Every finding on record at Nancy Hart Operation LLC

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Handwashing/Hand Hygiene and Infection Prevention and Control Program, the facility failed to ensure proper hand hygiene practices were followed, failed to implement Enhanced Barrier Precautions (EBP), and failed to establish a water management program to address the risk of waterborne pathogens, including Legionella. These failures had the potential to contribute to the transmission of infectious diseases among residents and staff. The census was 65.Findings include:Review of the facility's undated policy titled Handwashing/Hand Hygiene, revealed section (7.l) revealed, Use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: After contact with objects.in the immediate vicinity of the resident.Review of the facility's policy titled, Infection Prevention and Control Program, review date May 2022, included, Water Management: A water management program has been established as part of the overall infection prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. Additionally, review of the policy revealed there was no content addressing EBP, and the facility was unable to provide an EBP policy.1. Observations on 7/23/2025 at 2:09 pm revealed Laundry Aide MM entered and exited multiple resident rooms while delivering clean clothing and placing items inside residents' closets without performing hand hygiene at any point during the process.Observations on 7/24/2025 at 2:00 pm revealed Laundry Aide MM entered and exited multiple resident rooms while delivering clean clothing and placing items inside residents' closets without performing hand hygiene at any point during the process.In an interview on 7/24/2025 at 5:15 pm, Laundry Aide MM confirmed that she did not perform hand hygiene after entering and exiting each resident's room, and was uncertain about the exact moments when hand hygiene should be performed. Laundry Aide MM reported receiving hand hygiene training during her initial hire in 2020, and stated she had not received any additional or refresher training since.2. Review of the facility-provided MDS [Minimum Data Set] Resident Matrix, dated 7/22/2025, revealed three residents with an indwelling urinary catheter and two residents with a pressure ulcer. Review of a facility-provided document titled Long Term Care CNA Skills Checklist revealed EBP was not on the checklist. In an interview on 7/23/2025 at 2:05 pm, Certified Nursing Assistant (CNA) NN stated EBP involved applying barrier cream every two hours. She reported that she does not currently wear a gown for any resident and only performs hand hygiene before entering resident rooms, not after. She stated that she had not been required to demonstrate specific Personal Protective Equipment (PPE) competency check-offs, only general CNA skills.In an interview on 7/23/2025 at 1:07 pm, the Director of Nursing (DON) revealed that EBP had not been implemented at the facility. The DON described EBP as fairly new and acknowledged that no staff training had been conducted and no procedures, policies, or protocols were in place at the time of the interview.In an interview on 7/24/2025 at 10:03 am, the DON revealed that hand hygiene and PPE competency check-offs had not been conducted since she assumed her role. During the interview, the DON also mentioned that she had identified seven residents who met the criteria for EBP.3. Review of the facility's infection surveillance records revealed no documentation of a water management program or Legionella monitoring.Review of a facility-provided document titled Emergency Management Plan, dated 7/24/2025, revealed Samples are sent to State Lab. Lead, copper, E.coli, and coliform.In an interview on 7/23/2025 at 2:37 pm, the Maintenance Director revealed that the facility had not implemented a formal Water Management Program. He stated he possessed a Centers for Disease Control and Prevention (CDC) printout on the topic but had not developed a functional plan and admitted not fully understanding the program's requirements. He noted that an external company collected monthly well water samples, but was unsure of the specific contaminants tested. A follow-up with the Environmental Management Services confirmed that the testing is limited to lead, copper, and coliform (E. coli), with no monitoring for Legionella and no risk assessment or control measures in place.

Based on observations and staff interviews, the facility failed to ensure a safe, clean, and comfortable homelike environment in seven of 26 resident rooms. This deficient practice had the potential to impact the quality of life and safety of all residents occupying the areas. Findings include:Observation on 7/22/2025 at 11:30 am of room [ROOM NUMBER] revealed a two-inch hole in the wall behind the resident's door, and a two-inch hole in the door leading to the bathroom.Observations on 7/22/2025 beginning at 11:23 am revealed Rooms 108, 200, 201, 202, 203, 204, and 205 had chipped and peeling paint on the walls near the residents' beds and window areas. Further observations revealed the ceiling ventilation units in Rooms 108, 200, 201, 202, 203, 204, and 205 had a buildup of fuzzy material covering the ventilation slats. Continued observations of Rooms 108, 200, 201, 202, 203, 204, and 205 revealed jagged closet edges, soiled baseboards, and scuffed walls. During a walk-through observation on 7/24/2025 at 1:12 pm, the Maintenance Director verified all identified concerns.During an interview on 7/24/2025 at 2:00 pm, the Maintenance Director acknowledged that the rooms had ongoing cosmetic and structural issues. He stated that the repairs were pending due to supply delays and the fact that he was the only maintenance staff member at this time. He stated he understands the importance of the environmental concerns, emphasizing peeling paint, holes in walls, and dust accumulation, which are not consistent with creating or sustaining a homelike environment for all residents. He confirmed that the staff put work orders into the computer system, and he sorts them according to priority.

Based on staff interviews and record review, the facility failed to implement care plan interventions for one of 36 sampled residents (R) (R33). This deficient practice had the potential to place R33 at increased risk of medical complications and unmet care needs. Findings include:Review of the electronic medical records (EMR) revealed that R33 was admitted to the facility on [DATE] with diagnoses including, but not limited to, type 2 diabetes mellitus (DM) and stage 3 chronic kidney disease.Review of R33's admission Minimum Data Set (MDS), dated [DATE], revealed Section I (Active Diagnoses) documented diabetes mellitus as an active diagnosis. Section N (Medications) documented that R33 received insulin. Review of the care plan for R33 revealed a Focus date initiated 7/7/2025, of the resident has diabetes mellitus. The Goal included that the resident will be free from any signs or symptoms of hyperglycemia or hypoglycemia through the next review date. Interventions included administering diabetes medication as ordered by the doctor, monitoring and documenting for side effects and effectiveness, monitoring and documenting signs of hyperglycemia and hypoglycemia. Review of the Physician Orders for R33 revealed an order dated 7/3/2025 for insulin glargine subcutaneous solution 100 units/milliliter (ML) (a medication used to manage high blood sugar), inject 16 units subcutaneously at bedtime for DM.Review of the Medication Administration Record (MAR) for R33, dated July 2025, revealed that R33 was scheduled to receive a nightly dose of insulin glargine subcutaneous 16 units at bedtime and was scheduled for 9:00 pm. Further review of the July 2025 MAR revealed that the insulin glargine was not administered on 16 of 19 dates, and there was no documentation of monitoring for signs of hypoglycemia or hyperglycemia. In an interview on 7/23/2025 at 12:10 pm, Licensed Practical Nurse (LPN) HH stated she regularly cared for R33 and was unaware the resident was a diabetic. She confirmed that she had not administered any diabetes medications to him and had not been monitoring for signs or symptoms of hyperglycemia or hypoglycemia. She also stated that she had not seen it documented in the care plan.In a telephone interview on 7/23/2025 at 7:53 pm, LPN CC stated she regularly cared for R33. She further stated she was unsure if R33 was a diabetic, and she had not monitored R33 for signs of hypoglycemia or hyperglycemia or administered the insulin as ordered by the physician. In a concurrent interview on 7/24/2025 at 12:10 pm with the Director of Nursing (DON), Unit Manager (UM), and MDS Coordinator, the DON stated that her expectation is for nurses to review the care plans developed for each resident and to implement them. The DON further acknowledged that monitoring R33 for signs and symptoms of hypoglycemia was overlooked, despite being included in the care plan, because it was not included on the MAR.Cross-reference F760

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Policy and Procedure Manual: Clinical P&P Respiratory Care, the facility failed to ensure that oxygen therapy was provided as ordered for two of six residents (R) (R69 and R46) with oxygen orders. In addition, the facility failed to ensure respiratory circuits were cleaned as ordered for two of six residents (R46 and R48) with respiratory circuits. This deficient practice had the potential to place R69, R46, and R48 at increased risk of respiratory complications.Findings include: Review of the policy titled, Policy and Procedure Manual: Clinical P&P Respiratory Care, dated 4/1/2022, revealed the “Procedure” section included, 1. Verify that there is a physician’s order for respiratory procedures or oxygen use. Review the physician’s orders for oxygen administration. … 10. Oxygen, trach, and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. … 1. Review of the electronic medical record (EMR) for R69 revealed diagnoses including, but not limited to, acute chronic diastolic (congestive) heart failure and chronic respiratory failure with hypoxia. Review of the “Physician Orders” for R69 revealed an order dated 7/23/2025 for Oxygen at 2 liters per minute via (by way of) NC (nasal canula) PRN (as needed). Observations on 7/22/2025 at 1:21 pm, 7/23/2025 at 11:45 am, 7/24/2025 at 11:00 am, and 1:00 pm revealed R69 was in his bed and receiving oxygen via NC via a concentrator. The flow rate was set at 3 LPM. Observation and interview on 7/24/2025 at 1:30 pm of R69 with Registered Nurse (RN) Unit Manager (UM) BB confirmed the resident was receiving oxygen at 3 LPM. She further confirmed that R69 had a physician order for oxygen at 2 LPM. RN BB stated that she would adjust the oxygen setting. 2. Review of the electronic medical record (EMR) revealed R46 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to, chronic obstructive pulmonary disease (COPD) with acute exacerbation, hypertension, anemia, and a history of venous thromboembolism. Review of R46's Annual Minimum Data Set (MDS) assessment, dated 6/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 4 (which indicates severe cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the “Physician’s Orders” for R46 revealed an order dated 2/5/2025 for oxygen via NC at 2 LPM continuous. Observation on 7/22/2025 at 10:04 am revealed R46 in her room receiving oxygen via a NC via a concentrator with the flow rate set at 3 LPM. Observation revealed the oxygen tubing was dated 7/7/2025. In a concurrent observation and interview on 7/23/2025 at 10:10 am with R46 in her room, observation revealed R46 was not receiving oxygen. Further observation revealed the oxygen concentrator was turned off. R46 stated she did not turn the concentrator off. In an interview on 7/22/2025 at 2:00 pm, Licensed Practical Nurse (LPN) JJ confirmed that R46’s oxygen flow rate was set incorrectly and should be set to 2 LPM. In an interview on 7/23/2025 at 10:16 am, LPN DD confirmed that R46’s oxygen concentrator was turned off and that the resident was not receiving oxygen. LPN DD further confirmed that the oxygen tubing was dated 7/7/2025 and acknowledged it was overdue for replacement. She stated tubing should be changed weekly and confirmed it was two weeks past due. In an interview on 7/23/2025 at 2:10 pm, the Director of Nursing (DON) stated it was the nurse's responsibility to check oxygen settings each shift and change the oxygen tubing weekly.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Administration of Insulin, the facility failed to ensure that one of 15 residents (R) (R33) with physician orders for insulin received the insulin as prescribed by the physician. This deficient practice had the potential to place R33 at risk of medical complications and unmet needs. Findings include:Review of the facility's policy titled, Administration of Insulin, reviewed date 4/29/2025, reveals the Policy section included, It is the purpose of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. The Policy Explanation and Compliance Guidelines section included, 1. All insulin will be administered in accordance with physician's orders. 3. For new or emergency orders for insulin, the facility may use medications from the emergency kit.Review of the electronic medical records for R33 revealed an admission date of 7/3/2025 with diagnoses including, but not limited to, type 2 diabetes mellitus (DM) and stage 3 chronic kidney disease.Review of R33's admission Minimum Data Set (MDS), dated [DATE], revealed Section I (Active Diagnoses) documented diabetes mellitus as an active diagnosis. Section N (Medications) documented that R33 received insulin. Review of the Physician Orders for R33 revealed an order dated 7/3/2025 for insulin glargine subcutaneous solution 100 units/milliliter (ML) (a medication used to manage high blood sugar), inject 16 units subcutaneously at bedtime for DM.Review of the Medication Administration Record (MAR) for R33, dated July 2025, revealed that R33 was scheduled to receive a nightly dose of insulin glargine subcutaneous 16 units at bedtime and was scheduled for 9:00 pm. Further review of the July 2025 MAR revealed that the insulin glargine was not administered on 7/3/2025, 7/4/2025, 7/5/2025, 7/6/2025, 7/9/2025, 7/8/2025, 7/9/2025, 7/10/2025, 7/11/2025, 7/12/2025, 7/13/2025, 7/14/2025, 7/15/2025, 7/16/2025, 7/17/2025, 7/18/2025, 7/19/2025, 7/20/2025, or 7/21/2025. The MAR was marked with the number 9 on 7/3/2025, 7/4/2025, 7/5/2025, 7/6/2025, 7/9/2025, 7/10/2025, 7/11/2025, 7/13/2025, 7/15/2025, 7/16/2025, 7/17/2025, 7/18/2025, 7/19/2025, 7/20/2025, and 7/21/2025. The MAR was marked with the number 2 on 7/12/2025 and the number 3 on 7/14/2025. Review of the Chart Codes, located on the MAR, revealed 2 = Drug refused, 3 = Absent from home with meds, and 9 = other/see progress notes.Review of the Progress Notes for R33 revealed entries dated 7/3/2025, 7/13/2025, 7/14/2024, 7/21/2025, 7/22/2025 documented Awaiting pharmacy. There was no documentation for the other days when the insulin was not administered. In a telephone interview on 7/23/2025 at 7:53 pm, Licensed Practical Nurse (LPN) CC stated that she had not administered the insulin because it had not been received from the pharmacy, and she had continued to reorder it. LPN CC stated she had not called the pharmacy or notified the physician for further instructions and stated she assumed the insulin would eventually arrive.In a telephone interview on 7/23/2025 at 8:47 pm, Pharmacist CC stated the pharmacy delivered to the facility one or two times a day. Pharmacist CC stated an order for insulin glargine for R33 had not been ordered, and there was no prescription for it on file. In a concurrent interview on 7/24/2025 at 12:10 pm with the Director of Nursing (DON), Unit Manager (UM), and MDS Coordinator, the DON stated that her expectation was for nurses to follow the physician's orders as written. When a new resident is admitted , orders are to be entered immediately, and any issues with medications must be communicated promptly to the pharmacy. She emphasized that medications must be administered on schedule. If medication is not available, staff are expected to contact the physician directly for guidance. The UM stated that if medication was unavailable, staff have access to four emergency kits, and if the medication was still not available from the emergency kit, they will physically go to the pharmacy to obtain it. The DON further acknowledged that she could not explain why the nurse failed to follow through with obtaining the insulin.

Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Elopement Protocols, the facility failed to provide adequate supervision, frequent monitoring, and to ensure one of four exit doors was functioning properly to prevent the elopement for one out of three sampled Residents (R) (R1). Findings include: Review of the undated facility's policy titled Elopement Protocols under the Policy section revealed, It is the responsibility of all personnel to report any residents attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Elopement and wandering are two separate events and shall not be used interchangeably . Elopement is an event which requires immediate attention of the administrative staff up to and including reporting the event to the stated and obtaining a sheriff report. A resident is considered to have eloped if the boundaries of elopement have been crossed. For this facility, elopement boundaries are off the grounds of the nursing home. Review of R1's Admission Record revealed, the resident was admitted to the facility on [DATE] with the following diagnoses that included but not limited to: cerebral infarct, altered mental status, other symptoms and signs involving cognitive functions and awareness, generalized anxiety disorder. Review of R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment; Section E (Behaviors) revealed, he had behaviors including daily wandering and Section GG (Functional Abilities and Goals) revealed, R1 had no impairment to upper and lower extremities, required supervision with mobility and activities of daily living. Review of R1's care plan initiated on 12/6/2024 and last revised on 4/29/2025 revealed, Focus [R1 Name] is an elopement risk/wanderer related to (r/t) disoriented to place with impaired safety awareness, resident wanders aimlessly. 2/21/2025-continues to try and find a way out of the facility, tries to put in the code on the door pad, find a way out the windows, increase agitation when redirected. 4/19/2025 - resident left facility on foot. Review of the nurse's note dated 4/19/2025 revealed, [R1 Name] left the faciity on foot this morning, Nurse went to give medications a few minutes before 0900 and could not find him in the facility, nurse and nurse supervisor got into their vehicles to go look for him, approximately 0910 nurse found [R1 Name] with a couple of people with him on the side of the road, they had called 911. [R1 Name] had fallen to his knees, no injury noted, and he stated he was going to [Name of Store]. Emergency Medical Services (EMS) transported him to the hospital. [R1 Name] was last seen around 8 am walking in the hallway. Review of the Discharge Summary from the hospital dated 4/19/2025 revealed, R1 arrived by ambulance and was treated for fall. Further review revealed, R1 had good recollection of what happened and reported that he slipped and fell softly on the grass after he left the nursing home because he wanted to go to [Name of store]. R1 had a normal exam and was discharged to nursing home with fall precautions and to follow-up with Primary Care Physician (PCP) in 2 (two) days. Interview on 4/28/2025 at 12:35 pm with R1 while in his room revealed, he did not remember leaving the building about a week ago on a Saturday (4/19/2025). He revealed, he went out the door and pointed toward the end of the 200 Hall and that he didn't use the keypad because the door wasn't locked. He further revealed that he doesn't remember anyone going out the door before him. He stated that he wasn't hurt and that he wasn't going to try that again. In an interview on 4/28/2025 at 1:50 pm with the Maintenance Director (MD) revealed, that staff called him on 4/19/2025 after R1 left the facility to come check the exit doors at the end of the 200 Hall because they didn't think the door was latching all the way. He stated that he probably checked all the exit doors at the facility three to four times a day and changed the door codes at least weekly. He stated that they have residents who watch the staff put in the codes and they will tell other residents what the codes were. He stated that the Administrator had talked to staff about being careful when they put in codes because some of the residents were watching. He stated that R1 wanders all day long checking the doors to see if he could get out. He further stated that the facility's front property extends about 100 yards to the road and from what he was told, R1 was found about 50 yards from the road in front of the church that faces the main highway. He further stated that the doors at the end of the 200 Hall had not had any problems previously with latching when closed and stated that he checked the doors multiple times on 4/19/2025 without any concerns noted. In an interview on 4/28/2025 at 2:00 pm with Certified Nursing Assistant (CNA) CNA AA revealed that she was working on the 200 Hall on 4/19/2025 when R1 got out of the building. She stated that she had seen him walking in the hallway earlier in the shift at about 7:15 am and when she took his breakfast tray to him around 8:40 am, he wasn't in his bed but wasn't concerned because he liked to walk the halls. She revealed that she asked the nurse if she had seen R1 because he wasn't in his room to eat breakfast, and that was when the nurse and Registered Nurse (RN) Supervisor got in their cars and began looking for him while other staff looked inside the facility. In an interview on 4/28/2025 at 2:10 pm with CNA BB revealed that she was working on the 200 Hall on 4/19/2025 when R1 left the facility. She stated she wasn't assigned to him but that she saw him walking in the hallway at around 8:00 am that morning. She stated she went to get the breakfast trays around 8:40 am and while passing out trays to her residents, CNA AA asked her if she had seen R1 because he wasn't in his room. She further stated that when the resident got back to the facility from the hospital, she asked him where he was going when he left the facility, and he told her he wanted to go to the store for hair clippers, but he wouldn't do that again. She stated he told her that he felt 'foolish' because he tried to walk to the store. She further stated that R1 was the only resident who checked the doors to see if they were open and that the other residents who were wanderers just wander in the hallways. In an interview on 4/29/2025 at 10:05 am with Housekeeping Aide CC who stated that she was told by her supervisor to make sure the doors are locked when they take the trash out. She stated that she had seen R1 walking around in the hallways checking the doors to see if they were locked. In an interview on 4/29/2025 at 11:15 am with LPN DD revealed that when she realized R1 was not in the facility around 9:00 am, she and the RN Supervisor got in their vehicles and started looking for him. She stated when she turned off the road onto Highway 17, she saw a truck pulled over on the side of the road with a man and woman standing by R1. She stated that he had evidently tripped in the grass and fell to his knees. She stated that the man and woman had already called 911 to come pick up R1. She further stated that she and the RN Supervisor waited with the R1 until the ambulance arrived. She stated that R1 told them he had left the facility about 30 minutes ago and was going to the store. In an interview on 4/29/2024 at 1:30 pm with the Administrator revealed that after R1 eloped, the MD put alarms on all the exit doors except the front door which had a keypad. He further stated that he had requested a [Name of electronic alarm] system for the facility, but felt R1 was cognitive enough that he would remove it.

Based on staff interview, record review and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 59. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program dated May 2022 under the section titled Policy revealed, It is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Under the section titled Policy and Explanation and Compliance Guidelines revealed, 4(b). Monitoring antibiotic use: (iv). Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). Review of the Infection Control Monthly/Yearly Report from 1/2023 to 12/2023 revealed there was a lack of documentation of surveillance data collected for seven out of 12 months. Interview on 2/29/2024 at 4:41 pm with the Director of Nursing (DON), the Infection Control Preventionist (ICP) reported she had not been tracking, trending, or mapping the infections and use of antibiotics per the McGreers criteria. The DON/ICP revealed she had only been in the position for a short time and the previous DON had stopped monitoring the use of antibiotics and infections.

Based on observations, staff Interviews, record review and review of the facility's policy titled Food Receiving and Storage, the facility failed label and date food items stored in the refrigerator. In addition, the facility failed to maintain the appropriate concentration of sanitizing solution in the three-compartment sink. The facility census was 58 residents. Findings include: Review of the undated facility's policy titled Food Receiving and Storage under the Policy Statement revealed, Food shall be received and stored in a manner that complied with food and safety handling practices. Under the section titled Policy Interpretation and Implementation revealed, 7. All foods store in the refrigerator or freezer will be covered, labeled, and dated (used by date). Observation of the kitchen on 2/27/2024 at 9:15 am revealed the following: All food items in the refrigerator were not labeled or dated which included sausage, fish, turkey, and hot dogs; The sanitize strip test conducted for the three-compartment sink was negative and revealed the sanitizing solution was not at the appropriate concentration according to the manufacturer's instructions. Interview on 2/27/2024 at 9:15 am with Certified Food Manager (CFM), FF revealed that staff did not label the food as instructed and that there was a problem with labeling falling off on frozen foods. CFM, FF also confirmed that there was no chemical sanitizing solution added to the water. Interview on 2/28/2024 at 11:25 am with Cook, II revealed that the frozen foods identified from the freezer during the kitchen tour was thrown away.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled P&P Resident Council Meeting, the facility failed to provide documented responses to residents' grievances and concerns regarding resident care and life expressed during Resident Council meetings in six of eight meetings. The facility census was 58. Findings include: Review of the facility's policy titled P&P Resident Council Meeting dated 4/1/2022 under the section titled Procedure revealed, The purpose of the Resident Council is to provide a forum for residents: a. To discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; 4. The facility will provide a designated staff person who is approved by the resident group who is approved by the resident group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. 5. The facility will consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. a. The facility will demonstrate their response and rationale for such responses. Review of the Resident Council minutes dated 7/27/2023 revealed the following resident concerns: aides should check rooms more often; aides should be more respectful; and staff congregates in hallways on their phones. The minutes indicated that the Social Services Director (SSD) was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible as blank. There were no entries under Old Business Review and the fields of Issue, Status Update, and Person Responsible were blank. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated 14 residents present at the meeting. Review of the Resident Council minutes dated 8/31/2023 revealed the following resident concerns: not getting showers often; resident at window when food is being served; and aides being too loud at night. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible as blank. There were no entries under Old Business Review and the fields of Issue, Status Update, and Person Responsible were blank. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated 13 residents present at the meeting. Review of the Resident Council minutes dated 9/28/2023 revealed the following resident concerns: need satellite dish/cable; very loud roommates; need better smoking area; aides on nights are loud and residents can't sleep; and aides need to be more attentive and check on residents. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken as blank and Person Responsible indicated in first two issues with no Outcome indicated. There were no entries under Old Business Review and the fields of Issue, Status Update, and Person Responsible were blank. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated seven residents present at the meeting. Review of the Resident Council minutes dated 10/26/2023 revealed the following resident concerns: need more aides on weekends; takes too long to answer call lights; and staff too loud in hallway at night. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible as blank. There were no entries under Old Business Review and the fields of Issue, Status Update, and Person Responsible were blank. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated 13 residents present at the meeting. Review of the Resident Council minutes dated 11/30/2023 revealed the following resident concerns: hard time getting smokers out on weekends; need a van; and need to stop residents from wandering in and out of rooms. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible as blank. There were no entries under Old Business Review and the fields of Issue, Status Update, and Person Responsible were blank. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated nine residents present at the meeting. Review of the Resident Council minutes dated 12/28/2023 revealed the following resident concerns: need shower beds and shower team in place; need van; need extension over smoking area; and need more aides on weekends. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible as blank. There were entries under Old Business Review and two issues were listed as ongoing and one resolved. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days indicated No. The section Resident [NAME] of Rights review was blank. The sign-in sheet indicated six residents present at the meeting. Review of the Resident Council minutes dated 1/29/2024 revealed the following resident concerns: more Certified Nursing Assistants (CNA's) needed; takes long time to answer call lights; need more menu changes. The minutes indicated that the SSD and Administrator were present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible was complete. The Old Business Review and the fields of Issue, Status Update, and Person Responsible were complete. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days was blank. The section Resident [NAME] of Rights review indicated review of Right to Privacy. The sign-in sheet indicated 15 residents present at the meeting. Review of the Resident Council minutes dated 2/27/2024 revealed the following resident concerns: smoking on weekends; call lights not being answered timely; and mold in shower room. The minutes indicated that the SSD was present at the meeting. The section marked New Business Review/Action Plan revealed Actions Taken and Person Responsible was complete. The Old Business Review and the fields of Issue, Status Update, and Person Responsible were complete. The section Facility Policies and Procedures Developed/Revised/Updates in the last 30 days was blank. The section Resident [NAME] of Rights review indicated review of right to refuse medication and showers. The sign-in sheet indicated 10 residents present at the meeting. Observation and interview on 2/28/2024 at 11:00 am revealed a meeting held with six members of the resident council including the resident council president. The newly appointed resident council president said she would like the Administrator to attend more future meetings and to address individual and collective grievances. She added that she would appreciate any response to their ongoing concerns. The residents verbalized an understanding of the grievance process, but they were concerned about the lack of facility response to their concerns. Interview on 2/28/2024 at 11:57 am with the Administrator indicated that he does not respond in writing to any of the council's concerns. The Administrator voiced an understanding that the lack of documented follow-up to concerns presented by the resident council gave an indication that their complaints had not been resolved. A follow up interview on 2/28/2024 at 2:21 pm with the Administrator confirmed that he was aware he was to respond to resident council concerns, be he didn't.

Based on observations, staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for nine of 23 rooms (Rooms 100, 101, 107, 201, 202, 203, 204, 205, 206) and two of three hallways (Hallways 200 and 300). Specifically, the bathrooms in rooms 100, 201, 203, 204, and 206 contained unstable floors, cracked and broken tile, soiled toilets and sinks, and broken lights. Additionally, the residents' rooms and hallways contained loose tiles, holes in the walls, chipped and peeling paint, missing cabinet faces, and sticky hallway floors. The facility census was 58 residents. Findings include: Observations on 2/27/2024 from 9:15 am to 9:35 am revealed the following: The 200 and 300 hallway floors were noted to be sticky while walking the entirety of both floors. There were brown substances found stuck to the floor and paint chipping throughout both hallways; room [ROOM NUMBER]- bathroom light not working; room [ROOM NUMBER]-cracked tile and floor dug out in front of the bathroom door; room [ROOM NUMBER]- missing floor in front of the door leading to the bathroom; room [ROOM NUMBER]- soft floor at the bathroom entry and beside the sink; 201B- resident night stand missing cabinet face with no handle; room [ROOM NUMBER]A- tile missing under residents' bed; 202B- loose tile under resident's bed; room [ROOM NUMBER]-hole in the wall by A bed, soft floor at the bathroom entry, bedside the sink and at the foot of Bed A; room [ROOM NUMBER]- paint peeling on door; feces on the bathroom toilet and brown substance on the sink; room [ROOM NUMBER]- soft, unstable floor, sink clogged up repeatedly; room [ROOM NUMBER]-paint peeling on the outside of the door; 206 (bathroom)-leaking toilet, soft floor and broken tile. Interview on 2/27/2024 at 1:00 pm with the Maintenance Director (MD) revealed he has been employed with the facility for about six months and has not received any training related to maintenance. The MD stated he has no prior history in the maintenance field. The MD further revealed a contractor was coming into the building next week to begin repairs on the bathrooms that were not functional. He stated the floors are sticky from fogging during COVID-19 (Coronavirus Disease of 2019). An observational tour of the facility was conducted on 2/27/2024 at 1:30 pm with the MD, who confirmed the above findings. Interview on 2/27/2024 at 2:00 pm with the Administrator revealed the MD was unstopping the toilet in the bathroom for resident rooms 202-204 and noticed the floor felt soft when standing in the bathroom. The Administrator stated the MD notified him of the bathroom floor three weeks ago. The Administrator further stated the facility was awaiting a contractor to repair the flooring scheduled for 3/4/2024. Interview on 2/28/2024 at 9:00 am with the Administrator revealed the 200 hall with the severe sticky floor were stripped this morning around 5:00 am. There was little improvement when surveyors arrived that day (2/28/2024) in which the MD had gone to obtain more supplies to strip the floor again. The Administrator revealed that the 300 hall would not be stripped at this time and would be scheduled later since the 200 hall was worse. Policy requested from facility but not received.

Based on observations, staff interviews, record review, and review of facility's policy titled ''P&P Restraints,'' the facility failed to ensure one of one Resident (R) (R49) reviewed for physical restraints was free from an unnecessary physical restraint. Specifically, R49 did not have the necessary consent, physician's order, or a completed assessment in place for lap tray to be applied and used with a Geri chair. Findings include: Review of the facility's policy titled ''P&P Restraints'' dated 4/1/2022 under the section titled Policy revealed, ''It will be the policy of this facility that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience. Definition of a Restraint: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Under the section titled Procedure revealed, 5. Other in emergency situations, prior to placing a resident in restraints, there shall be a pre-restraining assessment/evaluation and review to determine the need for the restraints. 6. Should a resident not be capable of making a decision, the surrogate or responsible party may exercise the right of the use of non-use of a restraint. 7. Restrained individuals shall be reviewed regularly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 8. The resident's plan of care should include the use of restraint. Review of R49's ''Face Sheet'' found in the Electronic Medical Record (EMR) under the Profile tab revealed R49 admitted with diagnoses that included dementia unspecified severity with agitation, altered mental status, history of falling, Alzheimer's disease, restlessness, and agitation. Review of R49's Quarterly ''Minimum Data Set (MDS)'' assessment with an Assessment Reference Date (ARD) of 12/1/2023, found in the EMR under the ''MDS'' tab, indicated a Brief Interview for Mental Status (BIMS) score of 99 (the assessment was not able to be conducted due to the resident's poor cognition). The assessment indicated R49 was dependent upon staff for transfers. The assessment indicated physical restraints of any kind were Not Used. Review of R49's current physician orders located under the Orders tab in the EMR revealed there was not an order for use of the Lap tray while out of bed to Geri chair. Review of R49's Restraint Evaluation/Reduction assessment dated [DATE] located under the 'assessment tab in the EMR indicated there was not a medical symptom for the use of a restraint. The assessment did not indicate a type of restraint/device. Restraint Outcome - indicated there had not been any decline in condition negative response to restraint use. The following sections on the assessment were all blank: Restraint Alternative Attempts, Summary /Recommendations/Plan, Care Plan Initiation, Family notified, Physician notified, Staff notified. Review of R49's medical records revealed there was no documentation that an assessment had been completed for the use of the lap tray, for alternative interventions to the lap tray, or ongoing application of the lap tray. No documentation was found in R49's record to indicate informed consent had been obtained by the resident's representative for the use of the lap tray. No documentation was found in the record to indicate R49's lap tray was being monitored every 30 minutes or released every two hours. Observation on 2/28/2024 at 9:10 am, 11:38 am, and 12:23 pm revealed, R49 sitting in Geri chair with a lap tray affixed to it. The lap tray was observed to be secured in a locked position to the chair during each observation. Observation on 2/28/2024 at 1:01 pm revealed R49 sitting in Geri chair with lap tray attached during mealtime. A staff member was feeding the resident with the meal tray positioned on the dining room table. Observation on 2/28/2024 at 1:41 pm revealed R49 sitting in Geri chair with lap tray attached, in front of the nurses' station. During an interview on 2/28/2024 at 1:16 pm with the Therapy manager revealed, R49 was on Hospice Services and had not been evaluated by therapy for positioning while out of bed. During an interview on 2/28/2024 at 2:05 pm with Certified Nursing Assistant (CNA) EE revealed she fed R49 in the dining room today. CNA EE further stated the lap tray was intact during mealtime. She stated she moved the food from the lap tray and placed it on the regular dining table because R49 would play in the food if the tray was within her reach. CNA EE stated R49 had the lap tray because she would get up out the Geri chair unassisted and fall. During an interview on 2/28/2024 at 2:16 pm with Licensed Practical Nurse (LPN) AA revealed R49 should not have had the lap tray intact at all times, just during mealtimes. LPN AA stated that she had not seen any orders related to when the lap tray was to be used but knew what it was used for. LPN AA stated she had not noticed R49 with the lap tray intact until a few minutes ago. During an interview on 2/28/2024 at 2:29 pm with the Director of Nursing (DON) revealed R49 used the lap tray for safety. She stated she would not call it a restraint. DON further stated that if the lap trap was not used, R49 would get up unassisted and be on the floor. DON also stated the resident had been on Hospice Services since admission to the facility and the Hospice company supplied the Geri chair with the lap tray attached at the time of admission. DON further stated the Hospice company was responsible for giving them an order and obtaining consent for use of the lap tray. DON verified the record did not have an order or consent on the record related to the use of the lap tray. DON also verified the Restraint Evaluation/Reduction assessment completed upon admission was incomplete and there was no other information in the chair related to use of a restraint. During an interview on 2/28/2024 at 2:46 pm with the Administrator revealed if a resident had restraint, it was his expectation that the facility staff obtain a consent and order for the device. He stated that Hospice would typically obtain the order, but it was the facility's responsibility to ensure that orders and consents are in place for the device being used.

