Every finding on record at Mission Convalescent Home

Based on the American Council on Aging Website review, facility policy review, medical record review, and interview, the facility failed in their responsibility in maintaining assets under $2,000 for the 2026 Tennessee Medicaid allowance to prevent residents from losing Medicaid benefits for 6 of 19 (Resident #2, #13, #27, #34, #36, and #43) sampled residents reviewed for personal funds. The findings include: 1. Review of the American Council on Aging Website, Tennessee Medicaid (TennCare) Income & Asset Limits for Nursing Homes & In-Home Long Term Care, dated 7/29/2026, revealed .In 2026, single Medicaid Nursing Home applicant in Tennessee must meet the following criteria.Assets under $2,000. 2. Review of the undated facility policy titled, Resident Trust Fund Policy, revealed .The Administrator, Business Office Manager, and other designated staff are responsible for.ensuring compliance with all applicable federal and state regulations. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Anxiety, Depression, and Dysphagia. Review of Resident #2's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $3,507.47, an excess of $1,507.47. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Aphasia, Heart Failure, and Dementia. Review of Resident #13's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $3,328.76, an excess of $1,328.76. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Aphasia, Heart Failure, and Dementia. Review of Resident #27's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $2,514.49, an excess of $514.49. 6. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Dysphagia, Dementia, and Psychosis. Review of Resident #34's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $3,453.22, an excess of $1,453.22. 7. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphagia, Anxiety, and Hypertension. Review of Resident #36's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $2,747.36, an excess of $747.36. 8. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes Mellitus, Anxiety, and Depression. Review of Resident #43's Trust Transaction History document dated 1/1/2026 through 6/30/2026, revealed an account balance of $2,935.76, an excess of $935.76. 9. During an interview on 7/29/2026 at 8:24 AM, the Business Office Manager (BOM) was asked who manages the resident's trust accounts. The BOM stated, I do. The BOM was asked what the limit for resident trust accounts. The BOM stated, The amount should be under $2000. During an interview on 7/29/2026 at 10:13 AM, the Administrator was asked the limit resident for resident trust accounts. The Administrator stated, $2000.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Licensed Practical Nurse (LPN) A) Nurses failed to perform hand hygiene during medication administration for 1 of 5 (Resident #35) sampled residents reviewed for medication administration. The findings include: 1.Review of the facility policy titled, Hand Hygiene, dated 10/23/2025, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection.If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled, Medication Administration, dated 10/10/2025, revealed .Wash hands prior to administering medication per facility protocol and product.Administer medication as ordered.Wash hands using facility protocol and product. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Parkinson's Disease, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the Physician's Orders dated 7/15/2026, revealed .Allopurinol Oral Tablet 100 MG [Milligram] Give 1 tablet by mouth two times a day for Gout hand .Aspirin 81 Oral Tablet .Give 1 tablet by mouth one time a day for heart health .Benztropine Mesylate Oral Tablet 0.5 MG .Give 1 tablet by mouth one time a day related to PARKINSON'S DISEASE .Brimonidine Tartrate Ophthalmic Solution 0.15 % [percent] .Instill 1 drop in both eyes two times a day related to .CATARACT .Gabapentin Oral Capsule 100 MG .Give 1 capsule by mouth three times a day for neuropathic pain .hydrochlorothiazide Oral Tablet 12.5 MG .Give 1 tablet by mouth one time a day related to.HYPERTENSION .Meloxicam Oral Tablet 7.5 MG .Give 1 tablet by mouth in the morning for Osteoarthritis .Tramadol .Oral Tablet 50 MG .Controlled Drug Give 1 tablet by mouth every 12 hours for Osteoarthritis pain .Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML [Milliliter] .Inject 18 unit subcutaneously in the morning for DM [Diabetes Mellitus] .[Brand Named (analgesic - pain relief)] External Cream 10 % . Apply to right hand topically three times a day for Pain to right hand .buspirone .Oral Tablet 15 MG .Give 1 tablet by mouth two times a day related to GENERALIZED ANXIETY DISORDER .Calcium 600 Oral Tablet .Give 1 tablet by mouth in the morning for Hypocalcemia .Ferrous Sulfate Tablet 325 .MG Give 1 tablet by mouth in the morning for Iron Deficiency Anemia .Furosemide Oral Tablet 40 MG . Give 1 tablet by mouth in the morning for Edema of bilateral LE [lower extremities] . Observation during medication administration in the North Hallway in front of Resident #35's room on 7/28/2026 at 8:11 AM, revealed LPN A washed her hands, entered Resident's room, and checked Resident #35's blood pressure. LPN A exited the Resident's room and gathered the following scheduled medications from the North Medication Cart for administration: Allopurinol 100 mg, Aspirin 81 mg, Benztropine Mesylate 0.5 mg, Gabapentin 100 mg, hydrochlorothiazide 12.5 mg, Meloxicam 7.5 mg, Tramadol 50 mg, buspirone 15 mg, Calcium 600, Ferrous Sulfate Tablet 325 mg, and Furosemide 40 mg oral medications, Brimonidine Tartrate Ophthalmic Solution 0.15 %, Basaglar KwikPen, and (Brand Named) analgesic External Cream 10 %. LPN A donned gloves and did not perform hand hygiene. LPN A administered eye drops 1 drop per eye, in inner corner, removed gloves and did not perform hand hygiene. LPN A donned clean gloves and administered insulin to Resident #35's right lower abdominal quadrant. LPN A removed soiled gloves and donned clean gloves without performing hand hygiene in between glove change, applied cream to Resident #35's right hand, removed gloves, and administered oral medications. LPN A exited the room and performed hand hygiene. LPN A failed to perform hand hygiene prior to donning clean gloves and after removing soiled gloves. During an interview on 7/28/2026 at 8:36 AM, LPN A was asked should she have performed hand hygiene in between glove changes. LPN A stated, Yes. LPN A was asked if she performed hand hygiene in between her glove changes. LPN A stated, No I didn't. During an interview on 7/29/2026 at 7:41 AM, the Director of Nursing (DON) was asked when hand hygiene should be performed. The DON stated, Staff should sanitize or wash hands before administering medications and after administration. The DON was asked if hand hygiene should be performed in between glove changes during medication administration. The DON stated, Staff should sanitize in between glove changes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 (Licensed Practical Nurse (LPN A) failed to don Personal Protective Equipment (PPE) while administering medications and performing wound care to 2 of 3 (Resident #22 and #33) residents reviewed for Percutaneous Endoscopic Gastronomy (PEG) (a tube in the stomach that provides nutrition) tube and pressure ulcers. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/25/2025, revealed .Enhanced Barrier Precautions .EBP .refer to .an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .wounds .feeding tubes .High contact resident care activities include .device care or use .feeding tubes .wound care . 2. Review of the medical record revealed Resident #22 was admitted [DATE], with diagnoses including Hemiplegia, Diabetes, and Encounter for Surgical Aftercare Following Surgery on the Digestive System. Review of the Physician Order dated 4/10/2025, revealed .Enhanced Barrier Precautions R/T [related to] indwelling medical device [Gastronomy Tube] [PEG tube] . Observation in the Resident's room on 7/1/2025 at 11:30 AM, revealed LPN A accessed the PEG tube of Resident #22 for medication administration without donning PPE in an enhanced barrier room. 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anxiety, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of the Care Plan for Resident #33 dated 5/13/2025, revealed .The resident has (stage 3) pressure ulcer to left hip r/t HxA [History] of ulcers . Observation in the Resident's room on 7/1/2025 at 2:18 PM, revealed LPN A performed wound care on Resident #33's pressure ulcer without donning PPE in an enhanced barrier room. During an interview on 4/2/2025 at 11:55 AM, the Director of Nursing confirmed that nurses should don PPE when administering medication through a PEG tube and when performing wound care.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when frozen food was not stored on a shelf to allow circulation, the corn meal, sugar, and flour bins were undated and unlabeled, expired food and frozen food was observed with thick build-up of ice crystals in 2 of 2 reach-in freezers and 1 of 1 reach-in refrigerators, and a pink/brown substance found in 1 of 1 ice machines. The findings include: 1. Review of the facility's policy titled, Food Storage, with a revised date of 11/1/2014, revealed .Any expired or outdated food products should be discarded.All products should be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators. Review of the undated facility's policy titled, Infection Control Policy, revealed .Ice may be contaminated and may cause and [an] outbreak of nosocomial infections [an infection acquired in a hospital or healthcare facility].The following procedures should be followed to reduce contamination of the ice [ch]ests and machines .Maintenance is responsible for [ensuring] cleaning is done. Cleaning should be carried out with a detergent solution, after disconnecting the unit, removing and discarding all ice, and allowing the chest to warm to room temperature. Use clean rags or disposable wipes to scrub all surfaces. 2. Observation in the single door reach-in freezer on 6/30/2025 at 8:38 AM, 7/1/2025 at 8:49 AM, and 7/2/2025 at 9:09 AM, revealed 4 chocolate meringue pies on the floor of the freezer, not stored on a shelf to allow circulation. Observation in the kitchen on 6/30/2025 at 8:40 AM, revealed the corn meal, sugar and flour bins were undated and unlabeled. Observation in the double door reach-in freezer on 6/30/2025 at 8:47 AM, revealed the following: a. A bag of hot dogs with a use by date of 6/27/2025. b. A bag of Salisbury steaks with a use by date of 6/27/20205. c. A bag of Tater Kegs with a use by date of 6/19/2025. d. A bag of chicken with a thick white build-up of ice in the bag frozen to the bottom of the freezer. e. A bag of fried steaks with a thick white build-up of ice in the bag. f. 6 bags of frozen chicken stored on the floor of the freezer, not stored on a shelf to allow circulation. g. 4 packages of ground beef stored on the floor of the freezer, not stored on a shelf to allow circulation. h. 8 packaged rack of ribs stored on the floor of the freezer, not stored on a shelf to allow circulation. i. 3 packaged hams stored on the floor of the freezer, not stored on a shelf to allow circulation. Observation in the double door reach-in refrigerator on 7/1/2025 at 8:51 AM and 7/2/2025 at 9:11 AM, revealed a bag with 5 heads of lettuce stored on the floor of the refrigerator, not stored on a shelf to allow circulation. Observation in the double door reach-in freezer on 7/1/2025 at 8:53 AM and 7/2/2025 at 9:16 AM, revealed the following: a. 6 bags of frozen chicken stored on the floor of the freezer, not stored on a shelf to allow circulation. b. 4 packages of ground beef stored on the floor of the freezer, not stored on a shelf to allow circulation. c. 8 packaged rack of ribs stored on the floor of the freezer, not stored on a shelf to allow circulation. d. 3 packaged hams stored on the floor of the freezer, not stored on a shelf to allow circulation. During an observation and interview on 7/1/2025 at 8:30 AM, the Certified Dietary Manger (CDM) was asked what was the pink/brown substance on the inside of the ice machine along the entire width of the plastic dispenser. The CDM stated, I think it's mildew. The CDM wiped an area with a paper towel, a pink residue was left on the paper towel. 3. During an interview on 7/1/2025 at 3:26 PM, the CDM confirmed food items should not be stored beyond the use by date and food should not have a thick white build-up of ice crystals on it. During an interview on 7/1/2025 at 4:09 PM, the Maintenance Supervisor was asked whose responsibility it is to clean the ice machine. The Maintenance Supervisor stated, We are going to assign that to the floor tech . During an interview on 7/2/2025 at 9:28 AM, the CDM confirmed food items/storage bins should be labeled and dated to reflect its contents. The CDM was asked if food items should be stored without a rack or shelf on the bottom of the freezer/refrigerator to allow circulation. The CDM stated, .we try to keep it stacked to allow circulation .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure resident assessments were completed at the time of a fall and that a post fall assessment was completed after falls for 1 of 12 (Resident #29) residents reviewed for falls. The findings include: 1. Review of the facility's policy titled, Fall Documentation Protocol, with a revised date of 2/13/2025, revealed An incident report must be completed whenever there is a fall by the nurse on duty in [Named Electronic Medical Record] .MD [Medical Doctor], RP [Responsible Party], and DON [Director of Nursing] must be contacted .all falls must have neuro checks (witnessed or unwitnessed) .Fall investigation .statements .from staff on duty .Fall assessment should be completed .Fall assessment should be completed in [Named Electronic Medical Record] .care plan should be updated .72 hour follow up nurse's note must be done after each fall every shift .Ensure each section is completed. It's not completed until you have signed the last section. Review of the facility's policy titled, Fall Prevention Program, dated 10/21/2024, revealed .Each resident's risk factors and environment hazards will be evaluated when developing the resident's comprehensive plan of care.Interventions will be monitored for effectiveness.The plan of care will be revised as needed.When any resident experiences a fall, the facility will.Assess the resident.Complete a post-fall assessment.Complete an incident report.Document all assessments and actions.Obtain witness statements. 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Dementia with Psychotic Disturbance, Obsessive Compulsive Behavior, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had severe cognitive impairment. Review of the Care Plan dated 4/29/2025, revealed .fall no injuries obtain UA [urinalysis] .fall 5/26/2025 no injuries- Staff to do frequent checks while resident is in restroom he stays for extended periods of time .6/5/2025 fall no injuries Staff will encourage to use bigger bathroom with more room and transfer bars . Review of the facility's Fall investigation, dated 4/29/2025, revealed Resident #29 .Fell in the bathroom when resident got up to bathroom . Review of the Incident report dated 4/29/2025, revealed .[Resident #29] observed on floor on butt in bathroom. [named Resident #29] said I fell off the toilet . Review of the Progress Note for Resident #29 dated 4/30/2025, revealed continue f/u [follow up] observance, falling star safety measures in effect, neuro negative, no new c/o [complaints] . Review of the Fall Risk Evaluation dated 4/29/2025, revealed a score of 12, which indicated Resident #29 was a high risk for the falls. The facility was not able to provide a Resident assessment, the post fall assessment, or staff statements for Resident #29's fall on 4/29/2025. Review of the facility's Incident Report dated 5/26/2025, revealed Resident #29 was .observed in bathroom on floor upright in front of toilet. Review of the Progress Note dated 5/26/2025, revealed observed [Resident #29] at 0715 [7:15 AM] on floor in bathroom sitting upright in front of toilet, he says I fell getting off the toilet . Review of the Fall Risk Evaluation dated 5/16/2025, revealed a score of 14, which indicated Resident #29 was a high risk for falls. The facility was not able to provide a Resident assessment, the post fall assessment for the fall, or staff statements for Resident #29's fall on 5/26/2025. Review of the facility's Progress Note' dated 6/5/2025, revealed .Went in bathroom to check on resident and he was noted to be lying on the bathroom floor on his right side . Review of the Fall Risk Evaluation dated 6/5/2025, revealed a score of 11 which indicated Resident #29 was a high risk for falls. Review of the facility's Incident Report dated 6/5/2025, revealed .went to check on resident [Resident #29] and he was noted to be lying on the floor on his right side. The facility was not able to provide the Resident assessment or the post fall assessment for Resident #29's fall on 6/5/2025. During an interview on 7/1/2025 at 4:36 PM, the Director of Nursing (DON) was asked are these the complete fall investigations for Resident #29. The DON stated, Yes . During an interview on 7/2/2025 at 10:35 AM, the DON was asked if any statements were obtained from staff related to falls. The DON stated, Yes, ma'am .I found a statement for the fall on 6/5/2025, but no other statements. The DON was asked should staff get witness statements for falls. The DON stated, Yes . The DON was asked if the nurses should document Resident assessments for falls. The DON stated Yes, ma'am. The DON was asked do you see any Resident assessments or post fall assessments. The DON stated, No.

