 revealed no documentation of issues with tube feeding or that the tube feeding was not administered as ordered. On 05/12/26 at 9:55 AM, an observation was made of Resident #6 sitting up in bed sleeping with a bottle of Nepro 1.8 carbsteady infusing at 50 ml per hour via pump. The bottle was dated with a start of 05/11/26 at 1900 (7:00 PM). the bottle had 550 ml out of a 1,000 ml capacity bottle (The bottle should have had 250 ml of Nepro).On 05/13/26 at 8:45 AM an observation was made of Resident #6 sitting up in bed sleeping with a bottle of Nepro 1.8 carbsteady infusing at 50 ml per hour via pump. The bottle was dated with a start of 05/12/26 with no time documented on the label. The bottle had 400 ml out of a 1,000 ml capacity bottle of Nepro. On 05/13/26 at 6:40 PM an observation was made of Resident #6 sitting up in bed sleeping with a bottle of Nepro 1.8 carbsteady infusing at 50 ml per hour via pump. The bottle was dated with a start of 05/12/26 with no time documented on the label. The bottle had 200 ml out of a 1,000 ml capacity bottle of Nepro. On 05/14/26 at 7:00 AM an observation was made of Resident #6 sitting up in bed sleeping with a bottle of Nepro 1.8 carbsteady infusing at 50 ml per hour via pump. The bottle was dated with a start of 05/13/26 at 10:40 PM. The bottle had 800 ml out of a 1,000 ml capacity bottle (The bottle should have had 575 to 600 ml of Nepro). During an interview conducted on 05/14/26 at 9:00 AM with Staff D Licensed Practical Nurse (LPN) who was asked about the tube feeding order for Resident #6, the LPN stated it is for Nepro 1.8 carbsteady to infuse at 50ml per hour, it is turned on at 2:00 PM and turned off at 10:00 AM. When asked about the 1000ml/24 hours and the 100ml/24 hours she stated that she would need to call the physician to clarify the order. When asked if there was any report of the tube feeding not being given over the night shift she said no. When asked if the tube feeding bottle started at 05/13/26 at 10:40 PM and ran for 50ml per hour until 05/14/26 at 9:00 AM (10 hours and 15 minutes) how much should be left in the 1000 ml capacity bottle, she said it should be about 500ml. When asked where they document the tube feeding being turned on and off, she said it is on the Medication Administration Record. On 05/14/26 at 9:05 AM a side-by-side observation with Staff D LPN was made of Resident #6 sitting up in bed sleeping with a bottle of Nepro 1.8 carbsteady infusing at 50 ml per hour via pump. The bottle was dated with a start of 05/13/26 at 10:40 PM. The bottle had 700 ml out of a 1,000 ml capacity bottle. She acknowledged the amount left in the bottle should have been closer to 500ml. During an interview conducted on 05/14/26 at 1:00 PM with the Director of Nursing who acknowledged the tube feeding order was not clear. After reviewing the actual medication administration times for enteral feed order for Resident #6, she also acknowledged the enteral feeding (medication) was more than 1 hour late from the prescribed time to turn the tube feeding on and off several times in the month of May 2026.

Based on observations, interviews and record review, the facility failed to provide the correct fluid consistency ordered for 1 of 1 sampled resident. (Residents #44) The findings included: Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Parkinson's Disease, Dementia, Dysphagia, Chronic Respiratory Failure, and Atelectasis. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #44 dated 02/20/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of the Physician's Orders for Resident #44 revealed an order dated 11/03/25 for a Pureed texture, Honey Thick consistency Diet. Review of the Care Plan for Resident #44 initiated on 08/15/11 with a focus on Nutritional Status was observed with a goal stating, Diet as ordered. During an observation on 05/11/26 at 12:58 PM, Resident #44 was observed in the dining room, during the second seating. Her meal ticket read, Regular Pureed, Honey Thick Liquids, House Shake Honey Thick. The shake on the tray was observed to have a nectar thick consistency. During an observation on 05/13/26 at 08:35 AM, Resident #44's breakfast tray was in the meal cart. The house shake on the tray was of nectar thick consistency. The tray was brought into the room, and the resident was fed by Staff A, Certified Nursing Assistant (CNA), who had been employed by the facility for 10 years. The shake was poured into a cup and was observed to be of nectar thick consistency. Staff A confirmed she had not added anything to the shake to thicken it. Photographic evidence was obtained. On 05/14/26 at 10:04 AM an interview was conducted with the Director of Therapy, who had been the Director since the year 2017. The Director stated he knew Resident #44 well and she had a diagnosis of Parkinson's along with chronic respiratory issues. She had been declining during the past 5 years and was dependent on staff when eating and drinking. The Director further stated the resident had a lot of swallowing issues and had bouts of pneumonia recently. The last time she had pneumonia was in January 2026 when she was already on Honey Thick Liquid Consistency. He stated if the resident drank a beverage that was nectar thick or not honey thick, she would be at risk for aspiration. The Director was then shown the photographic evidence obtained from the resident's trays. An interview was conducted on 05/14/26 at 02:50 PM with the Licensed Dietitian (LD), who had worked at the facility as a contractor for 8 years. She stated the kitchen provided all beverages at the appropriate consistency on the meal trays. Thickening of beverages was performed by kitchen staff only.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 1 of 2 visits conducted in the Main Kitchen. The findings included: A tour of the Main Kitchen was conducted on 05/11/26 at 8:48 AM with the Dietary Manager (DM). The following was observed: The facility had a large reach-in refrigerator with multiple glass doors, 5 in total. a. A [NAME] Brand, Nectar thick Beverage, 32 ounce carton was found open in the reach-in refrigerator with a handwritten date in black of 04/26/26. The side panel of the carton stated the product could be kept under refrigeration for up to 7 days once opened. The DM stated it was the date the item was received and could not determine how many days it had been opened. b. A Silk Soy Brand, 32-ounce carton, was found open in the reach-in refrigerator. There was no opened date identified on the carton and the label read stays fresh 7-10 days after opening. The DM was unable to determine the date it was opened. c. Sitting water was observed on the lids of 2 5-pound cottage cheese containers. The stickers placed on them by the facility had dissolved in the water and were unreadable. Right above the cottage cheese containers on the top shelf was a large gallon-sized container of sauerkraut which was stored under one of the refrigerator fans. When the container was pulled off the shelf, water sitting on the lid poured onto this surveyor. d. The walk-in freezer was observed with 2 evaporator fans on the back wall. Under the left fan, 4 Chef [NAME] Brand, dessert pies were observed with a significant amount of ice accumulation. The top pie, which was out of the box and wrapped with plastic wrap, was observed with the most ice buildup. Water dripped and froze over the side of the pie and onto the others so that they were all stuck together. The fan cover of the evaporator fan above the pies had a frost like build up and towards the bottom of the cover, there was some ice build up from an accumulation of water. Photographic evidence was obtained.