Based on staff interviews, record review, and review of the facility's policy titled P& P Hemodialysis, the facility failed to have ongoing communication and collaboration with the dialysis center for one out of 29 sampled Residents (R) (R20) reviewed for dialysis. Findings include: Review of the facility's policy titled P & P Hemodialysis, dated 4/1/2022 under Procedure revealed, 9. The facility and the dialysis center should maintain regular communication and should a change in condition occur before or during the dialysis treatment, the sending facility should communicate the changes in needs to the receiving facility. Review of R20's Admission Record under the Profile tab in the Electronic Medical Record (EMR) revealed R20 was admitted with diagnoses that included end stage renal disease, dependence on renal dialysis, Type 2 diabetes Mellitus without complications, and unspecified sequelae of other cerebrovascular disease. Review of R20's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R20's EMR revealed there were no pre/post dialysis weights documented. There was no communication documented in the EMR of verbal/written reports from the dialysis center to the facility after each dialysis treatment. During an interview on 2/28/2024 at 3:02 pm, the Licensed Practical Nurse (LPN) CC provided surveyor with a green binder labeled R20 Hemodialysis Communication sheets. Review of the communication sheets in the binder revealed that the latest communication sheet was dated 7/14/2023 which was verified at this time by LPN CC During a telephone interview on 2/28/2024 at 3:38 pm with the dialysis center Administrator DD, revealed the facility would call the dialysis center to obtain R20's weights once a month. Administrator DD further stated the facility did not provide the dialysis center with communication sheets relevant to R20's care as they once did. During a follow up interview on 2/28/2024 at 3:52 pm with LPN CC revealed R20 attend dialysis three days every week on Monday, Wednesday, and Friday. LPN CC stated that she would check the resident's vital signs before she went to dialysis. LPN CC further stated she was supposed to send a communication form to the dialysis center, but she had not been doing it. She stated that she started completing the pre dialysis assessment in the electronic record today, and it was the first day she had done it. LPN CC further stated that the dialysis center would call her if anything went on with R20 while at the dialysis center, but the communications between the two centers were not routine. LPN CC stated she did not have any knowledge of resident's pre and post dialysis weights. During an interview on 2/28/2024 at 3:58 pm with the Director of Nursing (DON) revealed that the facility recently switched to the new electronic system and started utilizing the pre-dialysis assessment in the electronic record this week. In addition, the DON stated the facility did not complete communication sheets. DON further stated that the nurses at the facility are required to call the dialysis center if anything was going on with the resident but there wasn't any routine communication. She stated the pre-dialysis assessments started today were not sent to the dialysis center with R20 and the dialysis center did not send a report back.

Based on observations, staff interviews, record review, and review of the facility's policies titled Handwashing/Hand Hygiene, and Blood Glucose Monitoring, the facility failed to help prevent the development and transmission of communicable diseases and infections for two of 29 sampled Residents (R) (R39 and R21). Specifically, the facility failed to follow proper procedures for hand hygiene, donning and removing gloves while performing a blood glucose test. In addition, the facility failed to clean and disinfect the glucometer per the manufacturer's instructions. Findings include: Review of the undated facility's policy titled Handwashing/Hand Hygiene, under Policy Interpretation and Implementation revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: (d). before performing any non-surgical invasive procedures; (e). before and after handling an invasive device; g. before handling clean or soiled dressing, gauze pads, etc.; (i). after contact with a resident's intact skin; (j). after contact with blood or bloody fluids, (k). after handling used dressings, contaminated equipment, etc.; m. after removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the undated facility's policy titled Blood Glucose Monitoring under Policy Explanation and Compliance Guidelines revealed, 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Under Procedure revealed, 3. Perform hand hygiene and donn gloves. 17. Remove and discard gloves and perform hand hygiene. 1. Review of R39's clinical records revealed he had diagnoses that included but not limited to, Type 2 Diabetes Mellitus without complications. Review of R39's physician orders included but not limited to, Lantus solution 100 unit/ml (milliliters) (Insulin Glargine) inject 35 unit subcutaneously two times a day for diabetes mellitus, Admelog Injection Solution 100 100 unit/ml (Insulin Lispro) inject as per sliding scale, Admelog Injection Solution 100 unit/ml (Insulin Lispro) Inject 15 unit subcutaneously before meals related to Type II diabetes mellitus without complications, and accuchecks AC (before meals) and HS (at bedtime). During observation of medication administration task on 2/28/2024 at 10:49 am, Licensed Practical Nurse (LPN) AA entered R39's room, donned gloves while in the resident's room. LPN AA preformed fingerstick blood sugar, exited the room with contaminated supplies wearing the gloves used to perform the procedure, returned to medication cart, and disposed of the supplies. LPN AA then placed the contaminated glucometer directly on top of the medication cart, removed gloves, applied another pair of gloves, and proceeded to disinfect the glucometer with a sanitizing wipe. LPN AA placed the glucometer back on the med cart in the same area, obtained another sanitizing wipe and wrapped the glucometer with the wipe and then placed it on the medication cart. LPN AA then removed gloves and gathered insulin for administration (no hand hygiene or glove change observed). LPN AA returned to R39's room to administer insulin, applied gloves, used an alcohol wipe to clean the injection site, removed the cap from the needle and injected the medication into the right arm (no hand hygiene of glove change observed). LPN AA exited the room and returned to the medication cart wearing the gloves used for the procedure, disposed of the used supplies and sharps, removed gloves, and performed hand hygiene using a hand sanitizer on the medication cart. 2. Review of R21's clinical records revealed he had diagnoses that included but not limited to, Type II diabetes mellitus without complications. Review of R21's physician orders included but not limited to, Lantus Subcutaneous Solution 100 unit/ml inject 20 units subcutaneous at bedtime for diabetes mellitus type II, Novolog Flex pen Subcutaneous Solution Pen-Injector 100 unit/ml inject as per sliding scale, and accuchecks four times a day for diabetes mellitus. During observation of medication administration task on 2/28/2024 at 11:00 am, LPN AA entered R 21's room, upon entry into resident's room LPN AA placed the glucometer and other supplies onto residents' bed, applied gloves, cleansed residents finger using an alcohol wipe then pricked residents finger wearing gloves. LPN AA exited the room and returned to the medication cart wearing the gloves used during the procedure and disposed of the supplies. LPN AA then placed the contaminated glucometer directly onto the medication cart, removed gloves, applied another pair of gloves, and cleaned glucometer. LPN AA then removed gloves, obtained the insulin for administration, and returned to R21's room. LPN AA applied gloves and administered insulin. LPN AA returned to the medication cart, disposed of the sharps but never removed the gloves and/or performed hand hygiene during the observation. During an interview on 2/28/2024 at 11:11 am LPN AA acknowledged that glove change and hand hygiene should have been conducted before and after blood glucose checks and for administration of the insulin injections. She also agreed the glucometer and supplies should not have been placed on R21's bed and the contaminated glucometer should have not been placed on the medication cart. During an interview on 2/4/2024 at 2:28 pm with the Director of Nursing (DON) she stated she expected staff to follow the hand hygiene policy when performing injections and blood glucose monitoring. DON further stated she was not familiar with the process/procedure for disinfecting the glucometer. Cross Reference F583

Based on observations, staff interviews, and review of the facility's policy titled Storage of Medications, the facility staff failed to store physician ordered medications in a locked compartment when unattended for one of three medication carts in the facility. The facility census was 59. Findings include: Review of the undated facility's policy titled Storage of Medication under the Policy Statement revealed, The facility shall store all drubs and biologicals in a safe, secure, and orderly manner. Under the section, Policy Interpretation and Implementation revealed, 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport items shall not be left unattended if open or otherwise potentially available to others. Observation on 2/28/2024 at 8:04 am revealed a medication cart in front of the nurse's station. The cart was out of sight of a nurse. The medication cart was unlocked. There were three residents around the unlocked medication cart. Licensed Practical Nurse (LPN) AA returned to a medication cart directly alongside the unlocked medication cart at 8:15 am. LPN AA confirmed the medication cart was left unlocked while unattended. LPN AA opened the drawers of the unlocked med cart to verify there were blister packs of medications inside the first, second, and third drawers of the medication cart. LPN AA stated the unlocked medication cart was used for storage of medications delivered from the pharmacy. The drawers to the medication cart were easily accessible to anyone passing by the nurse's station. Observation on 2/28/2024 at 4:09 pm revealed the medication cart in front of the nurse's station to be unlocked again. There was not a nurse in the area at the time of the observation. Further observation revealed a resident in a wheelchair positioned on the right side and two residents positioned in front of the unlocked medication cart. After six minutes, the nurse did not return to the unlocked medication cart. The surveyor, while still observing the medication cart informed the Director of Nursing (DON) of the cart being unlocked. DON verified the medication was unlocked while not attended by a nurse. During an interview on 2/28/2024 at 4:27 pm with the DON revealed that the medication cart should be locked after each used. She further stated that medication carts were not used to administer medication during the med pass but used to store the medications delivered from the pharmacy. She stated that the medication cart should only be accessible by the nurses and the certified medication aides.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Standards and Guidelines: SG Resident Rights, Dignity, and Visitation Rights, and Blood Glucose Monitoring, the facility failed to ensure visual privacy during treatment for two of 29 sampled Residents (R) (R39) and (R21). Findings include: Review of facility's policy titled Standards and Guidelines: SG Resident rights, Dignity, and Visitation Rights dated 9/27/2022 under Guidelines revealed, 3. The facility will make effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits, observing resident's choices whenever able. Review of the undated facility's policy titled Blood Glucose Monitoring under Policy revealed, It is the policy of the facility to perform blood glucose monitoring to diabetic residents as per physician's orders. Under the section titled Procedure: revealed, 5. Provide privacy. 1. Review of R39's clinical records revealed he had diagnoses that included but not limited to, Type II diabetes mellitus without complications, essential hypertension, generalized anxiety disorder, restlessness and agitation, and unspecified intellectual disabilities. Review of R39's physician orders included but not limited to, Lantus solution 100 unit/ml (milliliters) (Insulin Glargine) inject 35 unit subcutaneously two times a day for diabetes mellitus, Admelog Injection Solution 100 100 unit/ml (Insulin Lispro) inject as per sliding scale, Admelog Injection Solution 100 unit/ml (Insulin Lispro) Inject 15 unit subcutaneously before meals related to Type II diabetes mellitus without complications, and accuchecks AC (before meals) and HS (at bedtime). Review of R39's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 11 which indicated he had moderate cognitive impairment; Section I-Medically complex conditions indicated, hypertension, cerebrovascular accident, diabetes mellitus, anxiety disorder, depression; Section N-Medication, indicated he received insulin injections. Review of R39's care plan dated 5/31/2022 revealed a focus for diabetes mellitus with interventions that included but not limited to, diabetes medications as ordered by doctor. Observation on 2/28/2024 at 10:49 am with Licensed Practical Nurse (LPN) AA gathered supplies, entered R39's room with supplies in hand. LPN AA conversed with R39 who was sitting on his bed (B Bed/middle). LPN AA performed glucometer check, the result was 287 which required insulin coverage per sliding scale, R39 also had a routine dose of insulin due at this time. LPN AA did not close the door or pull the privacy curtain while performing blood glucose monitoring or insulin administration to right arm. There was another resident in the room by the C bed at this time and other residents were in the hallway during the treatment which was visible from the hallway. 2. Review of R21's clinical records revealed he had diagnoses that included but not limited to, Type II diabetes mellitus without complications, essential hypertension, and dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R21's physician orders included but not limited to, Lantus Subcutaneous Solution 100 unit/ml inject 20 units subcutaneous at bedtime for diabetes mellitus type II, Novolog Flex pen Subcutaneous Solution Pen-Injector 100 unit/ml inject as per sliding scale, and accuchecks four times a day for diabetes mellitus. Review of R21's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C-Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 10 which indicated he had moderate cognitive impairment; Section I-Medically complex conditions indicated, respiratory failure, dementia, diabetes mellitus; Section N-Medication, indicated he received insulin injections. Review of R21's care plan dated 12/16/2022 revealed a focus for diabetes mellitus with interventions that included but not limited to, diabetes medications as ordered by doctor. Observation on 2/28/2024 at 11:00 am revealed LPN AA gathered supplies from the medication cart drawer and entered R21's room. Another resident was in the same room in wheelchair by bed A and a staff member was standing in the doorway of resident's room. LPN AA performed blood glucose check; the result was 340 which required insulin coverage per sliding scale. LPN AA did not close the room door. The privacy curtain was pulled, but the resident was positioned in the wheelchair beyond the point where the privacy curtain stopped. There was a resident present in the hallway during the treatment with R21 who was visible from the doorway during the administration of insulin. Interview on 2/28/2024 at 11:11 am with LPN AA acknowledged and confirmed she did not close the door or ensure privacy was provided during procedures for R39 or R21. LPN AA further stated R21's back was turned, so she thought that was enough privacy for him. Interview on 2/28/2024 at 11:16 am with the Director of Nursing (DON) revealed the nurse should have asked residents about privacy during the procedure. DON further stated privacy should be provided when providing treatments or care. Cross Reference F880

Based on record review, staff and resident interview, the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for one Resident (R) (R5) of 29 sampled residents. Findings include: Review of the clinical record revealed R5 was admitted to the facility with diagnoses that included but not limited to type 2 diabetes mellitus with hyperglycemia, schizophrenia unspecified, chronic systolic (congestive) heart failure, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, schizoaffective disorder depressive type, and gout unspecified. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R5 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident's cognition was intact. Interview on 2/27/2024 at 10:52 am with R5 revealed she requested $220.00 from the BOM last month (January) to purchase some items she wanted from the store. R5 revealed she had not received the $220.00 she requested nor was it explained why she had not received the funds. Interview on 2/28/2024 at 3:58 pm with the Business office Manager (BOM) reported that R5 requested personal funds in the amount of $200.00 on 1/26/2024. The BOM reported that she gave $70.00 of R5's personal funds to the Activities Director (AD) because she does the shopping for the residents. The BOM reported that the ledger was to be signed by residents when they receive their personal funds. A request for the ledger was made but the BOM indicated she was not able to find it. During the interview, the BOM reported that she did not feel comfortable giving R5 that amount of money because R5 likes to purchase wigs, perfume, and make-up. Interview on 2/29/2024 at 4:30 pm with the Administrator revealed his expectations were for residents who have a personal funds account, should receive their funds when they request them. A request was made to the BOM on 2/28/2024 for the facility's policy on Resident Personal funds and for the money distribution log that the residents would sign when he/she received money. The policy or money distribution ledger were not made available for review.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Storage of Medications, the facility failed to assess and obtain a physician order for one of 29 sampled Residents (R) (R56) to safely self-administer and store medication at bedside. Findings include: Review of the undated facility's policy titled, Storage of Medications under the Policy Statement revealed, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation and interview on 2/27/2024 at 9:53 a.m. with R56 revealed the resident pulled a single pill from his pocket and stated he was not sure what the pill was for. Observation and interview on 2/27/2024 at 10:06 a.m. with R56 in the resident's room revealed the following medications: atorvastatin 10 milligrams (mg), trazodone 50 mg, tamsulosin 0.4 mg, clopidogrel 75 mg, and Voltaren topical gel 1% (one percent) located in the bottom dresser drawer in R56's room. R56 reported his family member brought the medications from home and put them in his drawer. Review of R56's clinical record revealed the following diagnoses but not limited to unspecified injury of head, subsequent encounter, generalized anxiety disorder, unspecified atrial fibrillation, hypertension, insomnia, and muscle weakness. Review of R56's Admission Minimum Data Set (MDS) dated [DATE] revealed for Section C-Cognition, a Brief Interview Mental Status Score of nine, which indicated his cognition was moderately impaired. Review of R56's January 2024 Physician Orders revealed there were no orders for R56 to self-administer or store medications at bedside. Interview on 2/27/2024 at 9:59 a.m. with Licensed Practical Nurse (LPN) CC reported another resident told her R56 had medications in his pocket. LPN CC reported she did not verify if R56 had medications in his pocket. Interview on 2/27/2024 at 10:04 a.m. with the Director of Nursing (DON) reported that no resident in the facility had been assessed for self-administration of medications. The DON confirmed that R56 had medications in his pocket. Observation and Interview on 2/27/2024 at 10:16 am with the DON confirmed the medications were in R56's room. The DON revealed that residents are not allowed to keep medications in their room. She reported that R56 's medication incident was an oversight, and that R56 did not have an assessment to self-medicate or store medications in his room.