Based on policy review, medical record review, and interview, the facility failed to revise and update a care plan for 1 of 2 (Resident #11) residents reviewed for care plans. The Findings include: 1. Review of the facility's policy titled Fall Prevention Program, dated 4/2/2024, revealed .when any resident experiences a fall, the facility will .review the resident's care plan and update as indicated . 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Gastronomy, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 had severe cognitive impairment without behaviors and was dependent on staff for all care. Further review of the MDS revealed Resident #11 was always incontinent of bowel and bladder, and no falls since admission. Review of Nursing Progress notes on 8/1/2024, revealed that Resident #11 was found lying on the floor next to her bed wrapped up in a blanket. Staff was unable to come to a conclusion of how she got out of the bed since she was bedridden. Resident #11's care plan was not revised or updated to reflect the 8/1/2024 fall and interventions for the fall. During an interview on 9/18/2024 at 8:54 AM, the Director of Nursing confirmed that the care plan should have been updated to reflect an actual fall and intervention.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure staff followed physician orders for 1 of 1 (Resident #88) sampled residents reviewed receiving oxygen. The findings include: 1. Review of the facility's policy titled Oxygen Administration, dated 4/2/2024, revealed .Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . 2. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses including Sepsis, Multiple Myeloma, Anxiety, Congestive Heart Failure, Depression, and Chronic Respiratory Failure. Review of the Physician's Order dated 8/29/2024, revealed .oxygen at 2L [Liters] per BNC [Binasal Cannula] every shift . Review of the Medication Administration Record dated 9/2024, revealed Oxygen at 2 liters per BNC every shift was assessed by staff and initialed for completion. Review of the Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #88 was cognitively intact. Observation in the resident's room on 9/16/2024 at 4:44 PM, revealed Resident #88 was receiving 3 liters of oxygen per minute with binasal cannula. Observation in the resident's room on 9/17/2024 at 7:38 AM and 8:10 AM, revealed Resident #88 was receiving oxygen at 4.5 liters per minute by nasal cannula. During an interview on 9/17/2024 at 8:24 AM, the Director of Nursing (DON) was asked to confirm what Resident #88's oxygen was set at. The DON confirmed that the resident's oxygen was set at 4.5 liters per minute. The DON confirmed resident's oxygen order was for 2 liters per minute and should be set at 2 liters per minute.

Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis. The findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Diabetes, Insomnia, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Dialysis was not documented. During an interview on 9/18/2024 at 8:36 AM, the MDS Coordinator was asked should dialysis be coded on the annual MDS. MDS Coordinator stated, Yes dialysis should be on there .

Based on policy review, medical record review and interview, the facility failed to have a physician's order to provide dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis. The findings include: 1. Review of the facility's policy titled .Dialysis Policy, dated 8/12/2015, revealed .Residents who have End Stage Renal Disease [ESRD] and receive dialysis shall be provided care consistent with professional standards of practice, the physicians/practitioner's orders, and in accordance with the resident goals and preferences .Vascular Access [is] a connection made between an artery and a vein to provide good blood flow for dialysis. Bruit [is] a constant rumbling sound such as swishing or whoosh sound heard via stethoscope placed on the access .Thrill [is] a steady vibration or rumbling sensation felt at the AV [Arteriovenous] graft/fistula site .Medical conditions shall be monitored and managed to prevent complications .Licensed nurses shall participate in the management of medical conditions by following physicians orders, assessing the resident, and reporting changes in condition or behavior to the physician .Infection control practices shall be followed .Documentation shall include .Skin integrity at the access site [document every shift] .Prescence of thrill and bruit of the AV graft/fistula [document every shift] .Evidence of infection, bleeding, and other complications . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Dialysis was not documented on the assessment. Review of the facility's Order Summary Report, dated 9/17/2024 revealed there was no order for dialysis. During an interview on 9/17/2024 at 8:40 AM, the Director of Nursing (DON) was asked should Resident #7 have a Physician's order for dialysis. The DON confirmed it should be documented and she did not see dialysis coded.

Based on review of staff in-services, and interview the facility failed to ensure the mandatory annual 12 hours of Certified Nursing Assistant (CNA) in-service training hours were completed for 4 of 19 sampled CNA's (CNA A, B, C and D) reviewed for inservices. The findings include: Review of a list of CNA staff provided by the facility revealed CNA A was hired on 10/6/1999, CNA B was hired on 5/19/2005, CNA C was hired on 7/15/2014, and CNA D was hired on 5/2/2022. The facility was unable to provide documentation of 12 hours of required in-service training for CNAs A, B, C, and D for the past 12 months. During an interview on 9/18/2024 at 10:44 AM, the DON was asked about the CNA in-service hours. The DON confirmed she was unable to provide the documentation. The facility was unable to provide documentation of the mandatory annual CNA in-service hours.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when 4 bags of frozen chicken breasts and a thick build up of ice crystals were found in 1 of 2 reach-in freezers, and 1 of 1 nourishment refrigerator had unlabeled, undated foods, and a dirty freezer that did not have a thermometer or temperature logs. The findings include: 1. Review of the facility's undated policy titled FOOD FROM OUTSIDE SOURCES, revealed .Perishable food should be sealed and dated with a use-by date and placed in refrigeration .and/or nourishment room refrigerators .clean the refrigerators .discard outdated or uneaten foods . Review of the facility's policy FOOD STORAGE, dated 11/1/2014, revealed .Frozen Meat/Poultry and Foods .store items .at 0 degrees or less . 2. Observation in the reach-in freezer on 9/16/2024 at 9:38 AM and 9/17/2024 at 11:47 AM, revealed 4 bags of frozen chicken breasts with a thick white build-up of ice in all 4 bags. The bags were frozen together at the bottom of the freezer. 3. Observation in the Nutrition Refrigerator on 9/18/2024 at 7:46 AM, revealed the following: a. An unlabeled and undated bag containing a water bottle and peanut butter crackers. b. An unlabeled and undated bag containing a bottle of lemonade, a banana, and a container of food. c. The freezer had multiple brown sticky spots and food particles on both the top and bottom area and on the door shelves. d. The freezer did not have a thermometer or a temperature log. 4. During an interview on 9/18/2024 at 8:24 AM, the Certified Dietary Manager (CDM) confirmed the Nutrition Freezer should be clean and that all food put in the freezer or refrigerator should be initialed and dated. The CDM confirmed that there should be a thermometer in the freezer and a freezer log to monitor the temperature. The DM also confirmed that the Kitchen's freezer should not contain compromised frozen foods.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during random observations when 1 of 1 (Licensed Practical Nurse (LPN) #2) failed to use courtesy titles when addressing residents, and during dining when 8 of 10 staff members (Certified Nursing Assistant (CNA) #1), CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and LPN #2, and LPN #3, failed to knock and/or announce themselves, stood to assist with dining, failed to use courtesy titles when addressing residents, and when 1 of 1 (LPN #2) failed to knock or announce self before entering a resident's room during medication administration. The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/2/2023, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents rights . Review of the facility's policy titled, Medication Administration, dated 1/2/2020, revealed .Knock or announce presence . 2. Random observation in the Activities Room on 11/5/2023 at 8:35 AM, revealed Resident # 43 entered the Activities Room and LPN #2 states to the resident, Let me help you sweet girl . LPN #2 failed to use a courtesy title when addressing Resident #43. Random observation in the South hall at the medication cart on 11/5/2023 a 8:45 AM, revealed LPN #2, stated to Resident #43, Where are you going baby girl .what did you say baby . LPN #2 failed to use a courtesy title when addressing Resident #43. Observation during dining on the South hall on 11/5/2023 at 11:30 AM, revealed LPN #2 removed a tray from the meal cart, entered Resident #43's room and placed the tray on the over the bed table. LPN #2 failed to knock or announce self before entering the resident's room. Observation during dining on the South hall on 11/5/2023 at 11:38 AM, revealed LPN #2 standing at the bedside assisting Resident #1 with her meal. Observation during dining on the North hall on 11/5/2023 at 11:14 AM, revealed CNA #6 entered Resident #25's room placed and the tray on the over the bed table and stated, .welcome love. CNA #6 exited the room and returned to the meal cart, removed a tray, entered Resident #42's room, served the resident her meal tray and stated, girl them beans good for you, and exited the room. CNA #6 failed to use courtesy titles when addressing the residents. Observation during dining on the North hall on 11/5/2023 at 11:18 AM, revealed LPN #2, stated, Alright sweet girl to Resident #16 while setting up her meal tray and applying condiments to the resident's food. LPN #2 exited the room and returned to the meal cart, engaged in conversation with LPN #3 at the meal cart in the North hall. LPN #2 stated out loud in the hallway to LPN #3, She is a feeder, with LPN #2 repeating out loud She is a feeder. LPN #2 failed to address Resident #16 using courtesy titles. Observation during dining on 11/5/2023 at 11:47 AM, revealed CNA #5 removed tray from the meal cart, entered Resident #12's room, placed the tray on the over the bed table adjusted the resident in bed with the hand held control, assisted the resident with their meal while standing. CNA #5 failed to knock or announce self before entering the resident's room and stood to assist the resident with their meal. Observation during dining on the on the North hall on 11/6/2023 at 7:24 AM, revealed LPN #2 failed to knock or announce herself before entering the Resident #39's room. Observation during dining on the South hall on 11/6/2023 at 7:25 AM, revealed CNA #7 entered Resident #37's room, failed to knock or announce self, exited the room and returned back to the resident's room, placed meal tray on the over the bed table, adjusted the resident in bed and stated to Resident #37 You not going to eat friend, turned around and stated to Resident #31, There you go friend. CNA #7 failed to address Resident #31 and Resident #37 with courtesy titles. Observation during dining in the South hall on 11/6/2023 at 7:38 AM, revealed CNA #1 removed a tray from the meal cart entered Resident #28's room. CNA #1 failed to knock or announce self before entering the resident's room. Observation during dining on the on the North Hall on 11/6/2023 at 7:42 AM, revealed LPN #2 entered Resident #10's room and sat the tray on the over bed table and stated, Good girl. LPN #2 failed to use a courtesy title when addressing Resident #10. Observation during dining on 11/6/2023 at 7:46 AM, revealed CNA #2 was in Resident #30's room when CNA #3 entered the room asked CNA #2 who needed to be assisted with their meals, CNA #2 stated, [names of Resident #1 and Resident #12] on the front hall are feeders. CNA #2 exited the room returned to the meal cart and yelled from the hallway to CNA #3, [Name of Resident #11] in the middle bed is a feeder. Observation during dining on 11/6/2023 at 7:55 AM, revealed CNA #2 entered Resident #30's room, placed the tray on the over the bed table, set up the tray and stood to assist Resident #30 with his meal. Observation on the North hall medication cart on 11/7/2023 at 1:15 PM, revealed LPN #2 sanitized her hands and removed medications for Resident #16, locked the medication cart, entered the resident's room, administered the medications to Resident #16 and exited the room. LPN #2 failed to knock or acknowledge herself before entering Resident #16's room. During an interview on 11/8/23 at 8:39 AM, the Director of Nursing (DON) was asked what should staff do before entering a resident's room. The DON confirmed that staff should knock and announce themselves before entering a resident's room. The DON was asked how you expect staff to address residents when speaking to them. The DON confirmed staff should always use resident's name when addressing them and no pet names should be used. The DON was asked what position staff should be in when assisting residents with their meals. The DON confirmed staff should be in the sitting position when assisting residents with their meals.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to ensure the facility assessments were signed by a Registered Nurse (RN) as required by Federal Regulations for 12 of 12 (Resident #1, #9, #10, #20, #25, #31, #33, #39, #41, #43, #44, and #146) sampled residents reviewed. The findings include: 1. Review of the Centers for Medicare Services (CMS) RAI Manual Version 3.0 Manual dated October 2023 pages Z6- Z7 revealed, .the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted .Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete .use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator . 2. Review of the medical record revealed Resident #1 was admitted the facility on 7/14/2014 with diagnoses of Depression, Gastrostomy, Dementia, and Heart Failure. Review of the annual MDS dated [DATE] revealed Resident #1 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/Licensed Practical Nurse (LPN). Review of the quarterly MDS dated [DATE] revealed Resident #1 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Diabetes, and Heart Failure. Review of the quarterly MDS dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #9 had a BIMS score of 15, indicating intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Hypertension, Diabetes, Alzheimer's Disease, Anorexia, and Anemia. Review of the quarterly MDS dated [DATE] revealed Resident #10 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the admission MDS dated [DATE] revealed Resident #10 had a BIMS score of 3, indicating the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 5. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Dementia, Greater Trochanter of Right Femur Fracture, Anxiety, Arteriovenous Fistula, Peripheral Vascular Disease, and Chronic Kidney Disease Stage 4. Review of the quarterly MDS dated [DATE] revealed Resident #20 had a BIMS score of 00, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 6. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Depression, Torticollis, Gastrostomy Tube, Abnormal Weight Loss, Anemia, Dementia, and Psychosis. Review of the annual MDS dated [DATE] revealed Resident #25 had a BIMS score of 99, indicating that the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #25 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 7. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, Dementia, Epilepsy, Schizoaffective Disorders, and Anxiety. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 3, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the annual MDS dated [DATE] revealed Resident #31 had a BIMS score of 10, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 8. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Fracture [NAME] Leg, Glaucoma, Gout, Anemia, Obesity, Schizophrenia, Mental Disorder, and Insomnia. Review of the annual MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 14, indicating the resident was cognitively intact. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 12, indicating the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 9. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Insomnia, Pain, Anxiety, and Depression. Review of the annual MDS dated [DATE], revealed Resident #39 had a BIMS score of 99, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE], revealed Resident #39 had a BIMS score of 9, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 10. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Morbid Obesity, Dementia, Depression, Epilepsy, and Chronic Pain. Review of the admission MDS dated [DATE], revealed Resident #41 had a BIMS score of 15, which indicated intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 11, indicating moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 11. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of Dementia, Urinary Tract Infection, Anxiety, Insomnia, and Cerebral Infarction. Review of the admission MDS dated [DATE] revealed Resident #43 had a BIMS score of 8, indicating that the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #43 had a BIMS score of 10, indicating the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 12. Review of the medical record revealed Resident #44 was admitted the facility on 7/28/2023 with diagnoses of Abdominal Cancer, Asthma, and Benign Prostatic Hyperplasia. Review of the admission MDS dated [DATE] revealed Resident #44 had a BIMS score of 9, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/Licensed Practical Nurse (LPN). 13. Review of the medical record revealed Resident #146 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Anorexia, Glaucoma, Anemia, Dementia, and Schizophrenia. Review of the quarterly MDS dated [DATE] revealed Resident #146 had a BIMS score of 00, indicating the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the admission MDS dated [DATE] revealed Resident #146 was severely cognitively impaired. The signature of the RN Assessment Coordinator verifying assessment completion was not signed off by the MDS Coordinator/LPN or the RN. 14. During an interview on 11/8/2023 at 11:31 AM, the Director of Nursing (DON) was asked what RN signs that the MDS assessments are completed. The DON confirmed she is the RN who is responsible to sign that the MDS assessments were completed but she has not signed any completed assessments since October 2022. During an interview on 11/8/2023 at 2:18 PM, the MDS Coordinator was asked who the RN is signing for the completion of the MDS assessment. The MDS Coordinator stated, .no RN has been signing for the completion of the MDS assessment. The MDS Coordinator was asked should there be a RN signing for the completion of the MDS assessment. The MDS Coordinator confirmed a RN should be signing for the completion of the MDS.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of accident hazards when the facility failed to ensure fall risk assessments were complete for 1 of 1 (Resident #10) reviewed for falls, chemicals were observed 1 of 1 unsecured and unattended storage room, and when sharps were left unsecured on top of 1 of 4 (South Medication cart) medication carts. The findings include: 1. Review of the facility's policy titled, Fall Prevention Program, dated 1/2/2023, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk .Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes . Review of the facility's guidelines titled, Fall Program Guidelines, dated 11/2015, revealed .When a fall occurs the following assessments .will be completed to assist in the investigation .Fall Assessment . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease, Hypertension, Anorexia, Reduced Mobility, Legal Blindness, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was assessed as being severely cognitively impaired, and required extensive assistance with activities of daily living, walking did not occur, was total dependent on staff for toileting, incontinent of both bowel and bladder, and had 2 or more falls with no injuries. Review of the Care Plan revealed, .Risk for Falls .6/28/2023 fall with no injuries, 7/9/23 fall with no injuries, 7/13/23 fall with no injuries .Bed alarm to alert staff of attempts to transfer out of bed without assistance .Ensure bed is kept in lowest position .Ensure call light is available .Evaluate fall risk on admission and PRN (as needed) .Floor mats to both sides of bed .has limited physical mobility . Review of the medical record revealed Resident # 10 had unwitnessed falls on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023 and on 10/31/2023. Review of the medical record revealed no fall risk assessments were completed for the falls that occurred on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023, 10/31/2023 until 11/9/2023 and no fall risk assessment was completed for the quarterly MDS assessment dated [DATE] until 11/9/203. During an interview on 11/9/2023 at 9:10 AM, the MDS Coordinator confirmed fall risk assessments should be completed quarterly. During an interview on 11/9/2023 at 9:15 AM, the Director of Nursing (DON) confirmed nursing should complete fall risk assessments on admission, quarterly and when a resident falls. During an interview on 11/9/2023 at 9:38 AM, the DON confirmed the fall risk assessment for the falls that occurred on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023, 10/31/2023 and the quarterly MDS fall risk assessment dated [DATE] were not completed until 11/9/2023 when she completed them, and they should have been completed when the fall occurred and when the quarterly MDS assessment was due. 3. Review of the medical record revealed Resident #43 was admitted to the facility 2/28/2023 with diagnoses of Dementia, Diabetes, Insomnia, Disorder of the Brain, Anxiety, and Seizures. Review of the quarterly MDS dated [DATE] revealed Resident #43 was assessed with a Brief Interview for Mental Status score of 10, indicating the resident was moderately cognitively impaired. Review of the Care Plan revealed, .Risk for Wandering .date initiated 3/17/2023 . Review of the facility's wandering list revealed Resident #43 was on the list for wandering. Observation in the Activities Room on 11/5/2023 at 8:35 AM, revealed Resident #43 enters the Activities Room on the South hall looking for her room. LPN #2 enters the room and redirects the resident back to the South hallway. Observation in the South hall at the medication cart on 11/5/2023 a 8:45 AM, revealed Resident #43 asked LPN #2 where her room was. LPN #2 then redirects the resident back to her room. Observation on 11/5/2023 at 9:30 AM, revealed Resident #43 self-propelling in wheelchair on the South hall looking for her room. Observation on the South hall in an unsecured and unattended storage room on 11/5/2023 at 9:21 AM, revealed a door left ajar and containing the following items: a.1 unlocked, unsecured and unattended housekeeping cart with 1- 24 ounce bottle of clear liquid labeled NEUTRAL DISINFECANT SPRAY, DANGER KEEP OUT OF REACH OF CHILDREN stored unsecured and unattended on top of the housekeeping cart, 1- 24 ounce bottle of a yellow solution labeled PEROXIDE SURFACE CLEANER AND DISINFECTANT KEEP OUT OF REACH OF CHILDREN stored unsecured and unattended on top of the housekeeping cart, and 1 red handle metal scraper stored unsecured and unattended on top of the housekeeping cart, and 1-12 ounce can of WD-40 spray stored inside of the unlocked unsecured housekeeping cart. Observation in the South hall at the STORAGE AREA on 11/5/2023 at 9:29 AM, 9:32 AM, revealed the door remained ajar, and the storage room remained unsecured and unattended. Observation on 11/5/2023 at 9:33 AM, revealed the Business Office Manager entered into the door labeled STORAGE AREA, and immediately exited the room and failed to lock or secure the door. The Business Office Manager spoke to Resident #43 in the South hall and the resident stated, I am trying to find my room. Observation and interview in the STORAGE AREA room on the South hall on 11/5/2023 at 9:35 AM, the Housekeeping staff confirmed the room was a storage room. The Housekeeping Staff confirmed that some chemicals are stored in the STORAGE AREA room and that staff sometimes store the housekeeping cart in the room. The Housekeeping staff confirmed that some maintenance tools are also stored in the STORAGE AREA room. The Housekeeping staff was asked if the house keeping cart, chemicals and tools are stored in the room should the room be secured at all times to ensure the safety of residents. The Housekeeping staff was shown the house keeping cart with the chemicals and the red handled scraper with the metal edge and was asked should these chemicals be stored inside of the housekeeping cart and should this cart be locked and secured at all times. The Housekeeping staff confirmed the room should be locked and secured at all times and the chemicals should be stored on the locked housekeeping cart. The Housekeeping staff stated, We do not have a key (pointing to the housekeeping cart). The Housekeeping staff was asked who has the key to the housekeeping cart. The Housekeeping staff stated, Well we never had a key made to it . The Housekeeping staff was asked should chemicals or sharp tools be stored on top of a housekeeping cart that is unlocked and unsecured and stored inside of a storage room that is unlocked, unsecured and unattended. The Housekeeping staff stated, Yes, it should be locked . Observation in the South hall on 11/5/2023 at 9:57 AM, revealed Resident #43 self-propelling in the hallway looking for her room. Observation revealed the STORAGE AREA remained unlocked, unsecured, and unattended containing the following items on a metal shelf: a. 3 1-gallon plastic jugs of floor adhesive remover on a metal shelf b. 2 cans of furniture polish remover, c. 1 27-ounce plastic container of hardwood floor [NAME] d. 1 32-ounce container of sewer drainage remover e. 1 gallon of defoamer for carpet machinery f. 1 gallon plastic jug of general-purpose cleaner g. 1 red metal tool cabinet containing nuts, bolts, screes, and wires. h. 6 1-liter containers of hand sanitizer containing 70% alcohol i. 19 1-liter containers of fragrance hand sanitizer with labeled KEEP OUT OF REACH OF C HILDREN Observation on the North hall on 11/5/2023 at 10:38 AM, revealed Resident #43 self-propelling in wheelchair asking is it time to smoke. Observation on the North hall on 11/5/2023 at 1:39 PM, revealed Resident #43 in wheelchair near the front entrance. During an interview on 11/9/2023 at 10:08 AM, the Administrator was asked should the room on the South hall labeled STORAGE AREA be left with the door left ajar, with a housekeeping cart with chemicals and sharps stored on top of the cart, and with chemicals stored on a metal rack and a tool chest with items be left with the door ajar, unsecured, and unattended with wandering residents. The Administrator confirmed the door should not be left ajar and the room should not be left unlocked, unsecured, and unattended. The Administrator confirmed that the facility has residents who are at risk for wandering. Observation on the South hall medication cart on 11/5/2023 at 1:10 PM, 1:15 PM, and 1:18 PM, revealed 1 pair of hemostat scissors and 1 pair of bandage scissors on top of the medication cart unsecured and unattended. Observation on the South hall medication cart on 11/5/2023 at 2:14 PM, revealed 1 pair of bandage scissors on top of the medication cart unsecured and unattended. During an interview at the South medication cart on 11/5/2023 at 3:51 PM, the Director of Nursing (DON) was asked should the bandage scissors and hemostats be stored on top of the medication cart unattended and unsecured. The DON stated, No. The DON was asked where they should be stored. The DON confirmed the bandage scissors and hemostats should be stored on the treatment cart under lock and key away from residents.