Based on observations, interviews and record review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) during care provided for 1 of 19 residents on EBP (Enhanced Barrier Precautions), (Resident #6) and 1 of 1 sampled residents observed for wound care (Resident #48). The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with a revised date of 06/13/24 documented in part the following: To ensure understanding of Enhanced Barrier Precautions by staff when caring for residents. Enhanced Barrier Precautions are indicated: wounds, and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (Multidrug-resistant organism. Review of the Enhanced Barrier Precautions signage issued by the U.S. Department of Health and Human Services Center for Disease Control and Prevention with no date that the facility used to post on the residents'' door included in part the following: Enhanced Barrier Precautions – Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities: Transferring, Changing briefs or assisting with toileting, wound care: any skin opening requiring a dressing. 1). Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Vascular Dementia, and Gastrostomy Status. The Brief Interview of Mental Status evaluation dated 05/07/26 documented a score of 99, indicating the interview was not able to be completed. Review of the Physician's Orders for Resident #6 revealed in part the following: An order dated 01/29/26 for every shift Check g-tube placement q shift, before administration of meds and flushes. An order dated 02/13/26 for Enhanced Barrier Precautions every 24 hours. On 05/11/26 at 1:55 PM an observation was made of Resident #6 assisted back to her bed from Geri chair via Hoyer lift by Staff M, Certified Nursing Assistant (CNA) and Staff L, Certified Nursing Assistant (CNA). Once Resident #6 was in bed, they proceeded to change her brief. Neither staff member wore a gown during the transfer or during the incontinence care provided. The resident had a Peg tube in place and there was an Enhanced Barrier Precaution sign on the outside of the resident's door. During an interview conducted on 05/14/26 at 9:25 AM with Staff D Licensed Practical Nurse (LPN), who was asked about when someone has a wound or Peg tube when do you need to wear gown and gloves, she said whenever you provide care for the wound or Peg tube or when transferring the resident or providing incontinence care such as changing briefs. 2). Record review for Resident #48 revealed the resident was admitted to the facility on [DATE] with a readmission 0n 01/14/22 with diagnoses that included: Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery; Chronic Obstructive Pulmonary Disease; Type 2 Diabetes Mellitus with Severe Non-Proliferative Diabetic Retinopathy with Macular Edema, Bilateral. The MDS dated [DATE] revealed Resident #48 had a BIMS of 01, which indicated that she was severely cognitively impaired. Further review revealed Resident #48 had pressure reducing device for chair, for bed, and has Nutrition or Hydration intervention to manage skin problems. Review of the Physician's Orders showed Resident #48 had an order dated 02/19/26 to cleanse sacrum with wound cleanser; pat dry; apply skin prep to peri-wound. Then apply Calcium Alginate & cover with border gauze. Offer the resident pain medications 30-60mins prior to treatment and as needed for wound care. During an interview conducted on 05/14/26 at 10:25 AM with the Wound Care Licensed Practical Nurse (WCLPN), who stated Resident #48 had a sacral wound before and it had healed; however, the wound came back, she's not sure why, but it is getting better and it is expected to resolve within 2-3 weeks. During a wound care observation conducted on 05/14/26 at 10:30 AM with the WCLPN, who had pulled all the supplies for the treatment and had cleaned the surface of the bedside table for Resident #48. She was assisted by Staff G, Certified Nursing Assistant (CNA), who was wearing a gown and gloves (PPE) and had already positioned Resident #48 on her right side. The WCLPN washed her hands in Resident 48's room don clean gloves; then removed the soiled dressing, discarded the dressing and gloves, used hand sanitizer don clean gloves and followed Resident #48's physician order for the wound treatment. She removed her gloves and used hand sanitizer to clean her hands, then she realized and stated that she forgot to put on the gown. The WCLPN acknowledged she knows she is to wear a gown while providing wound care.

Based on observations, interviews, and record review, the facility failed to implement physician response to pharmacy recommendations for 1 of 5 sampled residents reviewed for Medication Regimen Review. (Resident #3).The findings included:Review of the facility's policy titled, Medication Regimen Review (MRR), dated 06/01/24, included the following: 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing act upon the recommendations contained in the MRR.Record review for Resident # 3 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Atheroscherotic Heart Disease of native coronary artery without angina pectoris, a condition where plaque builds up in the heart that restricts oxygen flow, and Gastro-esophageal reflux disease without esophagitis, a chronic digestive condition where stomach acid or contents flow back into the throat.Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident # 3 had a Brief Interview for Mental Status of 13, which indicated that he was cognitively intact.Review of the Physician's Orders showed that Resident #3 had an order dated 02/17/26 for Metoclopramide HCL oral tablet. Given by mouth three times a day for nausea/vomiting. The order to discontinue the medication was dated 05/01/26 and the last administration was on 05/08/2026.Review of the Care Plan dated 02/17/26 documented that Resident #3 had an alteration in gastro-intestinal status, episodes of nausea, vomiting and abdominal pain. Goals were to have decreased risk of discomfort, complications or signs and symptoms related to gastro-intestinal alterations through the review date. Interventions were to med as ordered for nausea, observe medications for side effects.Review of the Pharmacy Consultation Report dated 03/30/26 documented Resident #3 received Metoclopramide which may cause involuntary movements including tardive dyskinesia, but an abnormal involuntary movement scale (AIMS), Dyskinesia Identification System: Condensed User Scale (DISCUS), or other appropriate assessment was not documented in the medical record. The recommendation included monitoring involuntary movements using a clinically validated scale at baseline, 3 months after initiation or a dose increase, at least every 6 months thereafter and as clinically indicated for the drug Metoclopramide. Early detection of symptoms and discontinuation of the offending agent may help to avoid tardive dyskinesia (involuntary movements).During an interview on 05/14/26 at 11:40 AM, the March 2026 recommendations were reviewed for Resident #3. The DON stated that the medical director reviewed the document on 04/02/26 and made recommendations to the provider. The order was reviewed by the facility provider on 05/01/26 and the DON stated that she put in a stop date of 05/01/26. She stated that this medication is not a psychotropic drug , it is an anti-emetic and does not need behavior monitoring. During a speaker phone interview on 05/14/26 at 2:23PM with the Medical Director, the March 2026 pharmacy consultation report for Resident #3 was reviewed. She stated that she accepted the recommendations for behavioral monitoring and added a recommendation to the primary care physician to consider weaning off the Reglan (Metoclopramide) and verified that she signed the document on 04/02/26.Resident #3 was not monitored for behaviors while receiving Metoclopramide, as recommended from the period of 04/02/26 when the recommendation was accepted and the date of discontinuation on 05/08/26.