Based on observations, staff interviews, record review, and review of the facility's policy titled Use of Psychotropic Medication, the facility failed to ensure one of five Residents (R) (R30) was evaluated for use of as needed (PRN) psychiatric medications beyond 14 days. Findings include: Review of the undated facility's policy titled Use of Psychotropic Medication, revealed under Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication(s). Under the subheading titled Policy explanation and Compliance Guidelines revealed, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). 9(a). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of R30's Electronic Medical Record (EMR) revealed the resident was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease, dementia unspecified severity with agitation, restlessness, generalized anxiety disorder, and repeated falls. Review of R30's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/2024 revealed for Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 99 which indicated the assessment was not able to be conducted due to the resident's poor cognition; Section N (Medications) revealed she was receiving antipsychotics and antianxiety. Review of R30's care plan dated 12/29/2023 indicated a focus for use of anti-anxiety medications due to anxiety disorder and agitation. The goals included but not limited to residents will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review dates with interventions that included but were not limited to administering anti-anxiety medications as ordered by physician. Review of R30's Physician orders revealed a Medical Doctor's (MD) order for lorazepam 0.5 milligram (mg) one tablet by mouth every eight hours as needed (PRN) for increased agitation with start date of 12/19/2023 but did not include a stop date. Review of the Controlled Drug Record sheet located in a notebook on the medication cart revealed R30's lorazepam 0.5 mg was signed out as administered on 2/13/2024, 2/16/2024, 2/18/2024, 2/22/2024, 2/27/2024, and 2/28/2024. Review of R30's Medication Administration Record (MAR) revealed lorazepam 0.5 mg was documented as administered after the 14 days on 1/5/2024, 1/18/2024, 2/13/2024, 2/16/2024, 2/18/2024, 2/22/2024 and 2/27/2024. Review of R30's EMR revealed no documentation related to a rationale or a documented duration for continuation of the PRN antianxiety medication beyond 14 days. Interview 2/29/2024 at 11:43 am with the Nurse Practitioner revealed she had recently adjusted R30's Buspar due to behaviors, but she had not addressed the lorazepam (PRN medication) since the medication was initiated. Interview on 2/29/2024 at 11:45 am with the Director of Nursing (DON), she confirmed and verified the order dated 12/19/2023 for lorazepam 0.5 mg every eight hours as needed was started on 12/29/2023 without a stop date. She reviewed the record and verified there was no documentation in the EMR related to a rationale and duration for continued use of the medication. DON stated she was aware all PRN antipsychotics had to be re-evaluated for continued use after 14 days.

Based on record review, interviews, and review of the Administrator Job Description, Administration failed to provide protective oversight of the facility environment to prevent the elopement for one of eleven residents (R) (R#1) reviewed for elopement. Specifically, facility failed to ensure that exit doors were equipped with functioning locking systems, failed to complete elopement assessment for R#1 with a documented history of elopement, and failed to develop a person-centered care plan with interventions for elopement for R#1. R#1 eloped from the facility on 7/7/2023 and was found 3.5 miles away from the facility, had been hit by a car and sustained a fractured right hip, right arm, and right shoulder. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the undated document titled Administrator-Job Description revealed position purpose is leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The Administrator performs rounds to observe residents and ensure overall needs are being met, knows residents by name and sight, practices management by walking around, and makes himself/herself available to employees. Additional tasks include follow appropriate safety measures at all times to protect residents and themselves. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of the Facility Incident Report dated 7/8/2023 at 11:53 p.m. revealed R#1 eloped from the facility and was discovered on the road with apparent injury. Resident was sent to the hospital for evaluation. Review of the electronic medical record (EMR) revealed that an Elopement Risk Assessment wasn't completed until 7/8/2023, the day after R#1 eloped from the facility. The assessment revealed a score of 23.0, which indicated high risk for elopement. Review of the Police Report dated 7/8/2023 at 4:37 a.m. revealed during the investigation into R#1 elopement, deputies discovered a door that led to the outside of the facility unlocked. Deputies believe this is the door that R#1 used to leave the facility. According to staff this door stays unlocked, but while examining the door, deputies found the doors locking system to be broken and unrepaired. Deputies also discovered a shelf in front of the door that looked as if it was placed there to block the door. Deputy spoke with staff member about the shelf and staff stated the shelf had been moved, but admitted to moving it back after they noticed resident was missing. Review of the communications invoice #41856 revealed a service dated 7/11/2023 for a door off the dining room area not working. Lock is missing pieces, and the keypad is not working. Replaced a maglock and keypad. Reset all keypads to default and then reprogrammed the codes and tested the door release and function. Interview on 7/18/2023 at 10:40 a.m., the Administrator revealed he was not sure how long the door R#1 exited from had been unlocked. Interview on 7/20/2023 at 10:12 a.m., the Administrator revealed R#1 was admitted to the facility because he climbed out of a window at home and was not found until the next day. He revealed that on 7/7/2023 R#1 left the facility through a door in the dining room that was not locked. The Administrator stated although the door was not used as an exit it leads to the outside of the facility and the door should have had a working lock. During further interview, the Administrator stated the nursing staff failed to complete an admission elopement risk assessment for R#1 and failed to develop a care plan with interventions for elopement for R#1 with a known history of elopement. Cross Refer to F689 and F656 The facility implemented the following actions to remove the IJ: 1. An AD-HOC meeting was held on July 10, 2023- with the Administrator, Director of Nursing, Regional Director of Clinical Operations, and Medical Director to address the concerns identified related to the incident of July 7, 2023, with Resident #1. 2. Resident #1 was discharged from the facility on July 7, 2023. 3. On July 10, 2023, the Center Regional Director of Clinical Operations, Regional Director of Operations, Medical Director, and Administrator reviewed the policies on Care Plans and Incident and Accidents. No changes or recommendations were made or given. 4. On July 10, 2023, the Regional Director of Clinical Operations re-educated the center's administration to include Administrator, Director of Nursing, MDS, ADON, Social Worker, and Maintenance on the importance of implementing effective interventions for Care Plans and properly assessing potential access areas/exits throughout the center. 5. On July 10, 2023, a root cause analysis was conducted by the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Operations. The RCA indicated the root cause was related to one unsecured door and lack of individualized care plan for elopement risks on R#l. 6. On July 10, 2023, the Regional Director of Operations reviewed the job descriptions for the Administrator and Director of Nursing to ensure they understand their duties and responsibilities. No changes were made to the job descriptions and both acknowledged understanding of their responsibilities. Review shows that the Administrator and the DON can carry out their job duties. 7. The Regional Director of Operations reviewed the RCA results and Center's audits and shared the findings with the AD HOC Assurance Performance Improvement Committee on July 10, 2023. Onsite Verification of Removal Plan: 1. Review of the Immediate Jeopardy Removal Plan (IJRP) revealed the document titled QAPI Meeting Minutes. The document revealed ADHOC meeting was conducted on 7/10/2023. The subject matter Quality Assurance Performance Improvement Monthly Meeting, the duration of the meeting was ten minutes. The document attendance at meeting included: Administrator, Maintenance/Environmental Service/Safety, Director of Nursing (DON), Nurse Practitioner (NP), Medical Director (MD), Social Service Director (SSD), Minimum Data Set (MDS), and Assistant Director of Nursing (ADON). The facility discussed how R#1 eloped from the facility, a timeline of the elopement, and the plan of correction. The facility conducted an elopement assessment on the residents in the facility. Interview on 7/20/2023 at 10:12 a.m. with Administrator stated he became aware of R#1 elopement on 7/7/2023 at 11:55 p.m. when he received a phone call from the Maintenance Director (MD). The MD informed him that the resident (R#1) eloped from the facility. He stated the door was secured and the DON conducted a head count to ensure that the other residents were in the facility. 2. Review of the Immediate Jeopardy Removal Plan under F689 two physician progress notes dated 7/8/2023 revealed: A. on 7/7/2023 at 11:40 p.m., staff unable to locate resident during rounds. A search of facility was conducted by staff inside and outside with no results. 911 called. DON and Administrator notified. Responsible Party notified. B. on 7/8/2023 at 00:15 a.m., Sheriff here at facility to investigate and conduct interview about missing resident. Sheriff, DON, Administrator in the building. Sheriff reported resident located and sent to hospital. 3. Review of the document titled Care Plans, Comprehensive Person-Centered and Accidents and Supervision. Both documents in handwriting reviewed to unidentifiable letters /DON. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 4. Review of the document titled Employe Education/In-Service [facility name]. Subject Matter: Elopement Incidents/Accident. The presenter Regional Nurse Consultant. Overview: Elopement policy and prevention to include assessments and care plan interventions and elopement process. The document attendance at meeting included: the Administrator, DON, ADON, Maintenance/Environmental Service/Safety, MDS-Coordinator and SSD. Interview on 7/20/2023 at 11:55 a.m. with Licensed Practical Nurse (LPN) RR stated the ADON went over the elopement policy and procedures. She stated residents that are high risk for elopement information is in a book located behind the nurse's desk and receptionist desk. The ADON talked about what to do in the case of the eloping happening. The staff should notify the supervisor, look for the resident, call the police, Chief Executive Officer (CEO), Administrator, and responsible party. In the event the resident is not located, staff would provide the elopement book to the police upon arrival. The LPN was able to name R#7 and R#8 as residents that are high risk for elopement. Interview on 7/20/2023 at 11:49 a.m. Certified Nursing Assistant (CNA) QQ stated it was brought to her attention that one of the residents was able to have access outside of the facility and was injured. Moving forward we must have an elopement risk assessment for all residents and follow the protocol for elopement. In the event the resident is not able to be found we notify the supervisor/charge nurse, and we gather around and make sure we know who is responsible for what part of the protocol. The staff should look for the residents, contact the police, and the Administrator. When the police arrive provide them the elopement book. The CNA was able to name R#7, R#8, and R#11 as residents that are high risk for elopement. Interview on 7/21/2023 at 11:57 a.m. with CNA SS stated the Assistant Director of Nursing (ADON) in-serviced the staff to notify the supervisor immediately when a resident cannot be located. Search inside and outside of the facility. The elopement books are at the nursing station and receptionist area that should be provided to the police. 5. Review of the document titled Root Causes and Contributing Factors revealed the cause, corrective actions, the responsible individual, and correction date. Signed by the Administrator and DON. 6. Review of the removal plan revealed the Administrator and DON job descriptions attached. A post survey interview on 7/22/2023 at 9:50 a.m. with Regional Director of Clinical Operations stated the facility will review the baseline care plan document and make some changes that will include a section to include interventions. 7. Review of the document titled QAPI Meeting Minutes revealed a handwritten on the document was reviewed by the Regional Director of Operations (RDO) on 7/10/2023. Attached to the removal plan was a document titled Logbook Documentation [facility name] Emergency Preparedness Drills and Exercises: Conduct elopement drill marked done on-time by Maintenance Director (MD) on July 18, 2023. This drill was conducted on 7/17/2023 with 13 staff and 54 residents. Remarks of the person holding the drill revealed: Very good drill staff patient was hidden in the laundry area with staff supervision. Charge nurse was asked to go get patient and immediately realized patient was missing. Charge Nurse began to verbally communicate the notification. Staff began internal and external search of premises located patient within 4 minutes of notification. 911 notified at beginning and end of drill. The Surveyor also reviewed three residents that were not listed as risk for wander or elopement risk assessment: a. R#15 elopement risk assessment completed on 7/8/2023 score 0. b. R#16 elopement risk assessment completed on 7/8/2023 score 0. c. R#17 elopement risk assessment completed on 7/8/2023 score 0. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.