Based on the facility Monthly Schedules, Report of Nursing Staff Direct Responsible Resident Care Report, Registered Nurse (RN) Time Punches, and Daily Work Up Sheets, the facility failed to ensure there was RN coverage for 8 consecutive hours a day on Saturday and Sunday weekend days from April 1, 2023, to June 24, 2023 and October 14, 2023 to October 22, 2023. The facility census was 44. The findings include: 1.Review of the facility's Nurses Monthly Schedule for April 2023, revealed there was no RN scheduled to work 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for April 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's RN Time Punch report for April 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's Daily Work Up, schedule for April 2023, revealed no RN listed which indicated that no RN was on duty and covered for 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. 2. Review of the facility's Nurses Monthly Schedule for May 2023, revealed there was no RN scheduled to work 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for May 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's RN Time Punch report for April 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's Daily Work Up, schedule for May 2023, revealed no RN listed on the daily work up schedule, which indicated no RN was on duty and covered for 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. 3. Review of the facility's Nurses Monthly Schedule for June 2023, revealed there was no RN schedule to work 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for June 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's RN Time Punch report for June 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's Daily Work Up, schedule for June 2023, revealed no RN was listed on the daily work up schedule which indicated indicating no RN was on duty and covered for 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. 4. Review of the facility's Nurses Monthly Schedule for October 2023, revealed there was no RN scheduled to work 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for June 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's RN Time Punch report for June 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's Daily Work Up, schedule for June 2023, revealed no RN listed on the daily work up schedule, which indicated no RN was on duty and covered for 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. During an interview on 11/5/2023 at 9:11 AM, LPN #1 was asked who the RN on duty is today. LPN #2 stated, It is the DON (Director of Nursing) .she was here, but she had to run some errands and said she would be back . During an interview on 11/5/2023 at 6:23 PM, LPN #2 was asked do you work on weekends (Saturday and Sunday). LPN #2 confirmed she does work weekends at the facility. LPN #2 was asked is there a RN who works the weekends as a RN charge nurse. LPN #2 was asked is there a RN covering for at least 8 hours consecutive on Saturday and Sundays on the weekend. LPN #2 confirmed there is not always a RN covering but the DON will come in at times and check on the staff but does not always stay. LPN #2 stated, She is in and out . LPN #2 was asked if there ever a time when there is no RN coverage. LPN confirmed there are times when there is no RN coverage in the facility and that the RN will come and go and run errands and come back and check on them. During an interview on 11/8/2023 at 11:31 AM, the DON was asked do you have RN coverage for 8 consecutive hours on Saturday and Sundays weekends. The DON confirmed there is not always weekend RN coverage on Saturday and Sunday weekends and that she will cover at times. The DON was asked are there any RNs on staff other than yourself. The DON confirmed she has a RN that works on the 11-7 shift on Monday through Friday and a RN who works day shift on Mondays, 2 PRN (as needed) RNs. The DON was asked does the PRN RNs cover the weekends. The DON confirmed they do cover but if they do not cover and she does not cover then there is no RN on duty. The DON confirmed that if a PRN RN covered the shift they would clock in and it would show on the time punch sheet for RNs. The DON confirmed she has covered at times on the weekend but she does not clock in and there is no way to tell if she was covering in April 2023, May 2023, June 2023, and October 2023. The DON was asked if she was aware that there should be RN coverage for 8 consecutive hours, 7 days a week to include Saturday and Sunday weekends. The DON confirmed she was aware that there should be RN coverage for 8 consecutive hours for 7 days a week to include Saturday and Sunday weekends. The DON confirmed that the facility doesn't always have RN coverage for 8 consecutive hours 7 days a week to include Saturday and Sunday weekends. The DON confirmed if the time punches do not show a RN working then there was no RN coverage.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 3 of 3 (Licensed Practical Nurse (LPN #1, #2, and #3) nurses failed to perform proper hand hygiene during medication administration, when 1 of 1 (LPN #3) failed to clean reusable equipment, and when 1 of 1 (LPN #2) failed to clean medical supplies after dropping it on the floor during Percutaneous Endoscopic Gastrostomy (PEG) site care, and when the facility failed to maintain and monitor for an effective infection prevention and control program for 3 of 3 (Resident #15, #24, and #30) sample residents reviewed for Legionella Disease. The findings include: 1. Review of the facility's policy titled Hand Hygiene, dated 1/2/2023, revealed .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hygiene. If your task require gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Either Soap and Water or Alcohol Based Hand Rub .Before performing invasive procedures .Before applying and after removing personal protective equipment (PPE), including gloves .Before preparing or handling medications. Before performing resident care procedures . Review of the facility's policy titled, Legionella Surveillance, dated 6/14/2023, revealed .It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease .Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system .Residents with health-associated pneumonia or who have failed antibiotic therapy for community acquired pneumonia shall be tested for Legionella . 2. Observation during medication administration in the South hall on 11/6/2023 at 9:10 AM, revealed LPN #1, removed medications for Resident #44, entered the resident's room and administered the oral medications. LPN #1 donned a pair of clean gloves and removed the old Fentanyl patch (pain patch) 25 micrograms mcg transdermal patch from the resident's left upper chest area. Then cleaned the right upper chest area and applied the new Fentanyl transdermal patch, removed her gloves, and exited the resident's room and returned to the medication cart. LPN #1 failed to perform hand hygiene after the removal of the gloves. 3. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 1:15 PM, revealed LPN #2 donned a pair of clean gloves and removed medications for Resident #16, locked her cart and removed her gloves. LPN #2 then entered the resident's room, donned a clean pair of gloves, and failed to perform hand hygiene upon removal and before donning a clean pair of gloves. LPN #2 administered 2 puffs from an Atrovent inhaler (for improved breathing) to Resident #16 and administered the oral medications. LPN #2 removed her gloves, exited the room, and returned to the medication cart. LPN #2 failed to perform hand hygiene upon removal of the gloves. 4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis, Anemia, Dementia, and Gastrostomy. Review of the facility's Order Summary Report, dated 10/25/2023, revealed .Feeding Tube Site Care .Cleanse area around tube daily and prn [as needed] with wound cleanser or soap and water. Cover with dry 4 x 4 dressing . Observation in the North hall at the North hall treatment cart on 11/7/2023 at 1:18 PM, revealed LPN #2 removed the 4 x 4's, gloves, and a bottle of dermal wound cleanser from the treatment cart to perform PEG site care for Resident #25. LPN #2 entered the resident's room, placed the supplies on top of a barrier on the over the bed table. LPN #2 pulled the curtain and shut the door, entered the bathroom, washed her hands, returned to the bedside, then exited the room. Returned to the resident's room with a roll of tape. LPN #2 donned a clean pair of gloves and failed to perform hand hygiene. LPN #2 picked up the dermal wound cleanser and dropped it onto the floor. LPN #2 picked up the wound cleanser and placed it back on the barrier on top of the over bed table, pulled Resident #25's shirt up, placed a towel over her lower abdomen, removed the old dressing to the PEG site, sprayed the dermal wound cleanser to the PEG site. LPN #2 failed to clean or sanitize the dermal wound cleanser bottle prior to using it to perform PEG site care. LPN #2 dried the PEG site with 4 x 4 gauze, removed her gloves, donned a clean pair of gloves, placed a drainage sponge over the PEG tube site and secured with the tape, and failed to perform hand hygiene after removing her gloves. LPN #2 pulled Resident #25's shirt down, removed the towel, exited the room. 5. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 4:10 PM, revealed LPN #3 donned a clean pair of gloves, removed oral medications for Resident #34 and placed on a barrier on top of the medication cart, removed a vial of Levemir insulin [lowers blood sugar], cleaned the top of the insulin bottle and withdrew 14 units of the insulin into an insulin syringe and placed on top of a barrier on top of the medication cart. LPN #3 removed her gloves, knocked, and entered the resident's room, placed the insulin syringe on top of a barrier on the over the bed table, and administered the oral medications. LPN #3 failed to perform hand hygiene after removing her gloves. LPN #3 donned a clean pair of gloves and then instilled 1 eye drop into each of the resident's eyes, removed her gloves, failed to perform hand hygiene, exited the room and returned to the medication cart, donned a clean pair of gloves and removed the blood glucose test strip, removed her gloves, failed to perform hand hygiene, locked the medication cart and returned to Resident #34's room. LPN #3 donned a clean pair of gloves, performed the blood glucose test on Resident #34, administered the 14 units of insulin into Resident #34's right upper arm, removed her gloves and returned to the medication cart, failed to perform hand hygiene. LPN #3 donned a clean pair of gloves and disposed of the trash and syringe into the sharps container on the medication cart, entered the resident's bathroom washed her hands, returned to the medication cart, donned a clean pair of gloves, removed a Cavi wipe (disinfectant wipe) and cleaned the accucheck [blood glucose meter] machine, removed her gloves, and failed to perform hand hygiene. 6. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 4:50 PM, revealed LPN #3 entered Resident #25's room, with medications, donned clean pair of gloves, dropped the cap to the syringe on the floor, removed her gloves, exited the room. LPN #3 failed to perform hand hygiene after removing her gloves. LPN #25's room, removed the stethoscope from around her neck, checked for PEG tube placement and checked residual, LPN #3 replaced the stethoscope back around her neck. LPN #3 failed to clean or disinfect the stethoscope after use. LPN #3 administered the medications through the PEG tube, entered the bathroom and rinsed the syringe and plunger, and replaced back in the plastic bag with visible water particles. LPN #3 failed to thoroughly dry the syringe before replacing back in the bag. LPN #3 removed her gloves, adjusted the resident in bed, placed the call light within reach of the resident and exited the room. LPN #3 failed to perform hand hygiene after the removal of her gloves and after touching the resident and objects in the resident's room. During an interview on 11/8/2023 at 8:39 AM, the Director of Nursing (DON) was asked what process staff should use when removing and donning clean gloves. The DON confirmed the staff should use hand sanitizer or wash hands after removing gloves. The DON was asked what should staff do if they drop supplies on the floor when performing a treatment. The DON confirmed they should discard the item or clean and sanitize the item before using on a resident. The DON was asked what should staff do after using reusable medical equipment such as a stethoscope on a resident. The DON confirmed the equipment should be cleaned and disinfected after use on a resident. The DON was asked how the enteral feeding syringe should be stored after use. The DON confirmed the syringe should be cleaned, rinsed, and dried thoroughly before replacing back in the plastic bag. 7. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the (Named Imaging) dated 8/18/2023, revealed .XRAY [Electromagnetic radiation] CHEST .increased right hilar density that may be due to atelectasis or Pneumonia. Review of the August Infection Control, tracking and trending sheet revealed Resident #15 had Pneumonia. 8. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Hypertension, Alzheimer's, and Schizophrenia. Review of the (Named Imaging) dated 9/1/2023, revealed XRAY CHEST .Mild right upper lobe infiltrate .includes atelectasis or infection .The findings are new from 05JAN2023 [January 5, 2023] . Review of the September Infection Control, tracking and trending sheet, revealed Resident #24 had Pneumonia. 9. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of Above the Knee Amputation of the Left Leg, Depression, and Hypertension. Review of the (Named Imaging) dated 9/19/2023, revealed .XRAY CHEST .Left lower lobe atelectasis, aspiration, or pneumonia. A new finding since prior exam . Review of the September Infection Control, tracking and trending sheet, revealed Resident #30 had Pneumonia. During an interview on 11/9/2023 at 12:08 PM, the Maintenance Supervisor was asked what is being done to track and prevent Legionella and other bacteria in the water system. The Maintenance Supervisor stated, I do not know what that is . The Maintenance Supervisor was asked are you testing the facility's water. The Maintenance Supervisor stated, .not testing the water at all . During an interview on 11/9/2023 at 12:27 PM, the Administrator was asked if the facility was doing anything for the detection and prevention of Legionella. The Administrator stated, I do not know of anything. During an interview on 11/9/2023 at 4:51 PM, the Infection Control Preventionist was asked are you doing anything to track Legionella in the water system. The Infection Control Preventionist stated, No, I am not doing anything .