Based on observations, interviews, and record review, the facility failed to maintain an accurate medical record for 1 of 18 sampled residents reviewed for Resident Records (Resident #3).The findings included:Review of the facility's policy titled, Medical Record Management, dated 04/20/26, included the following: Medical records will be complete and accurate.Record review for Resident # 3 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Atheroscherotic Heart Disease of native coronary artery without angina pectoris, a condition where plaque builds up in the heart that restricts oxygen flow.Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 had a Brief Interview for Mental Status Score of 13, which indicated that he was cognitively intact. Review of Section O of the MDS dated [DATE] revealed that Resident #3 was under Hospice care.Review of the Care Plan dated 02/17/26 documented that Resident #3 was readmitted on hospice services for atherosclerotic heart disease. Goals were decreased risk of signs and symptoms of cardiac complications. Interventions were to observe for shortness of breath.Review of the medical record dated 03/02/26 titled Hospice Physician Telephone Order revealed six documents scanned as part of the file but only the first document was for Resident #3.During an interview conducted on 05/13/26 at 5:22PM, Staff O, Health Information Clerk stated that she is responsible for uploading the scanned documents to the resident's medical record. She stated that she verified the name of the resident on each document if she is scanning multiple documents. In addition, she does not shred the hard copy documents until she ensured that the documents were successfully scanned to the resident record.During a follow-up interview on 05/14/26 at 11:39AM a side-by-side review of Resident #3's medical record showed that several medical records for other residents were included in the document scanned for Resident #3 on 03/02/26 under Hospice Physician Telephone Order. The residents included were Resident #88, Resident #74, Resident #51, Resident #37 and Resident #23. Staff O acknowledged that she did not number and identify each document for each resident prior to scanning which created the error and all documents were scanned under the first resident, Resident #3.

Based on observations, interviews, and record review, the facility failed to document the census for 2 out of 4 days (05/13/24 and 05/14/26) reviewed for daily nurse staffing data.The findings included: During an observation conducted on 05/13/26 at 9:00 AM, it was revealed that the daily nursing staffing data was posted on the main hallway, near the nurses station. Further observation revealed the daily nursing staffing data posted, did not include documentation of the facility census.During a second observation on 05/14/26 at 7:47 AM the daily nursing staff posted was dated 05/13/26 and did not have the census documented. A third observation was conducted on 05/14/26 at 10:12 AM. The daily nurse staffing post was dated 05/14/26 but the facility census was not documented on the form.Photographic Evidence Obtained.During an interview conducted on 05/14/26 at 10:20 AM with the Human Resource Manager (HRM) she stated that she was responsible for entering the information on the form and posting the form. She stated that the scheduler provides the information for the staffing hours. When asked how she determines what census number to enter on the form she stated that it is midnight census.During a side-by-side review of the staffing sheets for 05/11/26, 05/12/26, and 05/13/26 it showed that the census for 05/11/26 and 05/12/26 were typed on the form. The census for 05/13/2026 was written by hand. When asked why the census was for 05/13/2026 written, she explained that she sometimes includes the census when she first generates the form but if not, she will fill it in when the form is taken down the following day when she reviews the form and makes any needed corrections since it will be used to calculate the two-week staffing.

Based on observations, interviews and record reviews, the facility failed to have an effective pest control program. The findings included: During a tour of the kitchen, on 09/10/25 at 8:50 AM, accompanied by the Dietary Manager, the following were noted: * One live and mature roach was observed on the door frame at the entrance to the janitorial closet.* One live and mature roach was observed in a container where a bag of sauce was stored.* Live mature and juvenile roaches, too numerous to count, were observed under the steamer around a floor drain where there was an accumulation of debris and residue.* Live mature and juvenile roaches were observed on the floor under and around the hand washing sink and the beverage station that were adjacent to each other. During an interview at the time of the observation, the Dietary Manager stated that the pest control company had just come out and treated the kitchen last week. The Dietary Manager stated, We do it every month (referring to the pest control company servicing the kitchen). Review of the most recent pest control invoices, on 09/10/25 at 10:20 AM revealed the following: * 07/11/25 - Pest Activity found during service - was blank* 08/01/25 - Pest activities found during service: Cockroaches noted during service - Cockroaches seen in kitchen area.* 08/18/25 - Pest Activity found during service: Cockroaches noted during service - Cockroaches seen in the kitchen During an interview, on 09/10/25 at 11:17 AM with the Pest Control Technician from the pest control company, when the findings were brought to his attention, the Pest Control Technician replied, We are treating tonight and that will be done. The plan moving forward is to keep treating until we don't see any. When asked about sanitation issues within the facility that contributed to the presence of pests, the Pest Control Technician replied, Mostly structural stuff. Every once in a while, there might be some issues around the dish pit - all in all it is a lot of wear and tear (the pest control technician was referring to the building and equipment being aged). The night crews are the ones that will be more likely to identify kitchen sanitation issues that contribute to pests because they come in after the kitchen is closed.

Based on observation, interview and record review, the facility failed to ensure personal privacy during medical treatment, of a med (medication) pass for 1 out of 6 sampled residents reviewed for med pass, affecting Resident #88. The findings included: Review of the facility's policy titled, Resident Dignity and Property Privacy with an effective dated of 04/2024, included in part, the following: The center provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Fundamental Information Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Procedure: 2. Examine and treat residents in a manner that maintains their privacy. a. Use a closed door, a curtain drawn, or both to shield the resident during all personal care and treatment procedures. Record review for Resident #88 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on 12/14/24. The resident's diagnoses included in part, the following: Pancytopenia, Cirrhosis of the Liver, Type 2 Diabetes Mellitus. and Unspecified Dementia. Review of the Minimum Data Set assessment for Resident #88, dated 12/20/24 with a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. On 01/13/25 at 10:23 AM, an observation of two med passes was performed by Staff A- Licensed Practical Nurse (LPN) for Resident #88. After entering the room, Staff A-LPN, did not provide privacy for the resident. She did not close the door, nor did she pull the privacy curtain around the resident. During an interview conducted on 01/13/25 at 10:25 AM with Staff A-LPN, she stated that she has worked at the facility for about 1 month. When asked why she did not provide privacy for the resident during med pass, she said she forgot. During an interview conducted on 01/14/25 at 8:30 AM with Staff B LPN, Charge Nurse, who was asked about providing privacy for resident during med pass, she said we always close the door and pull the privacy curtain.