Based on record review, interviews, document review, and review of the facility policy titled Elopement and Wandering Residents, the facility failed to provide adequate supervision and monitoring for one of 14 sampled residents (R) (R#1) and failed to ensure magnetic locking exit doors were functioning properly to prevent the elopement of R#1. Specifically, R#1 exited the facility on 7/7/2023, undetected through an unlocked door, walked approximately 3.5 miles away from the facility, was struck by a motor vehicle. Resident #1 sustained a fractured right hip, fractured right humerus, and fractured right scapula. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the policy titled Elopement and Wandering Residents revised June 2022, policy statement indicated residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: Number 1. The facility is equipped with door locks/alarms to help avoid elopements. Number 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Number 4. Monitoring and managing residents at risk for elopement or unsafe wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission; d. Adequate supervision will be provided to help prevent accidents or elopements. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of the comprehensive care plan initiated 6/26/2023 revealed there was no indication that nursing staff had developed a care plan with specific goals with interventions to address resident's history of wandering and recent elopement from his home prior to admission. Review of the Nurse's Note dated 6/27/2023 at 7:08 a.m. written by Licensed Practical Nurse (LPN) FF, revealed resident up wandering throughout the shift. Review of the electronic medical record (EMR) revealed an Elopement Risk Assessment was completed on 7/8/2023, the day after the resident eloped from the facility. The assessment revealed resident was at high risk for elopement with a score of 23.0. Review of a document provided by facility titled Elopement Timeline indicated: Friday 7/7/2023: 9:30 p.m. - last time R#1 was seen in facility by Licensed Practical Nurse (LPN) FF 11:00 p.m. - Certified Nursing Assistant (CNA) GG started to look for resident 11:15 p.m. - LPN EE was notified by CNA GG that he could not find R#1 11:20 p.m. - LPN FF was notified by LPN EE that R#1 was missing. All staff continue searching 11:40 p.m. - Daughter of R#1 was notified by LPN FF of resident elopement from the facility 11:55 p.m. - LPN FF called 911 and notified Director of Nursing (DON). DON notified Administrator. Staff continue to search Saturday 7/8/2023: 12:10 a.m. - staff notified that R#1 had been involved in accident and transported to hospital for evaluation 12:15 a.m. - DON on sight as well as police 1:15 a.m. - Administrator on sight as well as additional police. Scheduled CNAs to monitor door until repair was complete 10:00 a.m. - Maintenance placed lock on non-egress door Review of the sheriff's report dated 7/8/2023 at 4:37 a.m. revealed on 7/7/2023 the deputy was dispatched to [name of facility] in reference to a missing person. On 7/7/2023 at approximately 11:54 p.m. Central Dispatch received a 911 call stating that a male patient was missing. The deputy was advised by dispatch that according to the caller, the male patient had been missing 20 minutes prior to them calling. Upon arriving at the scene at approximately 12:09 a.m. the deputy was advised by the nursing home staff that they had received a call stating the resident had been hit by a car on the highway. The deputy left the nursing home and began looking for the resident. The Deputy was able to locate the resident just across the county line, laying on the side of the road. The resident advised the deputy that he had been gone from the nursing home for about two hours and was walking to get cigarettes, when he was hit by a car. The deputy documented that according to Google Maps the location of the scene was approximately 3.5 miles and was roughly an hour and 13-minute walk from the facility. The resident was transported to hospital. Review of the Facility Incident Report dated 7/8/2023 at 11:53 p.m. revealed R#1 eloped from the facility and was discovered on the road with apparent injury. Resident was sent to the hospital for evaluation. Review of the five-day follow-up revealed the following steps were taken to prevent further elopement: all exits were examined to determine how R#1 had exited the building, the door was identified and secured temporarily. Staff were assigned to the door to assure that no other residents in the facility could exit through the door. The facility completed an Elopement Risk Assessment on all residents to ensure appropriate interventions were in place for residents identified at risk. All staff were educated on the Elopement Policy and the Elopement Notebooks. A root cause analysis was completed on 7/10/2023 by the Administrator, the Assistant Director of Nursing (ADON), the DON, the Maintenance Director/Safety Coordinator and The Regional Director of Clinical Operations. Interview on 7/17/2023 at 10:40 a.m., Administrator revealed prior to the elopement, the door which R#1 exited was not secured and was not considered to be an exit door. Interview on 7/18/2023 at 10:00 a.m., Assistant Director of Nursing (ADON) stated her expectation is for the charge nurses to complete elopement assessments on admission. She stated there is an elopement book at the nurses' station that should be kept up to date with the resident's information. During further interview, she stated she expects the residents care plan to include if the resident was an elopement risk or a wanderer with interventions listed. Interview on 7/18/2023 at 10:40 a.m., the facility Administrator and the Maintenance Director revealed they had no idea about how long the door had been unlocked that R#1exited from when he eloped from the facility. Interview on 7/18/2023 at 11:00 a.m. with Dietary Aide CC revealed she has not used the back door in the corner of the dining room, nor had she seen anyone else use that door. Telephone interview on 7/19/2023 at 10:40 a.m., with LPN EE, stated the night of R#1's elopement, Certified Nursing Assistant (CNA) GG informed her around 11:15 p.m. that R#1 was missing. LPN EE stated she instructed the staff members to search for R#1 inside and outside of the building. During further interview, she stated that CNA GG got in his car and drove around and located the resident on the highway and informed her he had been hit by a car. LPN EE confirmed that nurses are supposed to complete an Elopement Assessment when a new resident is admitted to the facility. Telephone interview on 7/19/2023 at 11:42 a.m. with CNA GG, stated he works at the facility through a staffing agency. He stated on the night of 7/7/2023 around 11:00 p.m., he realized that he had not seen R#1 for a few hours, so he started looking for him. He stated when he couldn't find R#1, he told one of the charge nurses, who instructed the other staff to start a search for the resident inside and outside of the building. During further interview, he stated he got in his car and started driving around looking for the resident. He stated about three miles from the facility, he came upon an accident where the resident had been hit by a car. He stated the people who had hit the resident were at the scene and had already called 911. The following IJ Removal Plan was provided by the facility and accepted on 7/21/2023. 1. R#1 no longer resides at the center. 2. On July 7, 2023, at approximately 2300, it was noted that R#l was discovered to be missing by his assigned CNA who alerted her charge nurse. Staff were notified to start a search for R#1. The CNA and another charge nurse got in their vehicles and started driving around looking for R#l. At approx. 00:10 on July 8, 2023, the CNA came upon an accident scene approximately 3miles from the facility and discovered R#l was involved in a pedestrian vs. MVA accident and 911 had been called. On July 8, 2023, an initial state reportable was filed with the state at 1:45 a.m. 3. On July 7, 2023, at approx. 2300, staff at the center used a midnight census report to conduct an in-house head count to determine if other residents were missing from the center. All residents were accounted for except R#l. 4. On July 8, 2023, at approx. 00:00. it was determined that R#l exited the facility by means of the door in the dining room in the far-right corner that was not locked. 5. On July 8, 2023, at 00:15 a staff member was assigned by the DON to be stationed at the door where R#1 exited the center until repaired by maintenance personnel. 1:1 attendant stationed at the door until lock installed. 6. On July 8, 2023, the Regional Director of Operations and Regional Director of Clinical Operations reviewed and the center Elopement Policy and Incidents and Accidents Policy to include the frequency of elopement assessments (upon admission, re-admission, quarterly and change in condition). No changes were made. 7. Only July 8, 2023, the Regional Director of Clinical Operations completed education with the Administrator, DON, ADON, Social Services, MDS and Maintenance Director regarding the Elopement Policy and Incidents and Accidents Policy. 8. On July 8, 2023, at approximately 10:00 the door where R#l exited the center was repaired and a temporal padlock was placed by the center Maintenance Director while waiting for a permanent mag-loc to be installed. The Administrator assigned a CNA to be stationed at the door to monitor until placement of permanent mag-loc. 9. On July 8, the center implemented an hourly door check audit to ensure all doors are secure. This tool (the door check audit tool) was utilized for 72 hours until the mag-loc was installed. 10. On July 11, 2023, the permanent mag -loc was placed on the door and secured by the center Maintenance Director. 11. On July 8, 2023, the Assistant Director of Nursing completed new elopement risk assessments on all residents residing at the center to identify any residents at risks for elopement using the daily census roster to document completion. 12. On July 8, 2023, the MDS Coordinator reviewed the 11 identified at risk for elopement residents to validate elopement assessments and ensured identified risks were addressed in the care plans for all residents in the center. Any concerns identified were addressed according by the MDS Coordinator. 13. On July 8, 2023, the Director of Nursing confirmed that the elopement identification books at the nursing station and receptionist were accurate and up to date. 14. On July 8, 2023, and July 9, 2023, the center ADON completed education with all staff in the center regarding the center elopement policy. Center CNAs (l2 of 12- 100%); Center LPNs (7 of 7-100%); Center RNs (3 of 3-100%); Center Dietary staff (7 of 7-100%); Center EVS/Laundry (7 of 7-100%); Center non-clinical staff (5 of 5-100%); Contract NP (1 of 1-100%); Contract Rehab (2); Agency LPNs (8); Agency CNAs (24) were all educated. 15. On July 9, 2023, the center DON completed an audit of all incidents and accidents log for the last 30 days and no other elopements occurred. Findings of this log will be held in the ADHOC QAPI minutes. 16. On July 10, 2023, a root cause analysis was conducted by the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Operations. The RCA indicated the root cause was related to one unsecured door and lack of individualized care plan for elopement risks on R#l. 17. On July 10, 2023, the center completed an ADHOC QAPI Meeting to review the incident that occurred and root cause analysis results. Members of the QAPI meeting were Administrator, Medical Director, Director of Nursing, and ADON. Date corrective action will be completed is 7/11/2023 and IJ to be removed on 7/12/2023. Onsite Verification of Removal Plan: 1. Review of the removal plan document - a letterhead for the facility revealed R#1 no longer resides at the center. Review of the progress note on 7/7/2023 at 11:40 p.m. staff was unable to locate R#1 while doing rounds. A search of the facility was conducted by staff inside and outside the facility with no results. 911 was called, the sheriff reported the resident was located and transported to the hospital. Surveyor verified R#1 was still inpatient at the hospital via phone on 7/18/2023 at 9:50 a.m. prior to receiving the plan. Interview with the ADON on 7/21/2023 at 2:25 p.m. verified R#1 is no longer in the center. 2. Review of the removal plan documents revealed that a reportable was filed on 7/8/2023 at 1:46 a.m. by the Administrator. He identified R#1 in the facility reportable which stated the resident eloped from the facility and was discovered on the road with apparent injury and the door that is assumed to be the exit was secured. Interview with the Administrator on 7/21/2023 at 2:26 p.m. stated he reported the incident to the state on 7/8/2023. 3. Further review of the removal plan documents revealed [facility name] daily census dated 7/7/2023 - handwritten on the census was Midnight Census Head Count revealed checkmarks next to the residents' names with a total of 56 residents accounted for. Two residents were identified as being in the hospital and there was no checkmark beside R#1's name on the census. Interview with the ADON on 7/21/2023 at 2:25 p.m. stated she completed the Elopement Risk on the residents utilizing the census lists. 4. Review of the facility map with a section highlighted in orange and circled which was identified as a fire door. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified that he had highlighted the door on the facility map to indicate this was the door R#1 exited out of. 5. Review of an unidentified document with a written statement indicating after incident occurred on July 7th, 2023, Charge Nurses EE and FF monitored the dining room door continuously throughout the shift. The document was signed by Licensed Practical Nurse (LPN) FF and an unidentified signature. Interview with the Assistant Director of Nursing (ADON) on 7/21/2023 at 2:25 p.m. verified she obtained written statements from the LPN Charge Nurses. 6. Review of a document titled Elopement and Wandering Residents dated 7/8/2023 with three unidentifiable initials. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 7. Review of the Employee Education [facility name] dated 7/10/2023 presenter Registered Nurse (RN) WW with subject matter: elopement/incidents and accidents and overview: elopement policy and prevention to include assessments and care plan interventions and the elopement process. In attendance at the meeting were the Administrator, DON, ADON, Maintenance/Environmental Services Director, MDS Coordinator, and Social Services Director. Interview with the ADON and the Administrator on 7/21/2023 at 2:31 p.m. verified they attended the education provided by RN WW on 7/10/2023. 8. Review of the document titled Log for Door Checks initiated on 7/11/2023 with date/time, signature of staff and comments with hourly checks with no issues identified. The facility provided additional information with staff assigned to door checks beginning 7/7/2023 for 12-hour shifts. Interview with the ADON on 7/21/2023 at 2:31 p.m. stated she initiated the door checks and assigned staff to monitor the door. 9. Review of the removal plan revealed no documents to indicate evidence of a door check audit. 10. Review of the removal plan revealed there were no documents to indicate purchase of the mag-loc or a date and time of placement. In an interview with the [NAME] President of Clinical Services on 7/21/2023 at 12:30 p.m. provided an invoice entitled [name of provider] revealed invoice #41856 dated 7/14/2023 with total amount $1,042.47. 11. Review of the removal plan revealed completed Elopement Risk Assessments for the residents with the Census dated 7/8/2023 used to identify the high-risk residents. Interview with the ADON on 7/21/2023 at 2:31 p.m. verified she used the facility census to ensure she had completed Elopement Risk Assessments on all current residents. 12. Review of a checklist utilized for elopement risk re-evaluation completed by ADON identified 11 residents highlighted in yellow with risk scores ranging from 13 - 27. Verified each of the 11 residents had completed Elopement Risk Assessments and care plans. Review of three residents selected for review (the surveyor had already verified all 11 residents had an 'Elopement Risk Assessment and care plan prior to the IJR plan - R#'s 2, 3, 7, 8, 9, 10, 11, 12, 13, and 14). Interview with Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. stated the 11th resident was R#1 for a total of 11 residents. 13. Review of the removal plan revealed pictures and physical descriptions, face sheet for each resident at risk for elopement, with allergies, diagnoses, date of birth, sex, weight, height, and urgent medications for all 10 current residents. There were binders located at the nursing station and receptionist desk. These were verified by surveyor. Interview with the Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. verified both books were up to date with information on high-risk elopement residents. 14. Review of the document entitled [facility name] IJ Education that 7 out of 7 Dietary staff were educated; 12 of 12 CNA/CMA were educated; 7 of 7 LPN's were educated; 3 of 3 RN's were educated; 1 of 1 NP was educated; 2 contract rehab staff were educated, 8 of 8 Agency LPN's; 24 of 24 Agency CNA's received education. Interview with the ADON on 7/21/2023 at 2:33 pm who verified that she educated all staff as described above. Also verified via the following staff interviews on 7/20/2023 at 11:34 a.m. with LPN EE, 11:46 a.m. CNA PP, 11:49 a.m. CNA QQ, 11:50 a.m. LPN FF, 11:55 a.m. LPN RR. On 7/21/2023 at 11:57 a.m. CNA SS, 11:59 a.m. CNA TT, 4:23 p.m. Staffing Coordinator/Scheduler VV, 4:25 p.m. CNA MM, 4:37 p.m. CNA NN, and 4:41 p.m. CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 15. Review of the Incident/Accident List dated June 1 - July 16, 2023, identified 19 falls, 8 skin issues, 2 alleged abuse, 1 elopement (R#1). Interview with the ADON on 7/21/2023 at 2:33 p.m. confirmed the DON had identified the incidences from June 1 through July 16, 2023. 16. Review of the Root Cause Analysis for the Center's concern - the facilitators were the DON and the Administrator with team members the ADON and the Maintenance Director and The Regional Director of Clinical Operations. Concern - to ensure residents receive the necessary required supervision to maintain safety. Listed the 5 why's - the resident exited the facility through an unlocked door without staff's knowledge or supervision sometime around 9:30 p.m. - staff were unaware resident had left. The facility timeline was attached for review. Interview with the ADON and the Administrator on 7/21/2023 at 2:34 p.m. confirmed they participated in the root cause analysis regarding the elopement. 17. Review of the QAPI Meeting Minutes dated 7/10/2023 with subject matter - QAPI Monthly Meeting. Began at 12:30 p.m. and lasted 10 minutes. In attendance was the Administrator, Maintenance Director, DON, ADON, Social Services Director, MDS Coordinator, Medical Director, and Nurse Practitioner. Discussed the incident and timeline. Planned to meet again in four weeks. Interview with the Administrator on 7/21/2023 at 2:34 p.m. confirmed the members of the QAPI meeting on 7/10/2023 and items discussed. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.

Based on record review, staff interviews, and review of the policy titled Care Plans, Comprehensive Person- Centered, the facility failed to develop a person-centered care plan that focused on wandering and exit seeking behaviors for one resident (R) (R#1) with a known history of elopement from a sample of 14 residents. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. An Acceptable IJ Removal Plan was received on 7/21/2023 related to 483.21(b)(1), Development/Implement Comprehensive Care Plan (F656), 483.25(d)(2), Accidents and Hazards (F689), and 483.70, Administration (F835). Based on observations, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/12/2023. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings include: Review of the policy titled Care Plans, Comprehensive Person- Centered updated 12/2022, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: number 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Number 8. The comprehensive person-centered care plan: g. incorporates identified problem areas. h. incorporates risks factors associated with identified problems. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses including encephalopathy, traumatic subdural hemorrhage, dementia, hypertension (HTN), chronic kidney disease (CKD), and agitation. He was admitted post hospital stay after being found unresponsive on the side of the road after eloping from his home. The resident had a five-day Prospective Payment System (PPS) Assessment completed on 7/2/2023 indicating a Brief Interview Mental Status (BIMS) score of four, indicating the resident had severely impaired cognition. Section E revealed the resident exhibited wandering behaviors one to three days. Section G revealed resident required supervision with ambulation. Review of R#1's comprehensive care plan initiated 6/26/2023 revealed there was no indication that nursing staff had developed a care plan with specific goals with interventions to address resident's history of wandering and recent elopement from his home prior to admission. Review of the Nurse's Note dated 6/27/2023 at 7:08 a.m. written by Licensed Practical Nurse (LPN) FF, revealed resident up wandering throughout the shift. Review of the electronic medical record (EMR) revealed an Elopement Risk Assessment was completed on 7/8/2023, the day after the resident eloped from the facility. The assessment revealed resident was at high risk for elopement with a score of 23.0. Interview on 7/17/2023 at 10:40 a.m., Administrator stated the door R#1 exited the building from was not secured and was not considered to be an exit door. Interview on 7/18/2023 at 10:00 a.m., Assistant Director of Nursing (ADON) stated she would expect charge nurses who admit residents to complete an elopement assessment as part of the admission paperwork. During further interview, she stated she would expect the care plan to include the resident was an elopement risk or a wanderer with interventions put in place. Interview on 7/18/2023 at 10:50 a.m., Minimum Data Set (MDS) Coordinator stated she is responsible for collecting MDS data for the development of care plans. She stated when the charge nurses admit new residents, they should complete an Elopement Assessment at that time and make sure it is care planned. Telephone interview on 7/19/2023 at 10:40 a.m., LPN EE stated information for the MDS is obtained from resident's previous history, hospital records, and observations of the resident. She stated the night of R#1's elopement, Certified Nursing Assistant (CNA) GG informed her around 11:15 p.m. that R#1 was missing. LPN EE stated she instructed staff members to search for R#1 inside and outside of the building. During further interview, she stated that CNA GG got in his car and drove around and located the resident on the highway and had been hit by a car. LPN EE confirmed that nurses are supposed to complete an Elopement Assessment when a new resident is admitted to the facility. If the resident is at risk for elopement the care plan should include elopement interventions. Telephone interview on 7/19/2023 at 11:42 a.m. CNA GG stated he works at the facility through a staffing agency. He stated on the night of 7/7/2023 around 11:00 p.m., he realized that he had not seen R#1 for a few hours, so he started looking for him. He stated when he couldn't find R#1, he told one of the charge nurses, who instructed the other staff to start a search for the resident inside and outside of the building. During further interview, he stated he got in his car and started looking for the resident. He stated about three miles from the facility, he came upon a motor vehicle accident where the resident had been hit by a car. He stated the people who had hit the resident were at the scene and had already called 911. Cross Refer F689 The following IJ Removal Plan was provided by the facility and accepted on 7/21/2023. 1. R#1 no longer resides at the facility. 2. On July 10, 2023, the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Care Plan. No policy changes or recommendations were made as a result of this review. 3. On July 8, 2023, Center Director of Nursing identified 11 residents at risk for elopement out of the 54 residents on the center resident roster. Resident plans of care were reviewed and updated as needed, and physician and responsible parties were notified. 4. Licensed nurses to include MDS and nurse managers (Center RNs 3 of 3 -100%; Center LPNs 7 of7 -100% and Agency LPNs 8) were educated by Director of Nursing on the importance of completing care plans with interventions on residents identified through their assessments as being at risk for elopement on July 8, 2023. Employees on leave of absence FMLA- vacation or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 5. The Director of Reimbursement provided additional education to center Nurse Managers and MDS team on Person-Centered Care Plan to include development, implementation, and revision of care plans on July 10, 2023. 6. The Director of Nursing will review incidents and accident reports from the previous day during daily clinical meeting and will verify care plans are developed and revised as needed, to address interventions to prevent elopement risk. 7. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting weekly for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the physician and the members of the committee. Subsequent plans of corrections will be implemented as necessary. Date corrective action will be completed is 7/11/2023 and IJ to be removed on 7/12/2023. Onsite Verification of Removal Plan: 1. Review of the document on facility letterhead revealed R#1 no longer resides at the center. Review of the progress note on 7/7/2023 at 11:40 p.m. staff was unable to locate R#1 while doing rounds. A search of the facility was conducted by staff inside and outside the facility with no results. 911 was called, the sheriff reported the resident was located and transported to the hospital. Surveyor verified R#1 was still inpatient at the hospital via phone on 7/18/2023 at 9:50 a.m. Interview with the ADON on 7/21/2023 at 2:25 p.m. verified R#1 is no longer in the center. 2. Review of a document entitled Care Plans, Comprehensive Person-Centered and Care Plans - Baseline with a reviewed date of 7/8/2023 with three unidentifiable initials. Interview with the Administrator on 7/21/2023 at 2:26 p.m. verified the initials of the above-named staff as having reviewed the policies. 3. Review of a checklist utilized for elopement risk re-evaluation completed by ADON identified 11 residents highlighted in yellow with risk scores ranging from 13 - 27. Also verified each of the 11 residents had completed Elopement Risk Assessments and care plans. Review of three residents was selected for review (the surveyor had already verified all 11 residents R#'s 2, 3, 7, 8, 9, 10, 11, 12, 13, and 14) had an Elopement Risk Assessment and care plan completed. In an interview with Regional Director of Clinical Operations on 7/21/2023 at 12:55 p.m. stated the 11th resident was R#1 for a total of 11 residents identified to be at risk for elopement. 4. Review of the document entitled [facility name] IJ Education that 7 out of 7 Dietary staff were educated; 12 of 12 CNA/CMA were educated; 7 of 7 LPN's were educated; 3 of 3 RN's were educated; 1 of 1 NP was educated; 2 contract rehab staff were educated, 8 of 8 Agency LPN's; 24 of 24 Agency CNA's received education. Interview with the ADON on 7/21/2023 at 2:33 p.m., verified that she educated all staff as described above. Also verified via the following staff interviews on 7/20/2023 at 11:34 a.m. with LPN EE, 11:46 a.m. CNA PP, 11:49 a.m. CNA QQ, 11:50 a.m. LPN FF, 11:55 a.m. LPN RR. On 7/21/2023 at 11:57 a.m. CNA SS, 11:59 a.m. CNA TT, 4:23 p.m. Staffing Coordinator/Scheduler VV, 4:25 p.m. CNA MM, 4:37 p.m. CNA NN, and 4:41 p.m. CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 5. Review of the facility in-service titled Elopement Care Plans dated 7/10/2023 with the MDS Coordinator, Social Services Director and the ADON in attendance. Overview: The MDS Coordinator was educated on the importance of care planning residents who are an elopement risk determined by review of the Elopement Risk Assessment completed on admission and as needed. An interview on 7/21/2023 at 3:55 p.m. with (LPN MDS) Coordinator UU stated she has been in-serviced on making sure the care plans are updated and ensuring that the nurses know how to go in and look at the care plans and update the care plan if needed, as well as making sure the elopement risk assessments are completed. She stated a score of 24 or higher on the Elopement Assessment indicated resident is at risk for elopement. Record Review of the following sample residents (R#7, R#8, R#9, R#10, R#11, R#12, R#13, and R#14) revealed all residents had an Elopement Assessment completed and were care planned as an elopement risk with appropriate interventions. Review of the nurse's notes May 2023 until present day did not reveal any of the residents listed above had made any attempt to elope. 6. Review of the Incident/Accident List dated June 1 - July 16, 2023, identified 19 falls, 8 skin issues, 2 alleged abuse, 1 elopement (R#1). In an interview with the ADON on 7/21/2023 at 2:33 p.m. confirmed the DON had identified the incidences from June 1 through July 16, 2023. 7. Review of the QAPI Meeting Minutes dated 7/10/2023 with subject matter - QAPI Monthly Meeting. Began at 12:30 p.m. and lasted 10 minutes. In attendance were the Administrator, Maintenance Director, DON, ADON, Social Services Director, MDS Coordinator, Medical Director, and Nurse Practitioner. Discussed the incident and timeline. Planned to meet again in four weeks. In an interview with the Administrator on 7/21/2023 at 2:34 p.m. verified the members of the QAPI meeting on 7/10/2023 and items discussed. An interview on 7/21/2023 at 3:35 p.m. Social Services Director stated she was involved in the QAPI meeting. The team discussed what happened, how it happened, and what could be implemented to prevent any other residents from eloping. Also, the QAPI team discussed the residents in the facility that were assessed as high risk for elopement. The SSD was able to name R#9 and R#13 as residents that are high risk for elopement. She stated R#9 must be redirected often from the door. Administrative oversight of the above measures was reviewed and verified. All corrective action was completed on 7/11/2023. The IJ was removed on 7/12/2023.