Based on the [Named facility] HEALTH & REHABILITATION CENTER FINANCIAL RESPONSIBILITY AGREEMENT), medical record review, and interview, the facility failed to provide 3 of 4 sampled residents (Resident #23, #32, and #40) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice. The findings include: 1. Review of the facility's [Named facility] HEALTH & REHABILITATION CENTER FINANCIAL RESPONSIBILITY AGREEMENT) undated, revealed .Medicare/Skilled: The Resident is considered a Medicare beneficiary if the Resident is eligible to receive benefits from the Federal Medicare Program. The maximum number of Medicare days is 100; however, If the Resident does not meet the Medicare coverage criteria, coverage will end regardless of the number of allotted days left in the current benefit period. Medicare will pay 100% [percent] of all skilled nursing charge for up to the first 20 days of the Resident's skilled nursing home stay (this is a total of all days of skilled care by all skilled care providers for this period of illness). Beginning on day 21, Medicare will not pay for the total charges for that day or any days thereafter. The portion of charges which Medicare will not pay after the first 20 days is called the Resident's co-insurance. The current rate of coinsurance is $194.50 per day. The Resident/Legal Representative will receive a bill on day 21 the co-insurance balance for the co-insurance balance for the days left in the current month of the Resident's stay at the facility. If applicable, Medicare supplemental insurance may cover payment for the co-payments (normally this coverage is only for 21 days through 100 unless you have extended coverage with your insurance carrier). Upon expiration of Medicare benefits, the Resident may remain in the Facility if arrangements for timely payments are in place through either Medicaid or private pay . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Myocardial Infarction, Acute Kidney Failure, Dysphagia, and Diabetes. Review of the Occupational Therapy (OT) Recert [Recertification], Progress Report & [and] Updated Therapy Plan dated 9/25/2023, revealed Resident #23 was in OT for certification Period 9/25/2023 - 10/24/2023. Payer Source was Medicare A. Review of the Physical Therapy (PT) Recert, Progress Report & Updated Therapy Plan dated 8/4/2023, revealed Resident #23 was in PT for certification Period 8/4/2023 - 9/2/2023. Payer Source Medicare A. The facility was unable to provide an ABN letter for Resident #23 at the end of the skilled services. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Gastrostomy, Aphasia, Hemiplegia and Hypertension. Review of the Therapy Discharge Summary revealed Resident #32 was discharged from Speech Therapy (SPL) on 10/13/2023, discharged from Physical Therapy (PT) on 9/1/2023, and discharged from Occupational Therapy (OT) on 8/30/2023. Payer Source Medicare A. The facility was unable to provide an ABN letter for Resident #32 at the end of the skilled services. 4. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Sepsis, Diabetes, Dementia, and Heart Failure. Review of the Therapy Discharge Summary revealed Resident #40 was discharged from Speech Therapy (SLP) on 5/2/2023, discharged from Physical Therapy (PT) on 5/2/2023, and discharged from Occupational Therapy (OT) on 5/2/2023. Payer Source was Medicare A. The facility was unable to provide an ABN letter for Resident #40 at the end of the skilled services. During an interview on 11/9/2023 at 9:07 AM, the Minimum Data Set (MDS) Coordinator stated, .We have not sent any letters .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure choices to receive showers was provided for 1 of 1 (Resident #41) sampled residents reviewed for ADL care. The findings included: 1. Review of the facility's policy titled, Activities of Daily Living (ADLs) dated 11/29/2022, revealed .The facility will .Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Cerebral Infarction, Morbid Obesity, Dementia, Depression, Epilepsy, and Chronic Pain. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, required assistance from staff for bathing and dressing, and was incontinent of bowel and bladder. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 11, indicating moderately impaired cognition, required extensive assistance from staff for personal hygiene and dressing, totally dependent upon staff for bathing, and was incontinent of bowel and bladder. Review of the Shower List: South revealed Resident #41 is scheduled for showers on Tuesday, Thursday, and Saturday. Review of the facility's Skin Monitoring: Comprehensive CNA (certified nursing assistant) Shower Review sheets revealed Resident #41 did not receive any showers for the following days: 7/4/2023, 7/6/2023, 7/8/2023, 7/13/2023, 7/15/2023, 7/18/2023, 7/20/2023, 7/22/2023, 7/25/2023, 8/1/2023, 8/3/2023, 8/5/2023, 8/8/2023, 8/10/2023, 8/12/2023, 8/15/2023, 8/17/2023, 8/19/2023, 9/2/2023, 9/7/2023, 9/9/2023, 9/12/2023, 9/16/2023, 9/19/2023, 9/21/2023, 9/30/2023, 10/3/2023, 10/5/2023, 10/7/2023, 10/10/2023, 10/12/2023, 10/14/2023, 10/17/2023, 10/19/2023, 10/24/2023, 10/26/2023, 10/28/203, and 10/31/2023. The facility was unable to provide documentation that Resident #41 received showers from 3/2023 until 7/2023. During an interview on 11/8/2023 at 8:51 AM, Resident #41 confirmed she prefers to have showers and is not receiving showers. During an interview on 11/9/2023 at 3:16 PM, the Director of Nursing (DON) confirmed that documentation on the Skin Monitoring: Comprehensive CNA Shower Review sheets shows when a resident received a shower. The DON was asked is there any more documentation indicating when Resident #41 received a shower from 3/1/2023 to 6/30/2023. The DON stated, No . there are not. The DON confirmed the residents' showers should be documented. The DON confirmed Resident #41 should be getting showers.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure staff was following physician orders for automatic [auto] flush for a Percutaneous Gastrostomy (PEG) tube feeding for 1 of 1 (Resident #25) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the facility's policy titled, Flushing a Feeding Tube, dated 1/2/2023, revealed .Verify physician orders for tube feeding flush amount . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Abnormal Weight Loss, Anemia, Dementia, and Gastrostomy. Review of a Physician's Order dated 10/25/2023, revealed .Enteral Feed Order every shift ISOSOURCE 1.5 @ [symbol for at] 45 ml (milliliters) hr (hour) with 40ml/hr Auto Flush continuous pump . Review of the Care Plan revised 10/26/2023, revealed .10/26/2023 noted weight gain, reduced rate of tube feeding to 45ml/hr . Review of the Medication Administration Record dated November 2023, revealed .Enteral Feeding Order every shift ISOSOURCE 1.5 @ (symbol for at) 45ML/HR WITH 40ML/HR H20 (water) AUTO FLUSH CONTINUOUS PER PUMP . Start Date 10/26/2023 . Observation in Resident #25's room on 11/5/23 at 10:09 AM, 1:00 PM, and 1:47 PM, and on 11/06/23 at 8:58 AM, 11:13 AM, revealed IsoSource 1.5 Enteral Feeding infusing at 45ml/hr with an Auto Flush infusing at 45ml/hr. The auto flush was not infusing at 40 ml/hour as ordered. During observation and interview in Resident #25's room on 11/6/23 at 11:13 AM, the Director of Nursing (DON) was asked what rate the enteral feeding and automatic flush should be infusing at. The DON confirmed the enteral feeding should be infusing at 45ml/hr and the automatic flush should be infusing at 40ml/hr. The DON confirmed that staff should be following physician orders for the infusion of the automatic flush rate.

Based on policy review, medical record review, and interview, the facility failed to convey the funds to the estate of a deceased resident within the 30 days requirement for 1 of 1 (Resident #97) resident reviewed for personal fund account. The findings include: 1. Review of the facility's policy titled Resident Personal Funds, dated 2023, revealed .Conveyance upon Discharge, Eviction, or Death .Upon the discharge, eviction or death of a resident who has paid a patient liability in advance, the facility will convey a refund within 30 days to the individual .administering the resident's affairs . 2. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Urinary Incontinence, Schizophrenia, Anxiety, and Parkinson's Disease. Review of the facility's INTERDISCIPLINARY DISCHARGE SUMMARY, dated [DATE], revealed admitted [DATE] discharge date [DATE] .Reason for discharge .Expired . Review of the refund check for the Responsible Party of Resident #97 was dated [DATE]. This refund was 54 days past the date of death . During an interview on [DATE] at 3:30 PM, the Business Office Manager (BOM), was asked how long until the refund check is to be provided to the family after the resident's death. the BOM stated, We try to turn it around [refund] in a week .That was unusual. During an interview on [DATE] at 4:45 PM, the BOM, was asked when the policy stated upon death of a resident a refund should be within 30 days. Therefore, was the refund for Resident #97 past the timeframe for the refund. The BOM stated, I couldn't get in touch with her.

Based on video camera footage review, medical record review, and interview, the facility failed to report an elopement within 24 hours for 1 of 4 sampled residents (Resident #1) reviewed for elopement/wandering behaviors and accidents. The failure of the facility to report the elopement to the State Survey Agency within 24 hours placed Resident #1, an intellectually disabled resident, in Immediate Jeopardy when he left the facility through a window in his room. The facility staff were unaware Resident #1 was missing from the facility for 3 hours and 15 minutes, and the resident was outside unattended for 4 hours. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Assistant Administrator/Business Office Manager was notified of the Immediate Jeopardy on 12/3/2020 at 1:00 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/25/2020 through 12/7/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2020 at 2:40 PM, and was validated onsite by the surveyors on 12/8/2020 through policy review, observations, review of audits, review of meeting minutes, and staff interviews. The findings include: Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Social Service Note dated 10/20/2020, showed that Resident #1 had .possible short-term memory concerns noted by Nursing . Review of a Dietary Note dated 10/28/2020, showed, .Resident alert and oriented; some confusion . Review of an Activity Note dated 11/16/2020, showed that Resident #1 was .pleasantly confused but appears to be aware of his surroundings most of the time . Review of the facility's video camera footage with a timestamp of 11/25/2020 at 9:34 PM, showed Resident #1 walking outside along the north side of the building toward the front of the building (west). He then turned to the right and walked up the hill and up the street leaving the view of the camera. The video camera footage showed the resident returned inside the building on 11/26/2020 at 1:34 AM. The video camera footage confirmed he was out of the building unattended for 4 hours. Review of the facility's investigation of the elopement of Resident #1 showed that Certified Nursing Assistant (CNA) #1 saw Resident #1 on 11/25/2020 at 8:00 PM. When CNA #2 entered Resident #1's room on 11/25/2020 at 11:15 PM, Resident #1 was not in his room. The staff were unaware Resident #1 was missing for 3 hours and 15 minutes. Review of a Nurses' Note dated 11/26/2020, showed, .CNA went to take resident's (Resident #1) vs (vital signs) at 23:15 (11:15 PM) (on 11/25/2020). She did not see him in his room or bathroom .Checked the outside of the facility and did not see him. Went back into his room observed a chair sitting by the window, window cracked looked outside the window and the screen was bent lying on a bush. Did not see the resident . Review of the Facility Reported Incident (FRI) reported to the State Agency showed the incident was reported to the State Agency on 11/30/2020 at 4:25 PM, 4 days after the resident had eloped from the facility. During an interview on 12/3/2020 at 5:00 PM, the Administrator stated, .We reported on the fourth or fifth day. We have five days right .Ah, oh we are in trouble again . During an interview on 12/3/2020 at 5:00 PM, the Director of Nursing (DON) confirmed, .We didn't send anything to the state until 11/30 (2020) .thought we had five days . The DON stated, .We have not had any incidents since the 11/25 (2020) elopement . During an interview on 12/4/2020 at 3:30 PM, the Administrator stated, .I guess I need to print the regs (regulations), things have really changed . Refer to F-610 and F-689. The surveyor verified the Removal Plan by: 1. On 12/4/2020, the DON read the reporting regulation to prepare for a discussion with the Compliance Consultant to ensure understanding of the reporting requirements which included the appropriate time frames for investigation and reporting. The DON will notify the Compliance Consultant when a reportable event occurs that requires an investigation, root cause analysis and initiation of Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) support. The surveyors interviewed the DON. 2. On 12/5/2020, the Registered Nurse (RN) Compliance Consultant conducted a telephone in-service with the DON and Administrator to review Regulatory Requirements for F 609 related to Resident Freedom from Abuse, Neglect and Exploitation for the Reporting of Alleged Violations. The surveyors interviewed the Administrator and DON. 3. On 12/5/2020, the DON conducted additional in-services with all staff regarding the immediate notification of the DON and/or Administrator when an allegation or event of serious bodily injury, alleged abuse and/or resident elopement occurs. The surveyors reviewed the sign in sheets and interviewed staff on all shifts. 4. The DON will notify the RN Compliance Consultant immediately of all alleged violations involving abuse, neglect, exploitation, misappropriation, or mistreatment and/or serious bodily injuries of unknown origin and resident elopements. The surveyors interviewed the DON. 5. The RN Compliance Consultant, the DON and/or the Administrator will immediately initiate an investigation and notify the appropriate city, county, state entities and State Survey Agency after an allegation is made if the events that cause the allegation involves resident abuse or results in serious bodily injury. The surveyors interviewed the Administrator and DON. 6. The DON will complete the event investigation and finalize the State Survey Agency summary report within 5 days of the allegation/event to ensure timely reporting guidelines are met. The surveyors interviewed the DON. 7. The RN Compliance Consultant will review all summary reports when submitted to ensure a complete investigation was conducted and reported timely to the required agencies. The surveyor interviewed the Administrator and DON. 8. The DON will report all events alleging resident abuse, elopements, or serious bodily injuries to the Administrator immediately and the RN Compliance Consultant, State Survey Agency and appropriate entities within 24 hours. The surveyor interviewed the Administrator and DON. 9. The DON or Assistant Director of Nursing (ADON) will conduct a 100% chart audit weekly for four consecutive weeks and a 100% chart audit monthly x 3 months to ensure the DON/Administrator is aware of all documented events in the clinical record and the appropriate authorities notified of all allegations of abuse and serious bodily injuries. The surveyors reviewed the audit tool and interviewed the Administrator and DON. 10. Findings of the audits will be added to the agenda and discussed weekly during the Morning Managers meeting, reviewed by the RN Consultant during monthly compliance visits and reviewed monthly through QAPI to determine the needs for staff education. The surveyor interviewed the Administrator and DON. 11. This Plan of Correction will be monitored monthly through QAPI until such time as consistent substantial compliance has been met. Audits and compliance will be reviewed during the QAPI meetings with the Medical Director at least quarterly to determine any areas and incidents of non-compliance that occur or any persistent systemic concerns. The surveyor interviewed the Administrator and DON. Noncompliance of F-609 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, video camera footage review, facility investigation review, medical record review, observation, and interview the facility failed to ensure a thorough investigation was completed for 1 of 4 sampled residents (Resident #1) reviewed for elopement/wandering behaviors and accidents. Resident #1, an intellectually disabled resident, left the facility through a window in his room. The facility staff were unaware Resident #1 was missing from the facility for 3 hours and 15 minutes, and Resident #1 was outside unattended for 4 hours. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Assistant Administrator/Business Office Manager was notified of the Immediate Jeopardy on 12/3/2020 at 1:00 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-610. F-610 was cited at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/25/2020 through 12/7/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2020 at 2:40 PM, and was validated onsite by the surveyors on 12/8/2020 through policy review, observations, review of audits and meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, with a revision date of 11/11/2020, showed, .