Based on observations, interviews and record review, the facility failed to develop a care plan for 2 of 2 sampled residents, with a diagnosis of Post-Traumatic Stress Disorder (PTSD), affecting Resident#1 and #86. The findings included: Review of the facility's policy titled, Comprehensive Person-Centered Care Plans with a revised date of 08/2023, included in part, the following: The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Fundamental Information The comprehensive care plan will describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required are provided to the resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The comprehensive plan of care will include the following: Residents' individual needs, past trauma, strengths and preferences Identify triggers which may re-traumatize residents with trauma history and implement interventions which minimize or eliminate the effect of the trigger. 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Cerebral Ischemia, Anxiety Disorder Unspecified, Major Depressive Disorder Recurrent Moderate, Primary Insomnia, Post-Traumatic Stress Disorder Acute, Senile Degeneration of Brain and Unspecified Psychosis Not due to Substance or Known Physical Condition. Review of the Minimum Data Set Assessment for Resident #1 dated 10/17/24 documented in Section C a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Review of the Social Services Evaluation for Resident #1 dated 04/24/24 documented under evaluation in section G, TIC (Trauma Informed Care History): 1) Select all that may contribute to the resident - physical abuse 2) Does the event in your past cause you an emotional response, triggered by a sound, smell, touch or circumstance? - Yes 2a) Describe triggers- When people approach him too fast. Review of all of the care plans for Resident #1 revealed no care plan established for PTSD, including any triggers. 2. Record review for Resident #86 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Bullous Pemphigoid, Post-Traumatic Stress Disorder Chronic and Major Depressive Disorder Recurrent Unspecified. Review of the Minimum Data Set Assessment for Resident #86 dated 12/12/24 documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the Social Services Evaluation for Resident #86 dated 12/10/24 documented in Section H- TIC-History: 1) Select all that may contribute to the resident: Emotional abuse, Combat exposure/war, and Post-Traumatic Stress Disorder 2) Does the event in your past cause you an emotional response, triggered by a sound, smell, touch or circumstance -no Review of all of the care plans for Resident #86 revealed no care plan established for PTSD including any triggers. An interview was conducted on 01/13/25 at 10:58 AM with Resident #86 who stated he has PTSD and triggers. He explained briefly of his journey in the war. The resident became teary. An interview was conducted on 01/14/25 at 9:00 AM with Staff B, Licensed Practical Nurse / Charge Nurse she stated that she has worked at the facility since October 2024. When asked if a resident has PTSD how does she know what the triggers are? She stated she would have to go review the diagnosis, the doctor needs to diagnose the resident with PTSD. She said she does not know of any of her assigned resident's with PTSD. She added that the resident can have agitation and that can make the patient trigger. An interview was conducted on 01/14/25 at 1:17 PM with the Social Service Manager (SSM), who stated she has worked at the facility for under 1 year. When asked about residents with diagnosis of PTSD, the SSM said they do a Social Service Evaluation to ask about trauma informed care and the questions built into the form addresses triggers. For residents with a diagnosis of PTSD, we will automatically set them up with psych services. The SSM said once the Social Service Evaluation is completed, it will create a care plan for PTSD based on any identified triggers. She said there are specific questions for the triggers and if they are identified by saying yes to the questions, being asked, the system will automatically create a care plan for PTSD with triggers. When asked about Resident #86 if he has triggers, she said he answered no to triggers, so he would not have a care plan. When asked about Resident #1 if he has triggers, she said he also answered no to triggers and therefore no care plan. An interview was conducted on 01/14/25 at 12:57 PM with Staff E-Licensed Practical Nurse (LPN) / Resident Care Specialist, who the MDS (Minimum Data Set) assessments. She reported that she does not initiate care plans for residents, she updates and revises them for nursing and social worker and dietary do their care plans. She does oversee the care plans. If they need to be updated or revised she will complete that portion. Staff E was asked about care plans for Post-Traumatic Stress Disorder (PTSD) with triggers identified for Resident #86 and #1. She acknowledged neither resident had a care plan for PTSD with triggers identified An interview was conducted on 01/15/25 at 10:10 AM, with Staff D, Restorative Certified Nursing Assistant, who stated she has worked at the facility for 3 years. When asked if she has any residents that have diagnoses of Post-Traumatic Stress Disorder (PTSD), she said she did not really understand the question. When asked if she knows what PTSD is, she said not really. After it was explained to her, she was asked how she would know what, if any, triggers the resident may have and where she could find them. She said by how the resident acts, by what they tell you they remember, and their attitude. When asked if she would find anything in the resident's chart, she said maybe the chart or Kardex. An interview was conducted on 01/15 25 at 2:00 PM with Staff C Registered Nurse (RN) / Staff Develop Coordinator who stated she has worked at the facility for 3 years. When asked if a resident has PTSD, where she could find out what the triggers are, she said it would be in the care plan.

Based on policy review, record review, and interview, the facility failed to ensure a safe discharge, as evidenced by failing to provide necessary medications and reconciliation of all pre-discharge medications with the resident's post-discharge medications, upon discharge for 1 of 1 sampled resident reviewed for discharge (Resident #396). The findings included: The policy titled transfer, and discharge, dated 08/2023, indicated the transfer, and discharge process is designed to provide a safe, orderly transfer, or discharge from the center. The discharge planning process: the center will develop and implement discharge planning process that focuses on the resident's discharge goals and preparing residents to be active partners in post-discharge care, effective transition of the resident from SNF to post-SNF care, and the reduction of factors leading to preventable readmissions. The interdisciplinary team will involve the resident and resident representative in the development of the discharge plan, and communicate to the resident, and resident representative of the final plan encompassing the resident's goals to the extent possible. Documentation of a resident's interest in receiving information regarding returning to the community shall be completed and entered into the clinical record. A discharge order is obtained by nursing from the physician indicating where the resident is being discharged . Why is the resident being discharged , and if the resident is to be discharged with, or without medication. The interdisciplinary team discusses the discharge so that appropriate procedures can be implemented. Provide preparation, and orientation to the residents to ensure safe, and orderly transfer/discharge from the center. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the counter). Record review revealed Resident #396 was admitted to the facility on [DATE] and 09/28/24, and she was discharged on [DATE]. The quarterly comprehensive assessment reference date 11/20/24 recorded Resident #396 had pertinent diagnoses, including hypertension (high blood pressure), End Stage Renal Disease, and diabetes. The comprehensive assessment recorded a brief interview for a mental status score of 15, which indicated Resident #396 was cognitively intact. Further review of the clinical record showed evidence of a physician order dated 12/26/24 for Resident #396 to be discharged . An additional review of the records showed the following physician orders: 09/30/24 Gabapentin Capsule 300 MG give 1 capsule by mouth at bedtime for Neuropathy. 09/30/24 Rosuvastatin Calcium Tablet 5 MG: Give 1 tablet orally at bedtime related to Hyperlipidemia. 10/28/24 Carvedilol Oral Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth thrice daily every Tue (Tuesday) and Thu (Thursday) and related to essential (primary) hypertension. 10/28/24 Insulin Lispro Injection Solution (Insulin Lispro) injected as per sliding scale. 10/29/24 Protonix Tablet Delayed-Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning every Tue, Thu, Sat (Saturday), Sun (Sunday) related to gastroesophageal reflux disease. 10/29/24 Calcium Acetate Tablet 667 MG Give 1 tablet by mouth with meals every Tue, Thu, Sat, and for End Stage Renal Disease. 10/29/24 Levoxyl Tablet 50 MCG (Levothyroxine Sodium) Give 1 tablet by mouth in the morning every Tue, Thu, Sat, and Sun for Hypothyroidism and give 1 tablet by mouth in the morning every Mon (Monday), Wed (Wednesday), and Fri for Hypothyroidism. It was determined that Resident #396 was scheduled to receive the following medications: Rosuvastatin 5 mg on January 1st and 2nd at Bedtime. Carvedilol 6.25 MG on January 2nd, 3 times a day. Insulin on January 1st and 2nd as per sliding scale. Protonix 40 mg January 2nd in the morning. Calcium Acetate 667 mg on January 2nd with meals. Levoxyl 50 mg on January 1st in the morning. Review of Nursing progress notes dated 01/03/2025 at 2:25 PM, it was documented, (the writer) received a call from the insurance representative regarding Resident (#396's) medications; as per the resident's family, all her medications were refilled with the exception of 2 medications: Coreg and Rosuvastatin due to recent refills with the pharmacy. The writer informed the insurance representative that the family could come to the facility to pick up the resident's remaining medications for continuity of care. Resident #396's family member arrived at the facility and was provided with all active medications and diabetic supplies, which the resident received while residing at the facility, with additional discharge paperwork, education, and medication instructions. Resident #396's family member verbalized understanding of medications and their use. On 01/16/25 at 9:12 AM, an interview was held with the Director of Nursing (DON); when asked to explain the discharge-to-home process, she revealed the nurses are to obtain an order first, then social services do their part if the resident needs continuity of care. When the resident is ready, the facility provides scripts and medication if needed. Provide patient teaching and present with medication review. If the resident/representative requests the medications, we'll give them to them; for most Medicare patients, we give them their medications. The DON said she received a call from the insurance company; a representative stated, The resident's family member called them about her medications; the family member informed the insurance that Resident (#396) had medications filled upon discharge except for 2 (Rosuvastatin and Coreg). The insurance called the facility on January 3rd, around 10 AM, on behalf of the resident; the insurance indicated the medications were already filled for the month and paid by the insurance company, and the facility told the insurance company the family could come to get the medications from the facility. Resident #396's family member came to the facility and picked up the medications. On 01/16/25 at 10:40 AM, a phone call was placed to Resident #396's family member. She explained that no medications were given to the resident upon discharge, and the facility provided only a paper script; she came on 01/03/25 to pick up the medications, and the resident did not get any medications from 12/31/24 until 01/03/25. She stated, The facility provided the medications on 01/03/25 because the insurance company called them. When she went to the pharmacy, they informed her the script couldn't be refilled; they had already been refilled for the month.