Based on observation, record review, staff interview and interview with the Wound Care Physician, the facility failed to implement the care plans to provide treatment as ordered for three residents (R#1, R#2 and R#3) with pressure ulcers; to provide honey thickened liquids for one resident (R#9); to provide nutritional supplements as ordered for two residents (R#1 and R#8); and to determine the cause of the behavior of digging into his wound for R#1. This failure resulted in harm for R#1 when staff failed to provide treatments as ordered, failed to administer a protein supplement to promote wound healing, and failed to determine the underlying cause of the resident's behavior of digging into his coccyx wound in order to initiate appropriate treatment and R#1 had a decline in his pressure ulcers. Findings include: 1. Review of the medical record for R#1 (a closed record) revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan dated 1/12/21 revealed that R#1 had actual pressure ulcers and was at risk for the development of additional pressure ulcers due to immobility and [CONDITION(S)] with interventions for Registered Nurse (RN)/Licensed Practical Nurse (LPN) to administer treatments as ordered and monitor for effectiveness; to provide him with supplemental protein, amino acids, vitamins, minerals as per MD (Physician) orders to promote wound healing; and to provide weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Continued review of his care plan dated 2/4/21 revealed that he had a behavioral problem related to digging into his wound with his fingers with an intervention for staff to attempt to determine the underlying cause of the behavior. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff failed to provide subsequent treatments for R#1 for 8 of the remaining 10 days in 1/2021, for 17 of 19 days in 2/2021, and for 4 of 10 days in 3/2021. There was no indication that nursing staff performed weekly treatment documentation to include measurement (width, length, depth), type of tissue and exudate on 1/7/21 and 1/14/21 in order to monitor the progression/deterioration of the pressure ulcer to determine the effectiveness of current treatment. The resident's pressure ulcer declined to an infectious Stage IV with undermining and tunneling on 1/21/21. Nursing staff failed to perform subsequent weekly treatment documentation of the resident's coccyx pressure ulcer to include measurements and description on his 2/10/21 readmission from the hospital and as scheduled on 3/9/21. R#1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that nursing staff administered the liquid protein to R#1 to promote wound healing from 12/23/20 to 2/2/21 when he was hospitalized with [CONDITION(S)] of his coccyx wound. His [MEDICATION(S)] level on 1/14/21 was 2.4 and on 2/18/21 his level was 2.2 (normal range between 3.0-5.0). There was no indication that nursing staff attempted to determine the underlying cause of the resident's behavior of digging into his coccyx wound in order to prevent injury and further decline of his wound. Although the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Treatment Nurse/Licensed Practical Nurse (TN/LPN) AA on 3/19/21 at 8:46 a.m. revealed that R#1 told her one time that it itched. Telephone interview with the Wound Care Physician on 3/18/21 at 2:58 p.m. revealed that she expected nursing staff to provide treatments as ordered. 2. R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had received palliative care since 2/9/21. Review of a care plan dated 2/21/21 revealed that R#2 had a pressure ulcer and was at risk for the development of additional pressure ulcers with interventions for RN/LPN to administer treatments as ordered and monitor for effectiveness and to assess/record/monitor wound healing: measure length, width and depth where possible. Review of the medical record for R#2 revealed that she developed unavoidable pressure ulcers on her buttocks/coccyx and left heel in 2/2021. There was no indication that nursing staff provided treatments as ordered for 15 of 19 days in 2/2021 and for 8 of 21 days in 3/2021. Although staff had obtained a change in treatment on 3/3/21, there was no indication that the buttocks/coccyx pressure ulcer was assessed from 2/23/21 when it measured 2.5 cms. x 3 cms. x 0.1 cms. and had 15% slough in the wound bed to 3/16/21 (21 days later) when it measured 9 cms. x 6 cms. x 0.1 cms. and had 50% slough in the wound bed. Telephone interview with the Wound Care Physician on 3/18/21 at 2:58 p.m. revealed that she expected nursing staff to provide treatments as ordered. 3. R#3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his care plan dated 12/1/2020 revealed that R#3 had the potential for impairment to his skin integrity related to fragile skin and unawareness of safety. Continued review revealed that on 12/3/20, he had scabbed areas on the third and fourth digits of his left foot and scabbed area on the third digit of his right foot with an intervention to provide treatments as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview with the Wound Care Physician on 3/18/21 at 2:58 p.m. revealed that she expected nursing staff to provide treatments as ordered. 4. R#9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his care plan dated 8/31/2020 and revised 2/26/21 revealed that he was at nutritional risk due to his history of aspiration pneumonia and dysphagia resulting in his need for a mechanically altered diet with thickened liquids with an intervention for staff to provide, serve diet as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the meal service on 4/22/21 at 1:15 p.m. revealed that R#9 was served prepackaged nectar consistency sweet tea. Interview with the Food Services Manager (FSM) on 4/22/21 at 1:35 p.m revealed that the facility did not have the prepackaged honey thickened sweet tea and that dietary staff were responsible for using the thickener packets and following the directions to thicken the resident's sweet tea to honey consistency. Further interview revealed that dietary staff should review the resident's diet card during meal service and provide the liquids as ordered by the Physician. 5. R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for R#8, dated 11/6/2020 revealed that she had unplanned weight loss related to poor food intake with interventions for staff to provide house supplements as ordered. Her care plan was revised 1/14/21 for staff to provide magic cup with meals. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that the resident was administered the nutritional supplement from 11/2020 to 3/24/21 when staff initiated the nutritional supplement. R#8 also had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, observation of lunch on 4/22/21 at 1:00 p.m. and observation of supper on 4/22/21 at 6:06 p.m. revealed that staff failed to serve the Magic Cup to the resident. Interview with the Food Service Manager (FSM) on 4/27/21 at 12:50 p.m. revealed that any diet changes or supplement orders were written on a communication form and provided to her. The Director of Nursing (DON) was responsible for ensuring that the diet change/supplements were appropriately entered into the computer. If a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, review of the facility Enteral Management (revised 11/1/19), and staff interview, the facility failed to ensure that one resident (R) (R#1) with a gastrostomy tube (g-tube) received adequate nutrition to promote wound healing and adequate fluids to maintain hydration and one resident (R#8) received Physician Ordered house supplement and Magic Cup to maintain weight from three residents reviewed for weight loss and hydration. This failure resulted in harm for R#1 who was admitted to the hospital with an abnormally high Sodium (NA) level of 168 on 3/11/21. The census was 42 residents. Findings include: Review of the facility Enteral Management policy revealed that residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including .dehydration. 1. R#1 (a closed record) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his 12/29/2020 Admission Minimum Data Set (MDS) revealed that he had a Brief Interview for Mental Status (BIMS) score of 12, indicating that he was alert and oriented with some confusion; required extensive to total assistance from staff for activities of daily living (ADLs); weighed 193 pounds (#); required nutrition and hydration via a feeding tube; and had one Stage II pressure ulcer and two deep tissue injuries (DTI) on admission. Review of his care plan dated 1/12/21 revealed that R#1 required a feeding tube related to dysphagia status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff documented an intervention for the Registered Dietician(RD) to evaluate quarterly and as needed, monitor caloric intake and estimate his needs (nutrition and hydration), and make recommendations for changes to tube feeding as needed. R#1 had Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) of water after each meal (300 cc total per day). Review of the medical record for R#1 revealed that he weighed 193# on his admission on 12/23/2020. On 12/28/2020, the Registered Dietician (RD) assessed the resident and noted the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD also noted the Stage II pressure ulcer on the resident's left ankle and the unstageable pressure ulcers on his right heel and coccyx. The RD noted the resident's recent hospital low [MEDICATION(S)] level of 2.6 and calculated his nutritional needs of 25-30 cubic centimeters (ccs.) per kilogram (kg) of weight for fluids and 110 grams (gms) of protein for wound healing. However, the RD failed to provide the actual calculated fluid needs of the resident. (The surveyor calculated the estimated fluid needs for R#3 as between 2188.5 ccs and 2626.2 ccs). The RD failed to identify that R#1 was not receiving the house supplement or the liquid protein as ordered by the Physician. The Nurses Note dated 12/24/2020 revealed that the resident had refused any intake by mouth and requested all medications, nutrition and hydration be administered through his g-tube. Review of the Medication Administration Records (MARs) revealed that R#1 was administered the one can of [MEDICATION(S)] 1.5 and the 100 ccs of water flush three times per day (total water flush of 300 ccs) (scheduled at 10:00 a.m., 1:00 p.m. and 6:00 p.m.) from 12/24/2020 to 2/1/21. Review of the 1/31/21 Nutrition/Dietary Note revealed that the RD assessed R#1 with a current weight of 173# which represented a 10.3% significant weight loss in one month. The RD documented that the resident had a diet of mechanical soft with nectar liquids and a conditional order for [MEDICATION(S)] 1.5, one can after meals if he consumed less than 50% and 100 ccs water flush after each meal. However, there was no indication that the RD reviewed the 12/24/2020 Nurses Note that the resident refused all intake by mouth. There was no indication that the RD identified that staff had administered the [MEDICATION(S)] to the resident three times per day since 12/24/2020. There was no indication that the RD reviewed the resident's intake to determine if the bolus feedings of [MEDICATION(S)] and the water flushes were adequate to meet the resident's nutritional and hydration needs. (review of the Documentation Survey Report for 12/2020 and 1/2021 revealed that R#1 consumed 51-75% of his meals on 12/26/2020, 1/1/21, 1/2/21 and 1/6/21; he consumed 76-100% on 1/3/21; and he consumed 26-50% on 1/2/21. There was no indication that R#1 had additional intake by mouth after 1/2/21). Continued review of the Nutrition/Dietary Note dated 1/31/21 revealed that the RD recommended that the one can of [MEDICATION(S)] be provided after each meal regardless of the resident's intake and 100 cc water flush before and after each bolus. The RD also recommended that an extra can of [MEDICATION(S)] be provided at bedtime with 100 cc water flush before and after the bedtime bolus. Further review revealed that this feeding program would provide a total of 1420 kcals, 58 grams of protein and 1524 ccs of fluid. There was no indication that the RD noted the decline in the resident's pressure ulcers or that he was not provided the liquid protein as ordered. R#1 was hospitalized [DATE]-[DATE] for replacement of his clogged g-tube and fever. Review of the hospital Discharge Summary dated 2/20/21 revealed that his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/21, the Physician ordered staff to administer [MEDICATION(S)] 1.5, 360 ccs. via g-tube every six hours and 250 cc water flushes via g-tube every six hours (total 1500 ccs water flush per day). Review of the 2/2021 MAR revealed that staff administered the bolus feedings and water flushes as ordered from 2/20/21 to 2/25/21. Review of the Nutrition assessment dated [DATE] (a new RD) revealed that R#3 weighed 171# and his BMI was within normal limits at 23.8. The RD noted that the resident had completely stopped eating and received enteral feedings for his estimated nutrition and hydration needs. She recommended to change his feeding from bolus to continuous feeding to promote weight maintenance. She noted the pressure ulcers and that multivitamin, Vitamin C and [MEDICATION(S)] had been initiated. The RD calculated the resident's estimated nutritional needs as 1943-2332 kcals per day, 93-117 grams of protein per day, and 1943-2332 ccs fluids per day. She documented that due to the resident's weight loss and wounds she recommended [MEDICATION(S)] 1.5 at 85 ccs per hour x 18 hours which would provide 2295 kcals per day, 1166 ccs water and 96 grams of protein. She also recommended water flushes at 60 cc per hour x 18 hours to provide 1080 cc water. On 2/26/21, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 2/2021 MAR revealed that staff administered [MEDICATION(S)] 1.6 at 60 ccs per hour x 18 hours and 250 ccs water flush before start time and after stop time of [MEDICATION(S)] from 2/26/21-3/11/21. There was no indication that the RD's recommendation had been initiated in order to ensure that the resident received the necessary kcals, protein and fluids to meet his estimated needs. On 3/11/21, R#1 was sent to the hospital for labored breathing with abnormally low oxygen saturation levels. Review of the Hospital History and Physical dated 3/11/21 revealed that a chest x-ray showed possible left lower lobe pneumonia. His labs were significant for a high sodium (NA) of 168 and high creatinine of 2.61. An interview with LPN DD on 3/18/21 at 11:40 a.m. revealed that she remembered providing the 250 ccs water flush before and after the resident's feeding and that she also administered an additional 240 cc water during his medication administration. Continued interview revealed that there was no additional water flush ordered for R#1. A interview with TN/LPN AA on 3/18/21 at 12:21 a.m. revealed that she would flush the resident's g-tube with 30 ccs water before each medication administration, 5ccs water between medications and 30 ccs water after medication administration. Review of the MARS, however, revealed that there was no indication that R#1 was administered any additional fluids before or after medication administration. A telephone interview with the current Registered Dietician (RD) on 3/18/21 at 1:20 p.m. revealed that she was not aware that staff had failed to implement her 2/26/21 recommendation for [MEDICATION(S)] at 85 ccs per hour x 18 hours or water flush at 60 cc per hour x 18 hours. Continued interview revealed that she sent an email to the Director of Nursing (DON) to inform her that if a pump was not available to provide the water flushes, staff could administer 175 ccs water flushes every four hours to provide 1050 ccs total water per day. The RD stated at that time that if the nurses had administered 30 cc water flushes before and after the resident's medications plus the 250 cc water flush twice a day in addition to the water content in the [MEDICATION(S)], R#1 would have received more than adequate fluids to meet his hydration needs (approximately 1900 ccs). Further interview revealed that the resident was at his ideal body weight (IBW) of 170 pounds prior to his discharge from the facility and received enough kcals from his formula feeding to maintain his weight. An interview with the DON on 3/23/21 at 12:02 p.m. revealed that any RD recommendations were communicated to her via email. The DON stated that she reviewed the recommendations with the attending Physician/Nurse Practitioner and the Risk Management Committee. If the attending Physician approved of the recommendation, the nurses or the Nurse practitioner entered the order into the Electronic Medical Record (EMR). Continued interview with the DON revealed that nursing staff had incorrectly entered the tube feeding order ([MEDICATION(S)] 1.5 at 60 ccs per hour instead of the recommended 85 ccs per hour) into EMR and had also failed to enter the correct water flush as per the RD recommendation. There was no indication that the RD's recommendation on 2/26/21 had been initiated in order to ensure that the resident received the necessary nutrition and fluids to meet his estimated needs. Although the resident's weight remained stable between 171-172 pounds from 1/24/21 to 3/8/21, nursing staff failed to implement the RD's 2/26/21 recommendation of [MEDICATION(S)] 1.5 at 85 ccs per hour x 18 hours to provide the necessary kcals to promote wound healing. Although R#1 was hospitalized [DATE]-[DATE] with an abnormally high Sodium (NA) level of 155, nursing staff failed to implement the RD's recommendation on 2/26/21 for water flushes at 60 cc per hour x 18 hours to maintain hydration. On 3/11/21, R#1 was sent to the hospital for labored breathing with abnormally low oxygen saturation levels. Review of the Hospital History and Physical dated 3/11/21 revealed that a chest x-ray showed possible left lower lobe pneumonia. His labs were significant for a high sodium (NA) of 168. 2. R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Significant Change MDS dated [DATE] revealed that R#8 had a BIMS of 2, indicating that she had severe cognitive impairment; was independent with set-up for eating; weighed 122#; and had one SDTI. Review of her care plan dated 11/6/2020 revealed that she had unplanned weight loss related to poor food intake with interventions for staff to provide house supplements as ordered. Her care plan was revised 1/14/21 for staff to provide magic cup with meals. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition/Dietary Note dated 11/10/2020 revealed that R#8 weighed 131 pounds which represented a 5.7% loss in one month. Her BMI was within normal limits at 22.5 and she was above her Ideal Body Weight (IBW) of 120 pounds. Her food intake was between 50-75%. The Registered Dietician (RD) calculated her nutritional needs and recommended that staff provide Med Pass (a nutritional supplement) 120 ccs twice a day for additional 480 kcals to address her weight loss. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the 11/2020 MAR revealed that there was no indication that staff had administered the Med Pass to the resident. Review of the Nutrition/Dietary Note dated 11/18/2020 revealed that the resident's weight was remained at 130# and that house supplement (Med Pass) had been added on 11/10/2020. However, there was no indication that the RD or nursing staff identified that R#8 was not receiving the supplement as ordered by the Physician. Review of the Nutrition/Dietary Note dated 11/24/2020 revealed that R#8 weighed 129 pounds and had a new unstageable pressure ulcer on her right heel. Continued review revealed that the Med Pass would be increased to three times per day for additional 240 kcals. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no indication that staff administered the house supplement (Med Pass) to the resident since 11/10/2020. There was no indication that the RD identified that the house supplement (Med Pass) had not been administered to R#8. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician was notified and ordered staff to increase the house supplement 120 cc to four times per day. However, there was no indication that staff administered the house supplement to the resident in 12/2020. Review of the Nutrition/Dietary Note dated 12/9/2020 revealed that the resident's weight was down to 124 pounds and that the Med Pass was increased last week. [MEDICATION(S)] 7.5 milligrams every day was recommended to stimulate the resident's appetite. Review of the MARs revealed that the [MEDICATION(S)] was administered as ordered. However, there was no indication that staff administered the house supplement to the resident. There was no indication that the RD identified that the house supplement (Med Pass) had not been administered to R#8. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician was notified and ordered Magic Cup with lunch and dinner on 12/23/2020. The resident's weight remained stable from 12/20/2020 to 2/21/21. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition/Dietary Note dated 3/16/21 revealed that the resident's weight of 105 pounds and BMI of 18 indicated that she was underweight. The RD recommended a reweigh of the resident at that time to determine weight loss accuracy. Review of the 3/2021 MAR revealed that Med Pass 2.0, 4 ounces (120 cc) twice a day was initiated on 3/24/21. Review of the Nutritional assessment dated [DATE] revealed that R#8 weighed 105 pounds and had a BMI of 18 which indicated that she was underweight. Continued review revealed that R#8 received a regular diet, Magic Cup twice a day and Med Pass 2.0 120 ccs twice a day. The RD calculated the resident's nutritional needs and noted that the resdent's future weight loss and overall decline was likely unavoidable to to her advanced age and progression of dementia. The RD's recommendation at that time was for staff to reweigh the resident to determine weight loss accuracy. After the RD's second request for a reweigh on 4/16/21, 31 days after her initial request on 3/16/21, staff reweighed R#8 and she weighed 96.8 pounds. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of R#8 on 4/22/21 at 1:00 p.m. revealed that staff had served her roast pork, sweet potatoes, cauliflower, fruit cocktail, and roll. There was no magic cup on her tray. Continued observation revealed that she consumed bites only of her meal. She stated at that time that she was not hungry. Observation ofR#8 on 4/22/21 at 6:06 p.m. revealed that staff had served her a meat sandwich, mixed vegetables, potatoes and strawberries. There was no magic cup on her tray. Review of her diet card at that time revealed that there was no indication that she received magic cup at meals. An interview with Certified Nursing Assistant (CNA) EE on 4/27/21 at 11:03 a.m. revealed that she did not provide any nutritional supplements or magic cup to R#8. An interview with the Director of Nursing (DON) on 4/27/21 at 12:25 p.m. revealed that the RD usually calls her or notifies her via email within 24 hours of any nutritional recommendations. Continued interview revealed that she did not know the reason R#8 was not immediately reweighed per RD request on 3/16/21. The DON stated that any Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed that she audited resident records to ensure that RD recommendations were initiated but one person can not do so many things. Further interview revealed that the Magic Cup should have been entered into computer under Supplements so that it would be printed on the resident's diet card and dietary staff would know to place the Magic Cup on the resident's meal tray. An interview with the Food Service Manager (FSM) on 4/27/21 at 12:50 p.m. revealed that any diet changes or supplement orders were written on a communication form and provided to her. The DON was responsible for ensuring that the diet change/supplements were appropriately entered into EMR. If a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview with the resident's attending Physician on 4/27/21 at 4:00 p.m. revealed that R#8 had severe [CONDITION(S)] and recent blood in her stool. Continued interview revealed that he was concerned for malignancy but, that the family had refused a colonoscopy. He stated at that time that the resident's weight loss was due to her comorbidities and her advanced age. Although R#8's weight loss was unavoidable, staff failed to provide supplements/Med Pass and Magic Cup as ordered by the Physician in order to maintain her ideal body weight and prevent additional weight loss.