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Review of the facility's undated policy titled, Accidents and Supervision, showed, .The facility should make a reasonable effort to identify the hazards and risk factors for each resident . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #1 was cognitively intact for decision making. Resident #1's activities of daily living (ADL) needs ranged from supervision to extensive assistance. He required an assistive device for safe ambulation. Review of a Social Service Note dated 10/20/2020, showed that Resident #1 had .possible short term memory concerns noted by Nursing . Review of a Dietary Note dated 10/28/2020, showed, .Resident alert and oriented; some confusion . Review of an Activity Note dated 11/16/2020, showed that Resident #1 was .pleasantly confused but appears to be aware of his surroundings most of the time . Review of a Nurses' Note dated 11/26/2020, showed, .CNA (Certified Nursing Assistant (#2)) went to take resident's (Resident #1) vs (vital signs) at 2315 (11:15 PM) (on 11/25/2020). She did not see him in his room or bathroom .Checked the outside of the facility and did not see him. Went back into his room observed a chair sitting by the window, window cracked looked outside the window and the screen was bent lying on a bush. Did not see the resident . Review of the facility's investigation of the elopement of Resident #1 showed the facility obtained written statements from the staff on duty at the time of the incident. The investigation file did not contain any witness statements from staff that last cared for the resident before the incident. The facility's investigation showed that CNA #1 saw Resident #1 on 11/25/2020 at 8:00 PM. When CNA #2 entered Resident #1's room on 11/25/2020 at 11:15 PM, Resident #1 was not in his room. The investigation file also did not contain any investigation notes that determined the circumstances of Resident #1's elopement from the facility. During an interview on 12/2/2020 at 3:55 PM, CNA #1 stated, .About 8:00 PM I saw (Named Resident #1) coming from his bathroom shuffling his feet with no shoes .I didn't check on him again. I didn't go back in his room before I left at 10:30 PM . Review of the facility's video camera footage with a timestamp of 11/25/2020 at 9:34 PM, showed Resident #1 was walking outside along the north side of the building toward the front of the building (west). He then turned to the right and walked up the hill and up the street leaving the view of the camera. The video camera footage showed the resident was returned to the facility by the Administrator on 11/26/2020 at 1:34 AM. The video camera footage confirmed he was out of the building unattended for 4 hours. The temperature in the city at that time was 44 degrees. Observation in the resident's room on 12/2/2020 at 9:43 AM, showed Resident #1 was alert. He was wearing multiple layers of clothing. Resident #1 stated, .I put a chair over there and went out the window. I picked a stick up off the ground. I sat on the porch over there at that house to get some air. I did not know the way back (to the facility) . During an interview on 12/2/2020 at 1:06 PM, the Administrator was asked if a thorough investigation was completed to determine the safety needs of residents and prevent any elopement in the future. The Administrator stated, .I was back home before 3:00 AM .I don't think we've gotten around to doing all the windows yet. Put one (alarm) on his window on Monday (11/30/2020) . During an interview on 12/3/2020 at 11:55 AM, the DON was asked if staff on all shifts were interviewed or written statements were obtained from staff on all shifts during the investigation of Resident #1's elopement. The DON stated, No . During a telephone interview on 12/3/2020 at 4:20 PM, CNA #2 confirmed Resident #1 was not in his room or in the facility on 11/25/2020 at approximately 11:15 PM when she entered his room to obtain his vital signs. During an interview on 12/4/2020 at 10:30 AM, the DON was asked if she had watched the video camera footage when conducting the investigation of Resident #1's elopement. She stated, .No, we never watched the video footage and saw him (Resident #1) on the camera, until watching with you (surveyor) . The DON stated that her and the Police Officer started to watch the video camera footage, but when the resident was found, they stopped watching the footage and never saw the resident on the footage that they had viewed. The surveyors verified the Removal Plan by: 1. On 12/4/2020, the DON read F-610 -Freedom from Abuse, Neglect, and Exploitation-Investigate/Prevent/Correct Alleged Violation for discussion with the Compliance Consultant to ensure understanding of the requirement for necessary investigation of all resident events to determine cause and consideration of abuse, neglect, exploitation, elopement, or bodily harm. The DON will notify the Compliance Consultant when a reportable event occurs for investigation, root cause analysis and initiation of a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) support. The surveyors interviewed the DON. 2. On 12/5/2020, The Registered Nurse (RN) Compliance Consultant conducted a telephone in-service with the DON and the Administrator to review Regulatory Requirements for F-610 related to Investigation/Prevention and Correction of Alleged Violations. The surveyors reviewed the in-service and interviewed the Administrator and the DON. 3. On 12/5/2020, the DON in-serviced all staff regarding immediate notification of the DON and/or Administrator when an event of serious bodily injury, alleged abuse and/or elopement occurs. The surveyors reviewed the in-service and interviewed staff on each shift. 4. All staff will notify both the DON and the Administrator immediately when an allegation of abuse or actual bodily harm occurs to a resident at the nursing home to ensure timely investigation. The surveyors interviewed staff on each shift. 5. The DON will notify the RN Compliance Consultant immediately of all alleged violations involving abuse, neglect, exploitation, misappropriation, or mistreatment and/or serious bodily injuries of unknown origin and resident elopements and initiate an immediate investigation. The surveyors interviewed the DON. 6. The RN Compliance Consultant, the DON and/or the Administrator will immediately initiate an investigation to ensure appropriate notification of city, county, state entities and State Survey Agency within the required time frames. The surveyors interviewed the Administrator and the DON. 7. The DON will complete the event investigation and conduct a root cause analysis through record review, staff interview, family interview as appropriate, resident interview when capable and other individuals and agencies as involved to determine necessary corrective actions for compliance and/or resolution. The surveyors interviewed the DON. 8. The RN Compliance Consultant will review all investigations, root cause analyses, corrective actions and staff training to ensure necessary corrective action for compliance and/or resolution has occurred. The surveyors interviewed the Administrator. 10. The DON or Assistant Director of Nursing (ADON) will review and investigate the cause of all incident/event reports daily. The surveyors interviewed the DON. 11. The DON will notify the Administrator immediately and the RN Consultant within 24 hours of all events alleging resident abuse, elopements, or serious bodily injury for assistance in completion of the investigation and indicated corrective action. The surveyors interviewed the Administrator and the DON. 12. The Administrator will ensure the DON immediately initiates and timely completes the event investigation and root cause analysis through record review, staff interview, family interviews as appropriate, resident interview when capable and other individuals and agencies as involved to determine necessary corrective action for compliance and/or resolution. The surveyors interviewed the Administrator. 13. The DON or ADON will conduct a 100% chart audit weekly for four (4) consecutive weeks and a 100 percent chart audit monthly for 3 months to ensure the DON/Administrator is aware of all documented events in the clinical record and the DON completed an investigation to determine an appropriate corrective action. The surveyors interviewed the DON and the ADON. 14. The RN Compliance Consultant will review all incident reports and investigations during monthly compliance visits to ensure investigations are complete, root cause analyses are determined and corrective action plans are initiated and completed timely. The surveyors interviewed the Administrator and the DON. 15. Findings of the audits will be added to the agenda and discussed weekly during the Morning Managers meeting, reviewed by the RN Compliance Consultant during monthly compliance visits and reviewed monthly through QAPI to determine needs for staff education. The surveyors reviewed the audit tools and interviewed the Administrator. 16. This Plan of Correction will be monitored monthly through QAPI until such time consistent substantial compliance has been met. Audits and compliance will be reviewed during the QAPI meetings with the Medical Director at least quarterly to determine any areas and incidents of non-compliance that occur or persistent systemic concerns. The surveyors interviewed the Administrator. Noncompliance of F-610 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction

Based on policy review, video camera footage review, National Weather Service statistics, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement and failed to investigate an accident for 2 of 4 sampled residents (Resident #1 and #4) reviewed with wandering behaviors and accidents, which resulted in Immediate Jeopardy for Resident #1. Resident #1, an intellectually disabled resident, left the facility through a window in his room. The facility was unaware the Resident #1 was missing from the facility for 3 hours and 15 minutes and the resident was outside unattended for 4 hours. This resulted in an Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Assistant Administrator/Business Office Manager was notified of the Immediate Jeopardy (IJ) on 12/3/2020 at 1:00 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-689. F-689 was cited at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/25/2020 through 12/7/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2020 at 2:40 PM, and was validated onsite by the surveyors on 12/8/2020 through policy review, observations, review of audits and meeting minutes, and staff interviews. The findings include: The facility's undated policy titled, Accidents and Supervision, showed, .The resident will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risks(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident .The facility should make a reasonable effort to identify the hazards and risk factors or each resident . The facility's undated policy titled, Missing Person Procedure-Elopement, showed, .After the resident is found: .Complete an incident report .Take steps to assure the elopement is prevented in the future . Medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #1 was cognitively intact for decision making. He required an assistive device for safe ambulation. Review of a Social Service Note dated 10/20/2020, showed that Resident #1 had .possible short term memory concerns noted by Nursing . Review of the Care Plan revised 10/26/2020, showed, .Problem Onset: 10/26/2020 At risk for elopement . Review of a Dietary Note dated 10/28/2020, showed, .Resident alert and oriented; some confusion . Review of an Activity Note dated 11/16/2020, showed Resident #1 was .pleasantly confused but appears to be aware of his surroundings most of the time . Review of the facility's video camera footage with a timestamp of 11/25/2020 at 9:34 PM, showed Resident #1 was walking outside along the north side of the building toward the front of the building (west). He then turned to the right and walked up the hill and up the street leaving the view of the camera. The video camera footage showed the resident was returned to the facility by the Administrator on 11/26/2020 at 1:34 AM. The video camera footage confirmed he was out of the building unattended for 4 hours. The temperature in the city at that time was 44 degrees. Review of the facility investigation of the elopement for Resident #1, showed Certified Nursing Assistant (CNA) #1 saw Resident #1 at 8:00 PM on 11/25/2020. When CNA #2 entered Resident #1's room at 11:15 PM, Resident #1 was not in his room. Review of the National Weather Service records, the recorded low temperature on 11/25/2020, the night of the elopement, was 44 degrees Fahrenheit. Review of a Nurses' Note dated 11/26/2020, showed, .CNA (CNA #2) went to take resident's (Resident #1) vs (vital signs) at 23:15 (11:15 PM). She did not see him in his room or bathroom .Checked the outside of the facility and did not see him. Went back into his room observed a chair sitting by the window, window cracked looked outside the window and the screen was bent lying on a bush. Did not see the resident . Observation in Resident #1's room on 12/2/2020 at 9:43 AM showed Resident #1 was alert. He was wearing multiple layers of clothing. Resident #1 stated, .I put a chair over there and went out the window. I picked a stick up off the ground. I sat on their porch over there at that house to get some air. I did not know the way back (to the facility) . Observation in the Dining Room on 12/2/2020 at 10:54 AM and 12:20 PM, showed a window unlocked and completely open. During interview on 12/2/2020 at 12:21 PM in the Activity room, the Environmental Services Director stated, .Windows had been opened to let some air in. We do that. That's why they were not locked. The Environmental Services Director stated, .The windows in residents' rooms can be opened all the way. I put an alarm on his (Resident #1's window) on Friday (11/27/2020). He (Resident #1) can still open it (his room window) all the way. During interview on 12/2/2020 at 1:06 PM, the Administrator was asked what interventions had been implemented after Resident #1 had eloped. The Administrator stated, .We put an alarm on his window. I don't think we've gotten around to doing all the windows yet. I purchased two window alarms. Put one on his window. The Administrator was asked how he could ensure Resident #1, or any other resident, would not elope through a window. The Administrator stated, Well, we know our residents. We don't have any that actually wander or try to leave. We know our residents. We just know . During interview on 12/2/2020 at 3:55 PM, CNA #1 stated, .About 8:00 PM, I saw (Named Resident #1) coming from his bathroom shuffling his feet with no shoes .I didn't check on him again. I didn't go back in his room before I left at 10:30 PM . During interview on 12/2/2020 at 4:00 PM, the DON stated wander risk assessments and/or elopement risk assessments were completed on residents only when they exhibited the behavior of wandering. During interview on 12/2/2020 at 4:20 PM, the MDS Nurse was asked if residents were assessed for wandering/risk of elopement with each MDS assessment. The MDS Nurse stated, .No, ma'am . The MDS Nurse was asked if an assessment for wandering and risk of elopement was completed on Resident #1 on admission. He stated, No, he had no history of wandering. Would only be done on a resident with a history of wandering. During interview on 12/3/2020 at 12:10 PM, the DON was asked if Resident #1 was assessed for elopement risk on 10/26/2020 because the Care Plan showed a revision date of 10/26/2020 with a risk for elopement. The DON stated, That's wrong, should be 11/26 (11/26/2020). During a telephone interview on 12/3/2020 at 4:20 PM, CNA #2 confirmed Resident #1 was not in his room or in the facility at approximately 11:15 PM on 11/25/2020 when she entered the room to obtain his vital signs. During a telephone interview on 12/3/2020 at 5:13 PM, Resident #1's Responsible Party stated, .I was told they (staff) made rounds at 8:00 PM and didn't make any other rounds till (until) after 11:00 PM. I was told they would check every 2 hours when we brought him (Resident #1) there to live .He (Resident #1) said he went through the woods and got winded (short of breath) and sat on a porch . When asked if Resident #1 had any mental or cognitive disabilities, Resident #1's Responsible Party stated, My husband and I had kept him for [AGE] years. He needs supervision. Not safe for him to be on his own . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set MDS assessment dated [DATE], showed Resident #4 was severely cognitively impaired. Review of the Incident Report dated 10/29/2020 at 7:50 PM, showed, .Called to room by CNA, stated while giving care she turned the patient (Resident #4) over and didn't realize the patient had a firm grip on the siderail. CNA stated patient was being resistant to care. CNA noted patients finger was bleeding and notified this nurse. Left fifth finger laceration . Review of the Nurse's Note dated 10/29/2020 at 9:11 PM, showed, .Patient (Resident #4) to ER (emergency room ) regarding laceration to left hand 5th digit. Order to send given by FNP (Family Nurse Practitioner) .EMS (Emergency Medical Services) left facility with patient at 8:55 PM. Review of the Emergency Department Patient Summary dated 10/29/2020 showed, .Laceration of left little finger . Review of the facility's investigation, showed the facility only interviewed and obtained statements from the staff that provided care to Resident #4 when the laceration was discovered. There were no interviews of other staff on duty or staff working the previous shifts. There were no interviews of cognitive residents and no skin assessments of cognitively impaired residents. During an interview on 12/4/2020 at 10:35 AM, the Director of Nursing (DON) confirmed there was not a thorough investigation completed when Resident #4 had a laceration on 10/29/2020. The surveyors verified the Removal Plan by: 1. On 11/26/2020 at 1:45 AM, every 15 minute observations were initiated for the CNA to assess Resident #1's location and condition. The DON conducted an in-service for all 11:00 PM-7:00 AM staff related to checking the resident every 15 minutes. The surveyors reviewed the documentation and interviewed the DON. 2. On 11/26/2020, Resident #1 had a full assessment completed by the Licensed Nurse, Resident #1 had no injuries and every 15 minute location checks continued. All staff were in-serviced by the DON for the importance and process for every 15 minute location and condition checks. Resident #1's physician was notified of the elopement. The family was called at the time of the elopement. The surveyors reviewed the documentation and interviewed the DON. 3. On 11/27/2020, the Administrator and Maintenance Director applied a window alarm to Resident #1's window to alert staff if the window is opened. Every 15 minute location and condition rounds continued. The window alarm was observed by the surveyors. The surveyors interviewed the Administrator and the Maintenance Director. 4. Effective 11/27/2020, Resident #1's door will remain open with the use of the privacy curtain unless the resident specifically voices a request for the door to be closed. The surveyors interviewed the staff and made observations of the resident room. 5. On 11/27/2020, the window in Resident #1's room will be visualized during the location and condition checks and the lock and function of the window alarm will be checked daily by Maintenance/Housekeeping/Administrator. The surveyors reviewed the documentation of the daily window checks. 6. On 11/27/2020, a Wanderguard bracelet was placed on Resident #1 to alert staff to any elopement attempts through a door with a Wanderguard alert. The surveyor observed the placement of the Wanderguard. 7. On 11/27/2020, the psychologist was contacted to request a psychological consult and will evaluate Resident #1 during the December visit. The surveyors interviewed the DON. 8. On 11/28/2020, the DON initiated hourly location checks by the CNAs for Resident #1 to validate the resident's location and condition. The surveyor reviewed the documentation. 9. On 11/28/2020, observations checks of Resident #1 were modified to every hour. The surveyor reviewed the documentation. 10. On 11/29/2020, every 2 hour observations began of Resident #1's location and condition according to facility protocol for the CNA. The surveyor reviewed the documentation and interviewed CNAs. 11. On 11/26/2020, Resident #1's Care Plan was updated to reflect the elopement event and interventions, scheduled checks, use of the call light to call nursing if he had a desire to go outside. The Minimum Data Set (MDS) and Care Area Assessment (CAA) were reviewed for accuracy by the MDS Nurse and/or the DON. The surveyor reviewed the Care Plan and interviewed the MDS Nurse and the DON. 12. On 12/3/2020, a security screw was placed in all resident windows, all 7 offices, kitchen windows, activity windows, conference room windows, dining room windows, therapy room windows, bathrooms, and break room limiting the opening of the window to 6-8 inches. All windows were locked and completed by Maintenance and the Administrator. The surveyors observed all windows, security screws, and checked the width the windows would open. 13. On 12/3/2020, the CNAs process for making hourly visual checks on the residents for location and condition was reinstated. The rounding/documentation monitoring tool will be reviewed/signed at the end of the shift by the charge nurse to ensure rounds were completed. The tool will identify the location of each resident, i.e. the hall, dining room, activity room, bedroom chair, bedroom bed or out of the facility for appointment or hospital and will be initialed hourly by the CNA. The surveyors reviewed the documentation and interviewed CNAs. 14. The Licensed Nurse will conduct visual resident checks for resident location and condition every two hours, initial the visual check tool and sign at the end of the shift to validate compliance. The surveyors interviewed nurses from each shift. 15. The DON will review the audits daily and sign prior to submission for Quality Assessment Performance Improvement (QAPI) review. The surveyor interviewed the DON. 16. On 12/3/2020, the DON completed Elopement/Wander assessments on 100% of the residents. No additional elopement risks were identified. The surveyor reviewed the documentation and interviewed the DON. 17. On 12/3/2020, all residents were re-evaluated using the elopement risk assessment tool by the DON. The surveyor reviewed the documentation. The two residents identified as an elopement risk had a risk identification form completed and placed in the Elopement Binder at each nursing station by the DON. The surveyors reviewed the Elopement Binders and interviewed the DON. 18. On 12/3/2020, the DON provided an in-service to the nursing staff on wandering, elopement, and resident safety. The surveyors reviewed the in-service and interviewed staff on all shifts. 19. On 12/4/2020, the Elopement and Wandering Residents policy was reviewed by the DON, the Administrator, and Medical Director without revisions. The surveyors interviewed the Administrator and the DON. 20. On 12/4/2020, a new protocol was established for hourly CNA Resident Location/Condition Checks and a monitoring tool implemented for residents assessed as a risk for elopement. The surveyors reviewed the documentation, interviewed CNAs and the DON. 21. On 12/4/2020, the facility revised the admission Resident Assessment Instrument (RAI) screening to include a Resident Elopement Assessment, history of wandering behaviors, frequency of wandering and elopement for all new admissions. The surveyors reviewed the screening tool and interviewed the DON and the MDS nurse. 22. The MDS Nurse will complete a wandering/elopement assessment in accordance with the RAI schedule quarterly. The surveyor interviewed the MDS nurse. 23. A resident assessed for elopement will be care planned for interventions: a) The Charge Nurse will place a Wanderguard bracelet on the resident and it will be monitored every shift by the CNA/Licensed Nurse for placement and function. The surveyors interviewed the Charge Nurses on all shifts. b) A Risk Identification form will be placed in the Elopement Risk Binder at each nurses station by the DON or Assistant Director of Nursing. The DON will be responsible for updating. The surveyors observed the Elopement Binders and interviewed the DON and ADON. c) A Therapy Screen will be completed to determine resident mobility abilities. The surveyors reviewed the therapy screen documentation. d) Social Service will Contact the family to determine effective diversions to elopement, resident habit and work history to assess potential triggers for elopement. The surveyor interviewed the Social Worker. e) The MDS Nurse will revise the Care Plan and complete the CNA Kardex related to risk and potential and/or effective interventions. The surveyor interviewed the MDS Nurse and observed the CNA Kardex. 24. The DON will ensure all staff receive the Elopement and Resident Safety In-service. Those staff not scheduled to work will be called by the DON and/or ADON to review the Wandering, Elopement and Resident Safety In-service to ensure knowledge of the elopement policy, protocol for hourly rounds, resident location and condition, and the required monitoring documentation. The Wandering, Elopement, and Resident Safety in-service content which included the policy and rounding protocol will be included in new hire orientation education. The surveyor interviewed the DON and reviewed the in-service education. 25. The DON, ADON, or MDS Nurse will audit new admissions for elopement risk and ensure appropriate interventions are in place. The surveyors interviewed the DON, ADON, and the MDS Nurse. 26. The DON or ADON will audit completed MDSs to ensure the care plan reflects concerns identified in the Care Area Assessments related to elopement risk. The surveyor interviewed the DON and ADON. 27. The DON and/or ADON will check the location of the Elopement Risk Binders daily to ensure they are updated, complete and located at each nursing station. The surveyors interviewed the DON and ADON. 28. The DON initiated the Rounding Protocol to CNAs visualize each resident every hour for location, condition, and safety and the Licensed Nurse visualizes each resident every hour for location, condition, and safety. The surveyors reviewed the documentation and interviewed the DON. 29. End of shift rounds will be made with oncoming and off-going staff to ensure a complete report is given and smooth transition between shifts. The surveyors interviewed licensed nurses and CNAs from each shift. 30. The DON will ensure all residents are located by staff each hour and all rounding audits are complete for review and discussion in QAPI monthly. Any rounding non-compliance will be met with additional training and/or focused education. The surveyors interviewed the DON. Noncompliance of F-689 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, video camera footage review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of a resident elopement, report an elopement timely to the state agency, and conduct a Quality Assurance and Performance Improvement (QAPI) Committee meeting when a resident left the facility without facility knowledge. Administration's failure to ensure a safe environment placed 1 of 3 sampled residents (Resident #1) reviewed with elopement/wandering behaviors in Immediate Jeopardy when Resident #1, an intellectually disabled resident left the facility through a window in his room. The facility staff were unaware Resident #1 was missing from the facility for 3 hours and 15 minutes, and the resident was outside unattended for 4 hours. This resulted in an Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Assistant Administrator/Business Office Manager was notified of Immediate Jeopardy on 12/3/2020 at 1:00 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-835, and F-867. The facility was cited F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/25/2020 through 12/7/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2020 at 2:40 PM, and was validated onsite by the surveyors on 12/8/2020 through policy review, observation, review of audits, review of meeting minutes, and staff interviews. The findings include: Review of the Administrator job description dated 2003, showed, .Administrative Functions: Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies .as necessary .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the facility's committee as necessary .Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice. Inform the Medical Director of all suspected or known incidents of resident abuse .Safety and Sanitation: Review accident/incident reports ( .falls, injuries of an unknown source abuse .) Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing (DON) job description dated 7/9/2019, showed, Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing service department .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Monitor the facility's QI (quality indicators), QM (quality measures), and survey reports. Assist in developing plans of action to correct potential or identified problem areas .Committee Functions: Serve on, participate in, and attend various committees of the facility as appointed by the Administrator .Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Staff Development: Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on 'how to do the job,' and ensure a well-educated nursing service department .Assist support services in developing, implementing, and conducting in-service training programs that relate to the nursing service department . Review of the facility's video camera footage with a time stamp of 11/25/2020 at 9:34 PM, showed Resident #1 was walking outside along the north side of the building toward the front of the building (west). He then turned to the right and walked up the hill and up the street leaving the view of the camera. The video camera footage showed the resident was returned to the facility by the Administrator on 11/26/2020 at 1:34 AM. The video camera footage confirmed he was out of the building unattended for 4 hours. The temperature in the city at that time was 44 degrees. During an interview on 12/2/2020 at 12:21 PM, the Assistant Director of Nursing (ADON) was asked, how would she ensure Resident #1 or other residents would not go out of another window. She stated, .I can't ensure that . During an interview with the Administrator on 12/2/2020 at 1:06 PM, the Administrator was asked if a thorough investigation was completed to determine the safety needs of residents and prevent any elopement in the future. The Administrator stated, .I was back home before 3:00 AM. Put an alarm on his (Resident #1) window. I don't think we've gotten around to doing all the windows yet. Put one on his window on Monday (11/30/2020) . The Administrator was unaware the alarm had been placed on Resident #1's window on 11/27/2020. During an interview on 12/2/2020 at 3:40 PM, the DON confirmed the facility had no policy for the management of residents with wandering and/or exit seeking behaviors. During an interview on 12/3/2020 at 11:15 AM, the Administrator was asked about the investigation of Resident #1's elopement. He stated, .The DON had an in-service the next day (Friday 11/27/2020) .or maybe it was Monday (11/30/2020) when she had the in-service. Monday, we put an alarm on his (Resident #1) window . During a telephone interview on 12/3/2020 at 4:20 PM, Certified Nursing Assistant (CNA) #2 confirmed Resident #1 was not in his room or in the facility at approximately 11:15 PM on 11/25/2020 when she was making her first observations of residents in the facility after she arrived on duty. During an interview on 12/4/2020 at 3:30 PM, the Administrator was asked how he ensured Resident #1, or any other resident, would not exit through a window. The Administrator stated, Well, we know our residents. We don't have any that actually wander or try to leave. We know our residents. We just know . The Administrator stated, .I guess I need to print the regs (regulations), things have really changed . During an interview on 12/4/2020 at 10:30 AM, the DON was asked if she had watched the video camera footage when conducting the investigation of Resident#1's elopement. She stated, .No, we never watched the video footage and saw him (Resident #1) on the camera, until watching with you (surveyor) . The DON stated that her and the Police Officer started to watch the video camera footage, but when the resident was found, they stopped watching the footage and never saw the resident on the footage that they had viewed. Refer to F-609, F-610, F-689, and F-867 The surveyor verified the Removal Plan by: 1. The Administrator/Maintenance Director will conduct elopement drills weekly for each shift x 3 weeks, monthly each shift x 3 months and quarterly x 3 quarters. Findings will be reviewed monthly during Quality Assurance Performance Improvement (QAPI) meetings and a Performance Improvement Project (PIP) will be initiated for areas of non-compliance of concern for oversight by the QAPI committee. The surveyors reviewed the Elopement drills and interviewed the Administrator and staff on all shifts. 2. The Administrator will make sure Elopement Drills are completed and submitted to the QAPI committee for review, recommendations, and education needs. Concerns will be reviewed with the Medical Director at least monthly. The surveyors interviewed the Administrator. 3. Maintenance/Housekeeping will conduct window security assessments daily for 7 days to ensure the screws are stable and in place. Window security was added to the Preventative Maintenance weekly schedule to ensure on-going compliance. The Administrator will monitor the scheduled window checks and door alarm function conducted by the Maintenance/Housekeeping Department to ensure the screws are in place, audits are completed, and the identified secure doors are functioning for on-going compliance. The Administrator will ensure window/door maintenance and safety concerns are addressed immediately and findings submitted to the QAPI committee for review. The surveyors interviewed the Maintenance Director and Administrator and reviewed the window maintenance checks and the Preventative Maintenance weekly schedule. 