Based on record review and interview, the facility failed to ensure antibiotics were administered as ordered for 1 of 3 sampled residents, reviewed for antibiotic therapy (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. a). Review of Resident #60's orders revealed an order dated 12/03/24 for Ertapenem (antibiotic) 1 gram intravenously (IV) every 24 hours for a multi drug resistant organism (MDRO) in the urine for 9 days. The antibiotic order was reduced to 7 days (until 12/10/24) on 12/05/24 per antibiotic stewardship suggestion. Review of Resident #60's medication administration record (MAR) revealed the resident received 8 doses of antibiotics in 7 days (given twice on 12/04/24). b). An order dated 12/15/24 for Ceftriaxone (an antibiotic) was ordered for 1 gram every 24 hours for 5 days for an elevated white blood cell (WBC) count. Review of Resident #60's MAR revealed the antibiotic was administered one time on 12/15/24. No documentation was found regarding the other 4 doses ordered. c). An order dated 12/19/24 for Zyvox (an antibiotic) was ordered for 600 milligrams 2 times a day for Bacteriuria (urine infection) for 7 days. A review of Resident #60's MAR revealed the antibiotic was administered 10 out of 14 times over the 7 day period. Further record review revealed no evidence of the physician notified of the discrepancies of the administration of antibiotics.

Based on interviews and record review, the facility failed to ensure smoking evaluations were completed for 2 of 9 sampled residents identified as smokers (Residents #66 and #75). The findings included: The facility's policy titled Smoking effective 10/24/22 and revised 09/23 revealed Residents that are active smokers will be identified on admission and reviewed when there is a significant change of status, quarterly, and annually thereafter. 1). Resident # 75 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Myalgia, and Type 2 Diabetes Mellitus. Her Brief interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/28/24. This indicated the resident is cognitively intact. Record review revealed on 04/26/24 Resident #75 had a safe smoking evaluation. On 10/31/24 the resident had another smoking evaluation. There were no additional smoking evaluations. The resident did not have a smoking evaluation in July 2024. In an interview with Resident #75 on 01/15/25 at 10:35 AM she stated she does not keep her cigarettes or lighter, they (the facility) keep them in a locked cart. She further reported that when she goes out to smoke, she is given her lighter and cigarette and someone from the facility stays with the smokers. They can't go out alone. An interview was conducted with the Director of Nurses (DON) on 01/15/25 at 2:30 PM. She stated it is the responsibility of the DON, Unit Manager, and MDS for the smoking evaluations. The Social Service Director created the smoking list and makes sure that it is up to date. Nursing will complete the evaluation on the admission assessment. On 01/16/25 at 11:31 AM an interview was conducted with Staff J, Unit Coordinator and Registered Nurse, regarding the smoking evaluations. She stated she does keep track of the evaluation as to when they are due, but only the residents in her unit. She further stated, now that Resident #75 is on her unit, she will be keeping track of it. 2). Record review for Resident #66 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on 09/27/24 with diagnoses that included Tobacco Use. Review of the Minimum Data Set for Resident #66 dated 01/03/2025 documented in Section C, a Brief Interview of Mental Status score of 15, indicating a cognitive response. A review of the smoking evaluations for Resident #66 revealed evaluations for 11/01/23, 05/13/24, 09/14/24, and 09/27/24. The resident was hospitalized on [DATE]-[DATE]. The resident did not have a smoking evaluation completed in February 2024 and December 2024.

Based on interview and record review, the facility failed to ensure physician visits were conducted within the required time frame, for 1 of 18 sampled residents (Resident #66). The findings included: Record review for Resident #66 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 09/27/24 with diagnoses that included, in part, the following: Bullous Pemphigoid, Venous Insufficiency (Chronic Peripheral), Elevated [NAME] Blood Cell Count Unspecified, Morbid (Severe) Obesity, Tobacco Use and Chronic Gout. Review of the Minimum Data Set Assessment for Resident #66 dated 01/03/25 documented in Section C, a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician/Practitioner Progress Note for Resident #66 from 01/01/24 to 01/12/25 revealed the following: On 01/22/24 written by Staff F Primary Physician. On 03/19/24 written by Staff F Primary Physician, which documented in part the following: Visit performed by Staff I APRN. On 05/30/24 written by Staff I Advance Practice Registered Nurse (APRN). On 07/26/24 written by Staff I APRN. On 9/17/24 written by Staff I APRN. On 10/04/24written by Staff I APRN. On 12/12/24written by Staff I APRN. This indicated the last time the resident was seen by the primary physician was on 01/22/24 and visits were not altered every 60 days between the Primary Physician and the APRN. During an interview conducted on 01/15/25 at 12:00 PM, with the Administrator, who was asked physician visit frequencies, she stated the resident is to be seen by the physician every 30 days for the first 90 days after admission then every 60 days thereafter and those visits can be alternated with the nurse practitioner. During a telephone interview conducted on 01/15/25 at 2:34 PM, with Staff F Primary Physician, who was asked how often he visits his residents at the facility, he stated he sees the residents every 30 to 60 days. However, Staff I Advanced Practice Registered Nurse (APRN) is his APRN, and she rounds regularly usually once or twice a week. Staff F Primary Physician said when he rounds he always rounds with Staff I APRN, and they split the census (he was not able to clarify how they split the census). Staff F Primary Physician stated Staff I APRN acts as his scribe and documents on his behalf, he stated he cannot document, and she documents on his behalf. When asked about the Physician/Practitioner Progress Noted for Resident #66 dated 03/19/24 and authored by him, with documentation that included Visit performed by Staff I APRN he could not explain this. During a telephone interview conducted on 01/15/25 at 3:42 PM, with Staff I APRN, who was asked how often she visits the residents, she said she usually sees the residents monthly and as needed. When asked about Staff F Primary Physician visiting the residents, she stated she does most of the documentation for Staff F Primary Physician for the patients seen by him, but he signs. During an interview conducted on 01/15/25 at 4:00 PM with Resident #66 who was asked how often Staff F Primary Physician visits him, he said he does not recognize the name, and asked do you have a picture of him to look at. When asked how often Staff I APRN visits him, he said that name is also not familiar to him and asked do you have a picture of her to look at. When asked how often Staff G Advanced Practice Registered Nurse (APRN) visits, he said he knows her well she comes to see him all of the time. During an interview conducted on 01/15/25 at 4:20 PM with Resident #66 who was shown a photograph of Staff F Primary Physician, the resident said I may have seen him once when I was in the hospital but have not seen him here (in the facility). When Resident #66 was shown the photograph of Staff I APRN, he said he has never seen her. (The photographs shown to the reisdent, were verified by the Administartor on 01/15/25 at 4:15 PM).