Based on observation, record review, review of the the facility Skin Integrity Policy (no date), and staff and Physician interviews, the facility failed to provide treatments as ordered by the Physician and/or failed to perform weekly wound assessments in order to determine the progression/deterioration of a wound for three residents (R) (R#1, R#2 and R#3) of three residents reviewed for pressure ulcers. This failure resulted in harm for R#1 who was admitted with a Stage II coccyx pressure ulcer on 12/23/2020 that declined and was identified by the Wound Care Physician on 1/21/21 as an infected unstageable pressure ulcer. The census was 42 residents. Findings include: Review of the facility Skin Integrity Policy(no date) revealed that the purpose of the wound program was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds Staff were supposed to perform wound observations and measurement upon initial identification of altered skin integrity and with anticipated decline of the wound and perform daily monitoring of wounds or dressings for presence of complications or declines and document. Staff should document daily monitoring of ulcer site with or without a dressing for status of the dressing, status of tissue surrounding the dressing, and decline in wound .If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, (staff) should notify the Physician/APP 1. R#1 (a closed record) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his 12/29/2020 Admission Minimum Data Set (MDS) revealed that he had a Brief Interview for Mental Status (BIMS) score of 12, indicating that he was alert and oriented with some confusion; required extensive to total assistance from staff for activities of daily living (ADLs); weighed 193 pounds (#); required nutrition and hydration via a feeding tube; and had one Stage II pressure ulcer and two deep tissue injuries (DTI) on admission. Review of the resident's care plan dated 1/12/21 revealed that R#1 had actual pressure ulcers and was at risk for the development of additional pressure ulcers due to immobility and [CONDITION(S)] with interventions for Registered Nurse (RN)/ Licensed Practical Nurse (LPN) to administer treatments as ordered and monitor for effectiveness; to provide him with supplemental protein, amino acids, vitamins, minerals as per MD (Physician) Orders to promote wound healing; and to provide weekly treatment documentation to include meausrement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Continued review of his care plan dated 2/4/21 revealed that he had a behavioral problem related to digging into his wound with his fingers with an intervention for staff to attempt to determine the underlying cause of the behavior. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . He also had Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) of water after each meal. Review of the Nurses Note dated 12/24/2020 revealed that the resident had refused any intake by mouth and requested all medications, nutrition and hydration be administered through his g-tube. Review of the Medication Administration Records (MARs) revealed that R#1 was administered the one can of [MEDICATION(S)] 1.5 and the 100 ccs of water flush three times per day (scheduled at 10:00 a.m., 1:00 p.m. and 6:00 p.m.) from 12/24/2020 to 2/1/21. Review of the Wound Weekly Observation Tool dated 12/24/2020 revealed that the resident had a Stage II pressure ulcer on his left outer ankle with granulation tissue and scant amount of bleeding that measured 1.5 centimeters (cms.) x 1 cm. x 0.1 cm.; a suspected deep tissue injury (SDTI) on his right heel with red/purple wound bed that measured 2.5 cms. x 2.5 cms.; and a SDTI on his coccyx with red/purple wound bed that measured 2 cms. x 2 cms. The resident was admitted to the facility with Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 12/2020 Treatment Administration Record (TAR) revealed that there was no indication that treatments were provided as ordered for the three pressure ulcers on 12/24/2020, 12/28/2020 or 12/31/2020. Review of the 1/2021 TAR revealed that there was no indication that treatments were provided for the left outer ankle or right heel as scheduled on 1/3/21, 1/6/21, 1/9/21, 1/15/21, 1/18/21, 1/21/21 or 1/24/21. There was no indication that treatments were provided to the coccyx as scheduled on 1/3/21, 1/6/21, 1/9/21 or 1/12/21. Review of the Wound Weekly Observation Tool dated 12/31/2020 revealed that the Stage II left outer ankle pressure ulcer and the SDTI on the resident's right heel had not changed significantly and that treatments with the [MEDICATION(S)] every three days were to continue. The pressure ulcer on the resident's coccyx had increased in size and measured 3.5 cms. x 4 cms. x 0.2 cms. The wound had an open area with 25% slough present in the wound bed and moderate bloody drainage. The peri-wound was excoriated. Treatment with [MEDICATION(S)] dressing every three days was to continue and barrier cream applied to the excoriated areas. On 1/14/2021, R#1 tested positive for COVID 19 and was treated with antibiotic therapy, Vitamin C twice a day and [MEDICATION(S)] sulfate 220 milligrams (mgs.) every day. There was no indication that a weekly assessment of the wounds to include description, measurements, and staging was performed on 1/7/21 and 1/14/21 in order to evaluate the deterioration/progression of the wounds. On 1/12/21, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented assessment of the pressure ulcer on 1/12/21 that indicated its progression/deterioration. Review of the 1/2021 TAR revealed that there was no indication that treatments were provided daily on 1/13/21, 1/15/21-1/18/21 or 1/20/21. Review of the Wound Weekly Observation Tool dated 1/19/21 revealed an assessment only of the resident's right heel pressure ulcer. There was no indication that the pressure ulcers on the resident's left outer ankle or coccyx were assessed. On 1/20/21, an indwelling urinary catheter was inserted to aid in the healing of the resident's coccyx pressure ulcer. R#1 was assessed via video by the Wound Care (WC) Physician on 1/21/21. Review of the Wound Care Physician's Surgical Note dated 1/21/21 revealed the following assessment of the resident's wounds: Wound 1: coccyx Stage IV pressure ulcer that measured 11 cms. x 3 cms. x 1.5 cms with 75% slough and 25% granulation tissue; 2 cm. undermining from 12 o'clock to 3 o'clock, 2 cms. from 3 o'clock to 6 o'clock, 2 cms. from 6 o'clock to 9 o'clock, and 2 cms. from 9 o'clock to 12 o'clock; 3 cm. tunneling at 6 o'clock; copious, sero-purulent exudate; mild odor; and macerated wound edge. Continued review of the Surgical Note revealed that the WC Physician Ordered staff to cleanse the coccyx wound with ½ strength Dakin's solution (an antiseptic used to cleanse and prevent infection), apply Santyl (an enzyme that breaks up and removes dead tissue), and pack the wound with Calcium alginate (used to absorb exudate and form a gel-like covering to maintain a moist healing environment) every day. Review of the 1/2021 and 2/2021 TARs revealed that there was no indication that the Stage IV coccyx pressure ulcer was treated daily as ordered from 1/22/21-1/27/21, 1/29/21-1/30/21 and 2/1/21. The WC Physician ordered staff to administer [MEDICATION(S)] twice a day for the coccyx pressure ulcer infection and was completed on 2/4/21. Wound 2: right heel unstageable pressure ulcer that measured 0.2 cms. x 1.0 cms. with 100% eschar. Continued review of the Surgical Note dated 1/21/21 revealed that the Wound Care Physician Ordered staff to apply [MEDICATION(S)] every day. However, there was no indication that staff transcribed the 1/21/21 WC Physician's Ttreatment Order until 1/27/21, six days later. Review of the 1/2021 and 2/2021 TARs revealed that there was no indication that the unstageable right heel pressure ulcer was treated daily from 1/22/21-1/27/21, 1/29-1/30/21 and 2/1/2021. Wound 3: left lateral malleolus unstageable pressure ulcer that measured 0.5 cms. x 0.2 cms. with 100% eschar. The Wound Care Physician ordered staff to apply [MEDICATION(S)] every day. However, there was no indication that staff transcribed the 1/21/21 WC Physician's Treatment Order until 1/27/21, six days later. Review of the 1/2021 and 2/2021 TARs revealed that there was no indication the unstageable left ankle pressure ulcer was treated daily from 1/22/21-1/27/21, 1/29/21-1/30/21 and 2/1/2021. Review of the 1/14/21, 1/21/21, 1/26/21 and 1/28/21 facility Skin Notes revealed that staff had observed R#1 place his hands in his brief to scratch his wound (coccyx). Although staff redirected the resident, there was no indication that staff attempted to determine the underlying cause of the resident's scratching at those times as care planned. There was no indication that staff may have considered the underlying cause of the resident's scratching as a need to alleviate an itch and to apply the [MEDICATION(S)]-[MEDICATION(S)] cream as ordered. Review of the Wound Weekly Observation Tool dated 1/28/21 revealed that the coccyx pressure ulcer still measured 11 cms. x 3 cms. x 1.5 cms as on 1/21/21 and continued to have slough, odor, a large amount of bloody drainage and continued to decline. The pressure ulcers on the right heel and left outer ankle were improving. Review of the medical record for R#1 revealed that he was hospitalized [DATE]-[DATE] for replacement of his clogged g-tube and fever. The resident's infected coccyx pressure ulcer was debrided and a wound vacuum-assisted closure (VAC) (decreased air pressure around wound to assist in healing) applied. Review of the hospital Discharge Summary dated 2/20/21 revealed that his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital MRI showed [CONDITION(S)] of the S5-C3 vertebral bodies. His blood cultures were negative. Continued review revealed that after rehydration, the resident's [MEDICATION(S)] level on 2/4/21 was 2.8 ( normal range between 3.0-5.0) R#1 was readmitted from the hospital on 2/10/21 on antibiotic therapy and with the following Physician Treatment Orders: 1. Cleanse Stage II pressure ulcer on left outer ankle with normal saline, apply A&D ointment (a barrier cream that seal out wetness), and dressing every day. Review of the 2/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Cleanse pressure ulcer on coccyx with normal saline, pack wound with ½ strength Dakin's moistened gauze and apply dry dressing twice a day. Review of the 2/2021 TAR revealed that treatments were only provided once per day on 2/12/21, 2/13/21, 2/15/21, 2/17/21, and 2/19/21-2/23/21. There was no indication that any treatments were provided 2/11/21, 2/14/21, and 2/24/21-2/25/21. There was no indication that an assessment of the resident's pressure ulcers was completed on his readmission from the hospital on 2/10/21 to include measurements, description and staging of his wounds. Review of the Weekly Wound Observation Tool dated 2/16/21, revealed that R#1 refused to be assessed by the WC Physician. There was no indication that facility staff had later performed a weekly wound assessment of the resident's coccyx pressure ulcer to determine the progression of the wound. Review of the WC Physician's Surgical Note dated 2/23/21 revealed that the Stage IV coccyx pressure ulcer had 100% granulation tissue in the wound bed, copious serosanguinous exudate, mild odor and measured 6 cms. x 5 cms. x 4.5 cms. with macerated wound edge. Continued review of the Surgical Note revealed that the WC Physician recommended treatment with Santyl, Calcium alginate, and collagen powder. There was no frequency of treatments documented. Review of the 2/2021 TAR revealed that there was no indication that staff had transcribed the WC physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The coccyx pressure ulcer continued to be treated daily with ½ strength Dakin's solution from 2/23/21 to 3/2/21 except for 2/24/21, 2/25/21 and 2/28/21 when no treatments were provided. Further review of the 2/23/21 Surgical Note revealed that the unstageable pressure ulcers on the right heel and the left lateral malleolus had resolved. Review of the WC Physician's Surgical Note dated 3/2/21 revealed that the Stage IV coccyx pressure ulcer measured 6.0 cms. x 8.0 cms. x 4.0 cms with 25% slough, 50% granulation tissue, and 25% necrotic tissue; had 2 cm. tunneling at 12 o'clock; copious, serosanguinous exudate; mild odor; and unhealthy periwound and friable wound edge. There were no signs of infection. The WC Physician ordered staff to cleanse the pressure ulcer with ½ strength Dakin's solution, apply Santyl, pack the wound with alginate, and cover with a ABD pad every day. However, there was no indication that treatment was provided on 3/4/21, 3/5/21, 3/7/21. There was no indication that the pressure ulcer was assessed weekly as scheduled on 3/9/2021. Review of the Nurses Note dated 3/11/21 at 9:30 a.m., revealed that R#1 had labored breathing with abnormally low oxygen saturation levels. Staff increased his oxygen and notified the Physician who ordered R#1 to be sent to the emergency room . Review of the Hospital History and Physical dated 3/11/21 revealed that a chest x-ray showed possible left lower lobe pneumonia. His labs were significant for a high sodium (NA) of 168 and high creatinine of 2.61. Assessment diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not return to the facility. There was no indication that staff provided treatments as ordered for R#1 from 12/24/2020 to 1/20/21 and he had a decline in his coccyx pressure ulcer from a SDTI that measured 2 cms. x 2 cms. to a Stage IV pressure ulcer that measured 11 cms. x 3 cms. x 1.5 cms with 75% slough, undermining and tunneling, and copious, sero-purulent exudate identified by the WC Physician on 1/21/21. Although treatments to the coccyx pressure ulcer were provided on 1/14/21 and 1/19/21, there was no indication that the deterioration of the wound and presence of purulent drainage were identified and the Physician notified prior to 1/21/21 when the WC Physician assessed the wound. Staff failed to perform weekly wound assessments of the coccyx pressure ulcer to include measurements, description and staging as scheduled on 1/7/21 and 1/14/21 so that the deterioration of the wound could be identified and addressed timely. On 1/21/21 the WC Physician identified the wound as an infectious Stage IV pressure ulcer that required antibiotic therapy. An interview with the Director of Nursing (DON) on 3/17/21 at 8:35 a.m. revealed that the facility had a treatment nurse who assessed all residents with wounds with the Wound Care Physician every Tuesday via telewound. Continued interview revealed that the treatment nurse was responsible for the provision of treatments on Tuesday and Thursday and the weekly wound assessments. The DON stated that the charge nurses were responsible for providing wound treatments for their assigned residents the other days of the week. An interview with Licensed Practical Nurse (LPN) BB and LPN CC on 3/17/21 at 1:29 p.m. revealed that LPN BB could provide wound treatments on her shift (day) unless she had a new admission or had to send a resident to the emergency room . She stated that she remembered that she was not able to provide wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed that she may observe that a wound treatment had not been provided for a resident perhaps two times per month based on the dressing date. LPN BB stated at that time that the DON had been notified as recently as last week that wound treatments were not being provided at times and was told that the facility did not have enough wounds to warrant a full-time Treatment Nurse. Interview with LPN CC at that time revealed that she may not be able to provide wound treatments on day shift approximately one time per week but, she notified the next shift nurse so that she/he could provide treatment. Continued interview with LPN CC revealed that she was aware that Administration did not think that the facility warranted a full- time Treatment Nurse but, that Administration did not consider the high acuity of the resident population. An interview with the DON on 3/18/21 at 1:40 p.m. revealed that she was aware that there was a lack of documentation on the TARs but, she believed treatments were done because she made random rounds to observe dates and cleanliness of wound dressings. She stated that some of the facility nurses were not competent in the Electronic Medical Record (EMR) computer program which the facility used to document medical records and she believed that they did not know how to document treatments on the electronic TAR. She stated that the agency nurses that were utilized did not seem competent at documentation in PCC as well. Continued interview revealed that she initiated corrective action today to in-service staff. A telephone interview with the Wound Care Physician on 3/18/21 at 2:58 p.m. revealed that she assessed R#1 one time per week via video. She stated that staff had already removed the resident's coccyx pressure ulcer dressing and cleansed the wound prior to her assessment so she could not determine the quality of treatment R#1 had received. Continued interview revealed that R#1 was extremely unwell and was at risk for decline. He also had been hospitalized during his stay and in her opinion most residents experience a decline in wounds with a hospital admission. When asked about her 2/23/21 treatment order for Santyl, Calcium alginate and collagen, she stated that staff sometimes had to order needed supplies but, she expected them to obtain the ordered supplies as soon as possible and provide treatment as ordered. An interview with Treatment Nurse (TN)/LPN AA on 3/18/21 at 9:00 a.m. revealed that she had been on sick leave with COVID 19 the week of 1/7/21 and 1/14/21 when the wound assessments for R#1 were due. When asked who was responsible for performing wound assessments in her absence, TN/LPN AA did not answer the inquiry and stated that during this time there was only one nurse for the entire building because staff were out with COVID 19. Interview with TN/LPN AA on 3/19/21 at 8:46 a.m. and 10:39 a.m. revealed that she was part-time and worked three to four days per week. She stated that she was originally hired to provide wound treatments only, but that she was often pulled to work as a charge nurse so that there were two nurses available to administer medications. Continued interview with TN/LPN AA revealed that approximately two to three weeks per month, she would have to work as a charge nurse for the three to four days she worked. She stated that the facility needed three nurses (two nurses on the two medication carts and one nurse to provide treatments) due to the number of residents who required total care, ambulatory residents at risk for falls, and residents with behaviors who required constant supervision. Further interview revealed that the other nurses were responsible for providing treatments for their assigned residents when she was pulled to work as charge nurse on those days. TN/LPN AA stated that the days when she was able to provide treatments, she had not observed any dated dressings that indicated that treatments had not been provided as ordered. She stated that she was not able to perform weekly wound assessments when she worked as a charge nurse all week. When asked about the treatment change to alginate ordered on 1/12/21, TN/LPN AA stated that it was probably changed because the wound had increased drainage, but that she did not note any infection prior to 1/21/21 when the WC Ohysician assessed the wound. When asked about the lack of a wound assessment for R#1 as scheduled on 3/9/21, TN/LPN AA stated that she worked as a charge nurse on 3/9/21 and 3/10/21 administering medications and was not able to perform wound assessments on those days. Continued interview revealed that the last time she assessed the resident's pressure ulcer prior to his hospitalization on [DATE] was on 3/2/21 with the WC Physician. Interview with TN/LPN AA on 3/24/21 at 8:32 aa.m. revealed that she did not receive the WC Physician's notes with treatment order (2/23/21) until it was time for the WC Physician to assess R#1 again. Continued interview revealed that the Wound Care Physician would not send her orders until late Thursday when TN/LPN AA had left for the day or on Friday when TN/LPN AA worked as a Chrage Nurse. Further interview revealed that working on the floor administering medications kept her busy on Friday and she would not be able to enter treatment orders into the computer until the following Tuesday when she worked again. A telephone interview with the attending Physician for R#1 on 3/19/21 at 9:01 a.m. revealed that he could not remember if he had observed the resident's pressure ulcers. He stated that nursing staff did not notify him of deterioration of the resident's coccyx pressure ulcer from 12/31/2020 to 1/21/21 when the resident was assessed by the WC Physician with an infectious wound that required antibiotic therapy. Continued interview revealed that he remembered nursing staff calling him about the resident's pain during treatment and pain medication was ordered. The attending Physician stated that he expected nursing staff to notify him about the decline in the resident's pressure ulcer. An interview with the Administrator on 3/24/21 at 11:35 a.m. revealed that she was not aware of any concerns about wound treatments until 3/11/21 when family for R#1 called her and alleged neglect. She reviewed the TARS at that time and then interviewed the nurses who told her that they provided treatments, but were in a rush to complete their duties and did not document in PCC. The Administrator stated that the nurses should have documented in PCC to show that the treatments were provided. Continued interview revealed that the nurses were in-serviced on completing appropriate documentation. Further interview revealed that nursing staff should have been monitored to ensure that they were providing appropriate documentation prior to 3/11/21. Although the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . three times a day to promote wound healing, there was no indication that the resident was administered the supplement from 12/24/2020 to 2/2/21 when he was hospitalized for [CONDITION(S)] of his coccygeal wound. The resident's [MEDICATION(S)] level on 1/14/21 was 2.4 (normal range between 3.0-5.0). After rehydration, the resident's hospital [MEDICATION(S)] level on 2/4/21 was 2.8 and his level on 2/18/21 was 2.2. The liquid protein was not reordered on his 2/10/21 readmission from the hospital. Review of the Electronic Medical Record (EMR) a computer program used by the facility for electronic documentation with LPN DD on 3/18/21 at 11:40 a.m. revealed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN DD stated at that time that nursing staff had failed to enter the order correctly so that the protein would be documented in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that staff attempted to determine the underlying cause of the resident's digging into his coccyx wound as care planned and failed to apply the [MEDICATION(S)]-[MEDICATION(S)] cream 1% to his peri-wound in an attempt to alleviate possible itching and the resident's need to dig into the wound. Interview with TN/LPN AA on 3/19/21 at 8:46 a.m. revealed that she believed R#1 had a decline in his coccyx pressure ulcer because he would dig in his wound. She educated him on the risk of infection but he would continue to dig and that he told her one time that it itched. When asked about the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, however, that she believed the digging was more of a behavior issue. Review of the medical record for R#1 revealed that he weighed 193# on his admission on 12/23/2020. On 12/28/2020, the Registered Dietician (RD) assessed the resident and noted the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD also noted the Stage II pressure ulcer on the resident's left ankle and the unstageable pressure ulcers on his right heel and coccyx. The RD noted the resident's recent hospital low [MEDICATION(S)] level of 2.6 and calculated his nutritional needs of 25-30 cubic centimeters (ccs.) per kilogram (kg) of weight for fluids and 110 grams (gms) of protein for wound healing. However, the RD failed to provide the actual calculated fluid needs of the resident. (The surveyor calculated the estimated fluid needs for R#3 as between 2188.5 ccs and 2626.2 ccs). The RD failed to identify that R#1 was not receiving the house supplement or the liquid protein as ordered by the Physician. Review of the Nurses Note dated 12/24/2020 revealed that the resident had refused any intake by mouth and requested all medications, nutrition and hydration be administered through his g-tube. Review of the Medication Administration Records (MARs) revealed that R#1 was administered the one can of [MEDICATION(S)] 1.5 and the 100 ccs of water flush three times per day (scheduled at 10:00 a.m., 1:00 p.m. and 6:00 p.m.) from 12/24/2020 to 2/1/21. Review of the 1/31/21 Nutrition/Dietary Note revealed that the RD assessed R#1 with a current weight of 173# which represented a 10.3% significant weight loss in one month. The RD documented that the resident had a diet of mechanical soft with nectar liquids and a conditional order for [MEDICATION(S)] 1.5, one can after meals if he consumed less than 50% and 100 ccs water flush after each meal. However, there was no indication that the RD reviewed the 12/24/2020 Nurses Note that the resident refused all intake by mouth. There was no indication that the RD identified that staff had administered the [MEDICATION(S)] to the resident three times per day since 12/24/2020. There was no indication that the RD reviewed the resident's intake to determine if the bolus feedings of [MEDICATION(S)] and the water flushes were adequate to meet the resident's nutritional and hydration needs. (review of the Documentation Survey Report for 12/2020 and 1/2021 revealed that R#1 consumed 51-75% of his meals on 12/26/2020, 1/1/21, 1/2/21 and 1/6/21; he consumed 76-100% on 1/3/21; and he consumed 26-50% on 1/2/21. There was no indication that R#1 had additional intake by mouth after 1/2/21). Continued review of the Nutrition/Dietary Note dated 1/31/21 revealed that the RD recommended that the one can of [MEDICATION(S)] be provided after each meal regardless of the resident's intake and 100 cc water flush before and after each bolus. The RD also recommended that an extra can of [MEDICATION(S)] be provided at bedtime with 100 cc water flush before and after the bedtime bolus. Further review revealed that this feeding program would provide a total of 1420 kcals, 58 grams of protein and 1524 ccs of fluid. There was no indication that the RD noted the decline in the resident's pressure ulcers or that he was not provided the liquid protein as ordered. R#1 was hospitalized [DATE]-[DATE] for replacement of his clogged g-tube and fever. Review of the hospital Discharge Summary dated 2/20/21 revealed that his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/21, the Physician Ordered staff to administer [MEDICATION(S)] 1.5, 360 ccs. via g-tube every six hours and 250 cc water flushes via g-tube every six hours. Review of the 2/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition assessment dated [DATE] (a new RD) revealed that R#1 weighed 171# and his BMI was within normal limits at 23.8. The RD noted that the resident had completely stopped eating and received enteral feedings for his estimated nutrition and hydration needs. She recommended to change his feeding from bolus to continuous feeding to promote weight maintenance. She noted the pressure ulcers and that multivitamin, Vitamin C and [MEDICATION(S)] had been initiated. The RD calculated the resident's estimated nutritional needs as 1943-2332 kcals per day, 93-117 grams of protein per day, and 1943-2332 ccs fluids per day. She documented that due to the resident's weight loss and wounds she recommended [MEDICATION(S)] 1.5 at 85 ccs per hour x 18 hours which would provide 2295 kcals per day, 1166 ccs water and 96 grams of protein. She also recommended water flushes at 60 cc per hour x 18 hours to provide 1080 cc water. On 2/26/21, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that the RD's recommendation had been initiated in order to ensure that the resident received the necessary kcals, protein and fluids to meet his estimated needs. On 3/11/21, R#1 was sent to the hospital for labored breathing with abnormally low oxygen saturation levels. Review of the Hospital History and Physical dated 3/11/21 revealed that a chest x-ray showed possible left lower lobe pneumonia. His labs were significant for a high sodium (NA) of 168 and high creatinine of 2.61. 2. R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had received palliative care since 2/9/21. Review of the Significant Change MDS dated [DATE] revealed that she had a BIMS of 15 indicating that she was cognitively intact; had