4. The DON initiated a QAPI Performance Improvement Project (PIP) to interpret all audit findings weekly. All findings related to elopement, safety, and windows will be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained. The surveyors interviewed the DON and reviewed the PIP. 5. The DON will review all PIPs with the Medical Director at least quarterly for the Medical Director's input and recommendations. The surveyors interviewed the DON. 6. The Registered Nurse (RN) Compliance Consultant will review PIPs, audits, and QAPI minutes at least quarterly for non-compliance trends and education needs. The surveyors interviewed the Administrator. 7. On 12/5/2020, the RN Compliance Consultant conducted a telephone in-service with the DON and Administrator to review the Regulatory Requirements for F-689 Accidents/Supervision; F-835 Administration Responsibilities; F-609 Reporting Requirements; F-610 Investigation Requirements and F-867 Quality Assurance and Performance Improvement. The surveyors interviewed the DON and Administrator. 8. The DON will notify the RN Compliance Consultant of all allegations of abuse, elopements or injuries of serious bodily harm and initiate an investigation within 24 hours. The surveyors interviewed the DON. 9. The RN Compliance Consultant will review event documentation, investigations, reporting and notification documents and audits monthly during the scheduled monthly compliance visits in the facility. The RN Compliance Consultant will ensure investigations are complete and the required notifications by the DON are timely. The surveyors interviewed the Administrator. Noncompliance of F-835 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on job description review, policy review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to elopement/wandering behaviors. The QAPI committee failed to ensure a safe environment, a thorough investigation of resident elopement was completed, an elopement was reported timely to the State Survey Agency, and failed to conduct a QAPI Committee meeting when a resident left the facility without facility knowledge. The QAPI committee's failure to ensure a safe environment placed 1 of 4 sampled residents (Resident #1) reviewed with elopement/wandering behavior and injuries of unknown origin in Immediate Jeopardy when Resident #1, an intellectually disabled resident left the facility through a window in his room. This resulted in an Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Assistant Administrator/Business Office Manager was notified of the Immediate Jeopardy on 12/3/2020 at 1:00 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-609, F-610 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 11/25/2020 through 12/7/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2020 at 2:40 PM, and was validated onsite by the surveyors on 12/8/2020 through policy review, observation, review of audits, review of meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Committee (QAPI), revised 8/2017, showed, .The primary goals of the Quality Assessment and Performance Improvement Committee are .to oversee facility systems and processes related to improving quality of care and services; to promote consistent facility systems and processes and appropriate practices in resident care; to help identify negative outcomes relative to resident care and resolve them appropriately . Review of the Administrator job description dated 2003, showed, .Administrative Functions: Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies .as necessary .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the facility's committee as necessary .Inform the Medical Director of all suspected or known incidents of resident abuse .Safety and Sanitation: Review accident/incident reports ( .falls, injuries of an unknown source abuse .) Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing (DON) job description dated 7/9/2019, showed, Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing service department .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Monitor the facility's QI (quality indicators), QM (quality measures), and survey reports. Assist in developing plans of action to correct potential or identified problem areas .Committee Functions: Serve on, participate in, and attend various committees of the facility as appointed by the Administrator .Evaluate and implement recommendations from established committees as they may pertain to nursing services . Review of the facility's video camera footage showed Resident #1 walking outside along the north side of the building toward the front of the building (west) unattended by staff on 11/25/2020 at 9:34 PM. Resident #1 entered the street, turned right and walked up the hill and up the street leaving the view of the camera. Resident #1 was returned to the facility on [DATE] at 1:34 AM by the Administrator. The video camera footage confirmed he was out of the building unattended for 4 hours. During an interview on 12/2/2020 at 1:00 PM, the Administrator stated, .We didn't meet yet for QAPI about the incident. We will bring it up and discuss it this month (December). When asked if the facility had an ad hoc QAPI meeting to discuss the event/incident, the Administrator stated, .No, ma'am. We will do that this month (December) . During an interview on 12/2/2020 at 3:40 PM, the DON confirmed the facility had no policy for the management of residents with wandering and/or exit seeking behaviors. During a phone interview on 12/3/2020 at 10:50 AM, the Medical Director stated, .We have QAPI every three months. I was made aware of the elopement the day after (per answering service). I know he (Resident #1) has intellectual disabilities. They (facility) have not shared me what they were going to do . During an interview on 12/3/2020 at 11:15 AM, the Administrator was asked about the investigation of Resident #1's elopement. He stated, .The DON had an in-service the next day .or maybe it was Monday when she had the in-service. Monday, we put an alarm on his (Resident #1) window . During an interview on 12/3/2020 at 11:40 AM, the Assistant Administrator/Business Office Manager stated, .I oversee and facilitate the Quality committee. No, I didn't notify the Medical Director. No, I never called an ad hoc meeting to discuss the incident. I guess I would call one if there is a disaster or evacuation . During a telephone interview on 12/3/2020 at 4:20 PM, Certified Nursing Assistant (CNA) #2 confirmed Resident #1 was not in his room or the facility at approximately 11:15 PM on 11/25/2020 when she was making her first observations of resident in the facility. During a telephone interview on 12/3/2020 at 4:25 PM, Licensed Practical Nurse (LPN) #1 stated, .When I called the answering service to notify the resident's MD (Named Medical Director) of the elopement I never talked to him. I left a message. I stayed past 7:00 AM and never talked to him . During an interview on 12/4/2020 at 10:26 AM, DON stated, .No, I never talked to him (Medical Director) about the incident (elopement of Resident #1). The nurse that night called his answering service and left a message, no one ever talked to him . The DON confirmed no one spoke directly with the Medical Director about the elopement. During an interview on 12/4/2020 at 3:30 PM, the Administrator was asked how would he ensure Resident #1, or any other resident, will not go out of a window. The Administrator stated, Well, we know our residents. We don't have any that actually wander or try to leave. We know our residents. We just know . Refer to F-609, F-610, F-689, and F-867. The surveyor verified the Removal Plan by: 1. The Administrator/Maintenance Director will conduct elopement drills weekly for each shift x 3 weeks, monthly each shift x 3 months and quarterly x 3 quarters. Findings will be reviewed monthly during Quality Assurance Performance Improvement (QAPI) meetings and a Performance Improvement Project (PIP) will be initiated for areas of non-compliance of concern for oversight by the QAPI committee. The surveyors reviewed the Elopement drills and interviewed the Administrator and staff on all shifts. 2. The Administrator will make sure Elopement Drills are completed and submitted to the QAPI committee for review, recommendations, and education needs. Concerns will be reviewed with the Medical Director at least monthly. The surveyors interviewed the Administrator. 3. Maintenance/Housekeeping will conduct window security assessments daily for 7 days to ensure the screws are stable and in place. Window security was added to the Preventative Maintenance weekly schedule to ensure on-going compliance. The Administrator will monitor the scheduled window checks and door alarm function conducted by the Maintenance/Housekeeping Department to ensure the screws are in place, audits are completed, and the identified secure doors are functioning for on-going compliance. The Administrator will ensure window/door maintenance and safety concerns are addressed immediately and findings submitted to the QAPI committee for review. The surveyors interviewed the Maintenance Director and Administrator and reviewed the window maintenance checks and the Preventative Maintenance weekly schedule. 4. The DON initiated a QAPI Performance Improvement Project (PIP) to interpret all audit findings weekly. All findings related to elopement, safety, and windows will be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained. The surveyors interviewed the DON and reviewed the PIP. 5. The DON will review all PIPs with the Medical Director at least quarterly for the Medical Director's input and recommendations. The surveyors interviewed the DON. 6. The Registered Nurse (RN) Compliance Consultant will review PIPs, audits, and QAPI minutes at least quarterly for non-compliance trends and education needs. The surveyors interviewed the Administrator. 7. On 12/5/2020, the RN Compliance Consultant conducted a telephone in-service with the DON and Administrator to review the Regulatory Requirements for F-689 Accidents/Supervision; F-835 Administration Responsibilities; F-609 Reporting Requirements; F-610 Investigation Requirements and F-867 Quality Assurance and Performance Improvement. The surveyors interviewed the DON and Administrator. 8. The DON will notify the RN Compliance Consultant of all allegations of abuse, elopements or injuries of serious bodily harm and initiate an investigation within 24 hours. The surveyors interviewed the DON. 9. The RN Compliance Consultant will review event documentation, investigations, reporting and notification documents and audits monthly during the scheduled monthly compliance visits in the facility. The RN Compliance Consultant will ensure investigations are complete and the required notifications by the DON are timely. The surveyors interviewed the Administrator. 10. The QAPI program will take a systematic, interdisciplinary, comprehensive and data driven approach to maintaining and improving safety. The Program activities will rely on all department managers, staff, residents and families for information, observation, and data to contribute to practical and creative problem solving. The surveyors reviewed the QAPI program and interviewed the Administrator. 11. Each Department Manager will establish benchmarks of compliance for each of their departments utilizing data gathered through daily observation, staff performance reviews, resident and family satisfaction, Quality Measures, Nursing Home Compare data and CMS CASPER reports. The surveyors interviewed Department Managers. 12. The DON and ADON will track clinical data such as medication / treatment errors, resident events, behaviors, infections, antibiotic usage, wounds, resident satisfaction and staff performance. The surveyors interviewed the DON and ADON. 13. The DON will assist each department manager to establish a Performance Improvement Protocol (PIP)with goals, plans, interventions, causation through root cause analysis and corrective action process with concise timelines for each established PIP. The surveyors interviewed the DON. 14. The Administrator through the QAPI Committee will prioritize the timeline of the committee PIP focus based on the scope and severity of the open PIPs. High risk, high volume and historical problem prone areas associated with significant risk to the health and safety of the residents will remain a priority in addition to other areas needed for safety and performance improvement. The surveyors interviewed the Administrator. 15. On 12/4/2020, the Administrator called a Quality Assurance (QA) meeting to review, discuss and process the corrective action plan and goals resulting from the elopement, the committee met to review policy and procedure changes, staff education, physical plant improvements and monitoring process and tools. The called QA/QAPI meeting minutes will be reviewed during the scheduled QA/QAPI committee meeting. The surveyors interviewed the Administrator and reviewed the QA meeting minutes. 16. The Administrator, DON, or Medical Director may convene a QA/QAPI meeting to review, discuss and process the corrective action plan and goals resulting from the occurrence of a major incident. The committee will meet to review policy and procedure changes, staff education, physical plant improvements and monitoring processes and tools. The called QA/QAPI meeting focus will be reviewed during the scheduled QA/QAPI committee meeting. The surveyors interviewed the Administrator and the DON. Noncompliance of F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Intakes: TN 592 Based on medical record review and interview, it was determined the facility failed to ensure the resident environment remained free from accident hazards for 1 of 5 (Resident #3) sampled residents. The facility's failure to ensure both side rails remained up while the resident was in bed resulted in actual harm when Resident #3 fell from the bed sustaining a fracture of the right tibia and fibula. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] and 12/11/12 documented in Section C Cognitive Patterns, Resident #3 was unable to complete the Brief Interview for Mental Status. Staff Assessment for Mental Status documented the resident's Cognitive Skills for Daily Decision Making as a "2" indicating moderate impairment - decisions poor; cues/supervision required. Review of the physician's recertification orders for September 2012 with original order date of 1/26/12 documented, "...1/2 SIDERAILS UP WHILE IN BED TO ASSIST WITH BED MOBILITY, TURNING AND REPOSITIONING..." Review of the care plan dated 3/25/12 documented, "...Potential for falls/HX (history): of falls/recent fall... 1/2 side rails up when in bed to assist with repositioning/encourage not to try and transfer without assist... 9/8/12... Rehab to screen. Make sure 1/2 rails up when in Bed & (and) lock..." Review of the Nurse's Notes dated 9/8/12 at 2:45 PM documented, "...Summoned to Room (Resident #3's) by Resident in A bed. Observed resident (#3) lying on the floor beside bed on her left side. Neuro checks WNL (with in normal limits). c/o (complaint of) pain to R (right) knee & ankle. MD (Medical Doctor) notified. Order to send to ER (emergency room ) for eval (evaluation)..." Review of the x-ray report dated 9/8/12 at 4:23 PM documented, "Exam RIGHT TIBIA / FIBULA ...1. Acute nondisplaced fracture of the distal tibia. 2. Acute mildly angulated fracture of the distal fibula..." Review of the fall Investigation dated 9/9/12 documented Resident #3 was left unattended with only one side rail up. The resident rolled out of bed toward the side with the side rail down and sustained a fracture. Further investigation documented the certified nursing assistant (CNA #1) stated both side rails were left up. The beautician, who visited the resident's room and styled the resident's hair, stated one side rail was down upon entering the room and left the room as it was when she arrived. During an interview in the conference room on 12/13/12 at 11:30 AM, the Director of Nursing (DON) was asked if the facility had investigated Resident #3's fall from her bed. The DON stated an occurrence report was completed by the charge nurse on 9/8/12 and a complete fall investigation dated 9/9/12 was completed by the DON followed with interviews with the hair stylist and the CNA #1 assigned to care for Resident #3 on 9/8/12 7AM to 3PM shift. The facility was unable to determine who was at fault. It was one person's word against the others." During a telephone interview on 12/27/12 at 9:30 AM, the hair stylist was asked the position of the side rail on Resident #3's bed on 9/8/12 while she was styling the resident's hair. The stylist stated, "...I do not remember if the side rail was up or down on that date... I do not move or change anything in the resident's rooms, especially not the side rails..." During a telephone interview on 12/27/12 at 11:10 AM, the CNA #1 was asked the position of the side rail on Resident #3's bed on 9/8/12. The CNA #1 stated that after performing morning care to the resident, the CNA #1 raised both side rails before leaving the resident's room. The CNA #1 stated the resident leans to one side and definitely needed the side rails. The facility's failed to ensure Resident #3's siderails remained up when the resident was in bed resulted in actual harm when Resident #3 rolled out of the bed resulting in a fracture of the right tibia and fibula.