Based on record review and interview, the facility failed to coordinate care with hospice services for 1 of 1 sampled resident reviewed for hospice (Resident #13). The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and was dependent for activities of daily living. The assessment further documented the resident was receiving hospice services. A review of Resident #13's orders revealed the resident was admitted to hospice services on 11/15/24. Resident #13 was care planned for hospice services. An intervention included to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. A review of Resident #13's hospice record, located in the facility's hospice binder at the nurse's station, revealed missing hospice documentation. Resident #13's binder only included the initial certification for hospice and a plan of care. The binder lacked assessments, visitation notes, and services provided. An interview was conducted with the Nurse Manager (NM) on 01/16/25 at 10:00 AM. The NM stated when hospice personnel visit Resident #13, they usually leave documentation in the binder. The NM acknowledged there was no documentation of services received. The NM stated she would look in medical records to see if any documentation was to be uploaded. An interview was conducted with the Director of Nursing (DON) on 01/16/25 at 12:00 PM. The DON stated she called hospice to get copies of Resident #13's records/visits.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct an identified quality deficiency in the problem area as evidenced by repeated deficient practice for F656, Comprehensive Resident Centered Care plan. This repeated deficient practice had the potential to affect all 85 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited at F656, (Comprehensive Resident Centered Care Plan), during the Recertification and Relicensure survey with an exit date of 09/14/23. Review of the QAPI program with the Administrator revealed the lack of an effective corrective action plan for the above deficiency. During an interview with the facility's Administrator on 01/16/25 at 2:43 PM, the Administrator was apprised that this deficiency would be cited on the current survey. This was acknowledged by the Administrator.

Based on observation, interview, and record review, the facility failed to follow up for a Vancomycin Resistant Enteroccocus (VRE) (a multi-drug resistant organism) infection and precautions for 1 of 3 sampled residents reviewed for antibiotic therapy (Resident #60), and failed to wear appropriate personal protective equipment (PPE) during of care of resident on enhanced barrier precautions (EBP) (Resident #71). The findings included: 1). Record review revealed Resident #60 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment and was dependent for activities of daily living. Record review revealed Resident #60 was on enhanced barrier precautions for ESBL (a multi-drug resistant organism) in the urine from 12/03/24 - 12/11/24. A review of Resident #60's orders revealed an order dated 12/14/24 for a urinalysis culture and sensitivity. The culture was reported positive for VRE (a multi-drug resistant organism) on 12/18/24. An order dated 12/19/24 for Zyvox (an antibiotic) was ordered for 600 milligrams 2 times a day for Bacteriuria (urine infection) for 7 days. Further record review revealed no evidence of Resident #60 being placed on any precautions, or of any follow-up after the antibiotic was administered. 39167 2) Review of the facility's policy titled, Infection Prevention and Control, dated 06/28/24, revealed, Enhanced Barrier Precautions may be implemented for those with a documented or suspected infection or colonization with a multi-drug resistant organism, or have risk of acquiring infections based on portals of entry or indwelling medical devices such as indwelling urinary catheter; g-tube, central lines, tracheostomy, or wounds requiring a dressing; regardless of infection or colonization status, or reported by the infection preventionist laboratory based on the centers' antibiogram when available. Equipment includes the use of gown and gloves during the direct care of resident that consists of close contact such as: bathing, dressing, incontinent care, transferring, indwelling device care, and other activities that may have the resident in close contact with the staff member. Clinical record review revealed Resident #71 was admitted to the facility on [DATE] and 09/25/24, with a diagnosis that included Diabetes. The quarterly comprehensive assessment with a, reference date of 11/01/24, recorded no brief interview for mental status score, indicating Resident #71 was rarely/never understood. Review of additional clinical records evidenced the following physician orders: Dated 12/15/24 for Enhanced Barrier Precautions every 24 hours for Chronic Wound; dated 12/02/24 physical therapy treatment 3 times per week for 12 weeks, for wound care, Low frequency, non-contact, non-thermal ultrasound, Vaporox. Dated 01/01/25 for the right lateral ankle and left heel wound. On 01/15/25 at 12:42 PM, Resident #71 was observed lying in bed, she was receiving wound therapy with the Vaporox machine of the left heel wound. While the surveyor was standing in the room, on 01/15/25 at 12:48 PM, a staff member, Staff K, a physical therapist arrived. Staff K began attending to the Vaporox machine, by removing the bag that covered the left foot, and Staff K raised Resident #71's left foot, and a large wound with drainage was observed to the left heel, during that time, Staff K did not wear a gown while touching Resident #71's foot. On 01/16/25 at 12:37 PM, a phone call was placed to Staff K to inquire about the facility's Enhanced Barrier Precaution (EBP) process and procedure. She voiced that she was aware of the EBP procedure. She acknowledged she didn't wear a gown while providing direct care to the resident. On 01/16/25 at 1:30 PM an interview was held with the Director of Nursing (DON) and she was informed of the breach of infection control by Staff K.