Based upon observation, record review, staff interview the facility failed to ensure that equipment used by and/or for residents was in good repair and presented no safety hazards and that facility staff properly transfer and position residents resulting in harm to one resident ("C") from a sample of thirty (30) residents. In addition, housekeeping chemicals are not unattended in areas frequently used by confused residents. Findings include: 1. Record review revealed resident "C" was admitted to the facility in 2008 with multiple [DIAGNOSES REDACTED]. A recent [DIAGNOSES REDACTED]. The resident was assessed as having behaviors including the hitting at staff, resisting care, and needing two (2) person assist for transfers on the Minimum Data Set (MDS) assessment dated [DATE]. Record review of the Nurse Notes dated 7/10/2011 at 4:55 p.m. revealed the resident was being repositioned in a Geri chair and being transferred to the chair by one (1) Certified Nursing Assistant (CNA) "EE". During the transfer/repositioning, the resident's right ring finger was caught in the chair mechanism resulting in an amputation of the tip of the finger. The resident was seen in the emergency roiagnom on [DATE] and returned to the facility on [DATE] at 9:30 p.m. Observation of 11/01/11 at 1:00 p.m. the resident was sitting in a Geri-chair with a bandage to the right fourth and fifth fingers. Following the incident, facility Maintenance Director checked all Geri-chairs in the building (total of nine) and found two (2) with loose side panels. These Geri-chairs were repaired but no record was available as to if the chair resident "C" was sitting in on 7/10/11, was one of the chairs that needed repair. There was not a scheduled maintenance routine for Geri-chairs. A telephone interview with the family member of resident "C" on 11/1/11 at 1:31 p.m. revealed the family member was present the day the accident occurred. The family member stated it was an accident that occurred when the CNA was repositioning the resident in the Ger-chair. 2. A random observation 11/2/11 at 9:05 a.m. revealed a housekeeping mop bucket outside a resident room on the 100-Hall with two (2) spray bottles handing on the rim of the bucket. At 9:10 a.m. housekeeper "FF" came out of resident's room (the door was closed) and pushed the mop bucket to the janitor closet located next door to the resident's room. Observation during this time revealed several confused resident's were in the hallway in wheelchairs or ambulating in the hallway. No other staff were observed in this area. Review of the Material Safety Data Sheets, provided by facility staff, the chemicals were identified as Triple DDD, a germicidal cleaner with warnings: Causes eye and skin irritation. Harmful if swallowed. May be absorbed through intact skin. May cause irritation to throat and gastrointestinal tract. The second chemical was 3P with warnings: Skin contact/absorption, eyes: flood with water for 15 minutes, if irritation develops, contact physician. skin: flush well with water. Inhalation: If symptoms of overexposure are experienced, evacuate to fresh air. Consult physician if breathing is difficult. Ingestion: Drink large quantity of milk or other liquid. Contact physician. The DON supplied the Material Safety Data Sheet for the two (2) chemicals. An interview with housekeeper "FF" at the time of the observations, revealed that she usually doesn't leave the cart unattended and thought she was only in the resident's room for a minute. An interview with the Administrator on 11/02/11 at 3:45 p.m. revealed it was not acceptable for the Housekeeping staff to leave the mop bucket unattended.