Based upon interview, observation and record review the facility failed to provide a safe environment to prevent a resident from eloping. This affected 1 of 3 sampled residents reviewed for wandering/elopement risk, Resident #1. Resident #1 exited the facility without staff knowledge on 03/19/21 at approximately 1:00 AM. The facility's system failure with a lack of adequate supervision, an exit door where the door alarm did not sound and the alarm annunciator at the nurses' station not being loud enough to be heard, allowed the resident to elope without staff knowledge and wander outside of the facility unsupervised. Resident #1 was returned to the facility, unharmed, by the police at 1:25 AM on 03/19/21. While resident #1 was out of the facility unsupervised there was likelihood she could have fallen, become lost or been struck by a car or a train, resulting in serious injury, harm, or death. These actions resulted in Immediate Jeopardy. At the time of the investigation there were 8 residents who were identified as wander/elopement risk. The facility administrator was informed of the Immediate Jeopardy on 04/02/21 at 5:06 PM. The Immediate Jeopardy was removed on 03/19/21. The facility's noncompliance at F689 was corrected on 3/21/21 and determined to be past noncompliance when the facility had fully implemented corrective actions, prior to the complaint survey. The findings included: Record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. The Resident had an admission Minimum Data Set (MDS) assessment on 07/02/20. This assessment indicated the resident Brief Interview for Mental Status (BIMS) score of 1/15, indicating Resident #1 was severely cognitively impaired. Resident #1 was coded as having wandering behaviors that occurred between 1 to 3 days prior to the assessment. Resident #1 was assessed initially as requiring Extensive Assistance with one-person physical assist for Locomotion on and off the unit, and Limited Assistance with one person physical assist for Walking. The Resident had her admission Minimum Data Set (MDS) assessment on 07/02/20. In that assessment under Section E - Behavior, Resident #1 was identified having wandering behaviors that occurred between 1 to 3 days prior to the assessment. Based upon the frequency of wandering identified in the assessment, along with Resident #1's Brief Interview of Mental Status (BIMS) of 1/15 (indicating severe cognitive impairment) with a primary [DIAGNOSES REDACTED].#1 was an elopement/wander risk and placed a wander guard device on her right leg. On the Significant Change in Status MDS dated [DATE], the resident had changes in Activities of Daily Living (ADL) as follows: Walking: Supervision with one person physical assistance; Locomotion: Supervision with one person physical assistance. During an interview with Staff C on 03/31/2021 at 9:48 AM, Staff C indicated that Resident #1 walked freely about the hallway and clarified that Resident #1 did not use any assistive devices. The resident had a Care Plan that addressed elopement risk from admission, 06/25/20. The Focus of the care plan stated Resident #1 (her name was stated) is at risk for elopement AEB (As Evidenced By) Disoriented to place, history of attempts to leave the facility unattended, impaired safety awareness, resident wanders aimlessly. The Goal section that Resident's safety will be maintained through next review date, with the target being 4/12/21. Interventions included: Alerting bracelet is placed (Right Leg); Check Alerting bracelet function every day; Check alerting bracelet placement every shift; Involve resident in appropriate activities such as coloring and drawing, listening to music as tolerated; Offer pleasant diversions, structured activities, food, television, books; Offer reassurance and support as needed; Picture of resident kept in Elopement Binder(s); reorientation to person, place and time as needed Review of the facility's investigation report revealed Resident #1 was last seen in the facility, prior to the elopement, at approximately 12:57 AM (just before 1:00 AM) on 03/19/21. The report documented Resident #1 eloped from the Southeastern side, alarmed, and magnetically locked fire safety door located in the Southeastern residential wing away from the main entrance. During an interview with the Administrator, on 03/31/21 at 10:30 AM, it was revealed that there were mechanical failures with the alarm system. Resident #1 was out of the facility and off the grounds until 1:25 AM on 3/19/21. This was the time the police returned Resident #1 to the facility. This information was determined by photographs, captured from video surveillance, supplied by the facility. Resident #1 was identified as an elopement risk and had a wander guard bracelet on her right leg. The facility did not have wander guard sensors on all doors, only on the front door. The Administrator explained that all the other doors were alarmed with a 15 second delay between the time the release bar is pressed, and the door opens. During that time frame the alarms are supposed to sound and staff is expected to respond promptly to the alarm. Resident #1 left the facility through the southeastern exit and turned right. Resident #1 passed an out-building, with an area behind it that had large coral stones and a wooden fence in disrepair. In front of the building there was a steep drop-off. Lining the drop-off was a concrete barrier that appeared to have loose, large, cement slabs vertically placed and leaning away from the building. Resident #1 then walked through the parking lot to the sidewalk that runs along the 4-lane roadway, with traffic lights, that is adjacent to the facility. The resident walked eastward toward a traffic circle within 50 feet of the driveway. Just north of the traffic circle there is a residential, two-lane divided roadway with a 25 mile per hour (mph) speed limit. To the south and east of the traffic circle there are two similar roadways. On the left of the sidewalk there is a vacant lot with trees along the edge. The soil in the vacant lot is loose, soft sand and there are tree roots sticking out of the ground. The police found Resident #1 in the vacant lot. The police had not been called by the facility as the staff was unaware of the elopement until the police came to the facility. A determination could not be made as to whether the police were called by someone else or were in the area on patrol. On 04/01/21 at approximately 10:00 AM a telephone interview was conducted with police to determine if the police report was completed. During the interview it was learned that there no formal report created on the night of the incident and the cursory report only supplied the base information already known. Upon her return, Resident #1 had a full assessment that revealed no injuries. Resident #1's family and doctor were notified of the elopement and her safe return. During the day of 03/19/21, documentation noted in progress notes entered at 9:09 AM, Resident #1 was described as being extremely agitated. New orders were received for [MEDICATION NAME] to 1 mg by mouth every 4 hours as needed for agitation, for [MEDICATION NAME] to 7.5 mg by mouth 2 times daily, and for a psych consult. On 3/19/21 at 2:53 PM an order was received to transfer Resident #1 to a hospital with an on-site hospice unit (Internal Palliative Unit (IPU)) for increased agitation and anxiety. Staffing at the time of Resident #1's elopement was as follows: On the Northwest wing, where Resident #1 lived, there was one CNA and one Nurse assigned. For the combined North wing, east and west, there were three CNAs, and 1 Nurse. For the South wings, east and west, there was one Nurse and three CNAs. There was one RN Supervisor for the entire facility. The Northeast wing is the long-term care unit with stable residents that have a low acuity of need as per the Director of Nursing (DON). There was a 1:11 ratio of CNAs to resident for short term care for the South wing with three CNAs for 33 residents and there was a 1:15 ratio of CNAs to residents on the long-term care, North wing, with 3 CNAs for 44 residents. There was one Nurse on the South wing who would assist with care on the north wing. According to the DON there was a ratio of 1:38 Nurses to residents for the entire facility. The DON stated that there was no high acuity (unstable or requiring extra care) residents in the facility at the time of the elopement. Observations, on 03/30/21 at 11:13 AM, revealed the facility has a chain link fence that runs the perimeter around the building from the southeast paved area north to the employee parking, turning west and along the western side of the building and ends prior to the front of the building/parking lot. Directly behind the building, there is an area where there are discarded pallets and a trash compactor. From the southeastern exit and turning right there is a small outbuilding with an area of large coral stones and a wooden fence in disrepair. Heading westward (turning right) there is steep drop-off in front of the outbuilding. Lining the drop-off is a concrete barrier that appears to have loose, large, cement slabs that are vertically placed but are leaning away from the building. The pathway leads to the parking lot and driveway. The facility is adjacent to a 4-lane roadway with traffic lights and a traffic circle. Heading east on the sidewalk there is a traffic circle within 50 feet of the driveway. To the left of the sidewalk at approximately 25 to 50 feet from the driveway of the facility there is a vacant lot with seven trees at the southeastern border of the vacant lot. The ground of the lot is sandy and there are exposed tree roots near the trees. Just north of the traffic circle there is a residential, two-lane divided roadway with a 25 mile per hour (mph) speed limit. The facility is surrounded by several residences in the general vicinity. To the south and east of the traffic circle there are two similar roadways. To the west of the driveway there is a sidewalk that is adjacent to the road. Along this part of the sidewalk, at approximately 0.2 miles away, there is a storm drain with a metal grate that is somewhat protected by a handrail. At approximately 0.4 miles there is a railroad crossing and a passenger train station. The station is on the south side (the opposite side from the facility) of the main roadway. While out the facility Resident #1 may have gotten lost, may have fallen, may have been struck by a car or may have been struck by a train. All these dangers may have resulted in severe injury or death. On 03/31/21 at 9:04 AM an interview was conducted with Staff A, a Licensed Practical Nurse (LPN). Staff A stated that she was working in the Northwest wing of the facility, where Resident #1 lived, and she had seen Resident #1 wandering the hallways. Staff A stated that it was not unusual for Resident #1 to be walking the halls at night. Staff A stated that she only found out about the elopement when Staff C, a Registered Nurse (RN), informed Staff A that the police were at the facility asking to speak with the nurse regarding Resident #1. Staff A stated that she was in either room [ROOM NUMBER] or 49 performing care at the time of the elopement. Staff A stated that she did not hear any alarms during her shift. When asked about post-elopement training, Staff A stated drills were done for alarms and elopement and reviews were done for Code Yellow (missing person). On 03/31/21 at 9:29 AM an interview was conducted with Staff B a Certified Nursing Assistant (CNA). Staff B stated that she did not know resident #1 was out of the building until the police returned Resident #1 to the facility. Staff B stated that Resident #1 was brought back to the facility. Staff B stated that Resident #1 was frequently walking around the facility at night, but Staff B did not feel that Resident # 1 was exit seeking. Staff B stated that she did not hear any alarm sound during her shift. The CNA stated she has a tablet to document resident observation and room checks. The CNA stated education was done after the elopement. Training was done on Code Yellow (Missing Person), elopement, and alarm drills. Staff B stated that she believes alarm drills were done for 7 days. On 03/31/21 at 9:48 AM an interview was conducted with Staff C, a Registered Nurse (RN). Staff C stated that she found out about Resident #1's elopement when the police returned Resident #1 to the facility at about 1:30 AM. Staff C stated that she was the one who responded to the police at the front door at around 1:30 Am on 3/19/21. Staff C stated that she notified Staff A that the police wanted to speak to Staff A regarding Resident #1. Staff C stated that she had seen Resident #1 wandering in the halls but was not concerned because this was common with Resident #1. Staff C stated that she had not heard an alarm at that time. On 03/31/21 at 10:48 AM, an interview was conducted with the Vice President of Operations (VPO). The VPO confirmed that there had been a system failure involving the Alarms and the annunciator, an alarm panel at nurses' station that signals when a locked door that has been opened by pressing on the release bar. The Screamer Alarm on the door had a dead battery and therefore did not sound and the annunciator panel volume was set too low to be heard away from the nurses' station. The VPO stated that there had been a CNA documenting near where Resident #1 had eloped, but she was in a Family Visitation Room/Television Room and did not have a line of sight on the residential area where Resident #1 eloped. On 03/30/21 at 1:38 PM, an interview was conducted with Maintenance Director. According to the Maintenance Director, the batteries in the alarm were to be changed every six months per manufacturer's guidelines. A copy of these guidelines was reviewed by surveyor. The batteries for the failed alarm had been changed 11/30/20. The Maintenance Director provided a copy of his monthly alarm testing sheet. The Maintenance Director confirmed that on the morning of 03/19/21, after the elopement, the battery had been found to be dead. The Maintenance Director tested both the door lock alarm and the door exit (Screamer) alarm on the Southeastern door on the morning of 3/19/21, the Maintenance Director was unsure of the time he made his test. The Maintenance Director stated that when he tested the door, he first pushed on the door release bar for 3 seconds which activated the alarm panel at the nurses' station. It was at that time that a determination was made that the volume of the panel was not loud enough for the alarm to have been heard in other parts of the building as it was barely heard in the Southeastern wing. When the Maintenance Directed opened the door the Screamer Alarm did not sound. This is how he determined that the battery was dead. On 03/31/21 at 12:48 PM a telephone interview was conducted with family of Resident #1. The family confirmed that after Resident #1 was transferred to the hospital inpatient hospice unit the family visited Resident #1 in that unit. During their visit the family realized that Resident #1 was acting like she did when she had previously had a Urinary Tract Infection [MEDICAL CONDITION]. The family stated that Resident #1 was exhibiting aggressive behavior toward the hospice staff. The family stated that treatment for [REDACTED]. The family stated that they think Resident #1 may have left the facility, in the early morning of 03/19/21, because the family had visited Resident #1 earlier on the day prior to the elopement, 03/18/21, and Resident #1 was reluctant to let the family leave. The family stated that Resident #1 repeatedly asked them to stay or to let her come home with them. The family stated that they did not think to tell the facility of this at the time. On 04/01/21 10:29 AM an interview was conducted with Staff D, a CNA, who worked the 11 PM- 7AM shift that spanned from 03/18/21 to 03/19/21. Staff D was the CNA identified by the VPO as to not documenting in a proper location. Staff D admitted to being in the Television (TV) room documenting when the elopement occurred. Staff D stated that she could not see the exit door from her position in the TV room. Staff D stated that the facility had in-services to make sure nursing staff knew that documentation was to be done at the nurses' station or in the hallway. On 04/02/21 at 2:32PM, an interview was conducted with Staff E regarding wander guard placement and testing. Staff E explained that there are two testing units within the facility, one for the North wing and one for the South wing. Staff E explained that to test a wander guard the operator would turn on the test, wait for the screen to show ready, and place the tester near the wander guard bracelet. The test will indicate in its screen if the wander guard is working. A wander guard that is not working is replaced with a new wander guard. Staff E stated that the facility dose random knowledge checks for testing wander guards. On 04/02/21 at 2:54 PM, an interview was conducted with Staff F, an RN, regarding wander guard placement and testing. Staff F stated that to test a wander guard the operator would turn on the testing device, wait for the screen to show ready, and place the device near the wander guard bracelet. Staff F stated that if the wander guard is working the testing device would have the word OK on its screen. A wander guard that is not working is replaced with a new wander guard. Photographic evidence obtained. The facility's immediate jeopardy removal plan included: 1. The replacement of the Screamer Alarms with an upgraded model where the alarm can be silenced with a key but will remain armed without further intervention. These alarms also include a low-battery warning. These were installed on 3/19/21. 2. A correction to the annunciator panels at the nurses' stations to increase the volume levels that allowed the alarms to be heard through-out the facility. This was completed on 03/19/21. 3. Training in-services for Elopement, Abuse/Neglect/Exploitation, and Caring for Cognitively Impaired Residents were completed from 03/19/21 to 03/21/21 for all staff excluding new hires who were trained between 03/23/21 to 03/30/21 during orientation. All nurses and CNAs were provided in-services on proper location for documentation to ensure a visible presence to discourage elopement from 03/19/21 to 03/21/21. 4. There were QAPI initiatives created on 03/19/21 which included the following: a. Elopement drills will be done once per shift per month, for a total of three drills monthly. b. The staff has been educated on documentation being done with an emphasis on being constantly visible and have eye contact on the surroundings. c. The DON, the unit managers and supervisors will do active rounding on all shifts to ensure documentation is done as prescribed. d. There will be an audit sheet to be completed during the rounds. e. These will be brought to QA monthly. Audits are expected to be on-going. f. The staff is being quizzed with retention questions to ensure the staff continue to document as expected. 5. The Managers on Duty as well as the Maintenance Director have been trained on proper procedures for checking the door locks and alarms. This ensures all doors are check daily 7 days a week.